Juliet Haarbauer-Krupa

Trends in Sports- and Recreation-Related Traumatic Brain Injuries Treated in US Emergency Departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012.

Importance:Sports- and recreation-related traumatic brain injuries (SRR-TBIs) are a growing public health problem affecting persons of all ages in the United States. Objective:To describe the trends of SRR-TBIs treated in US emergency departments (EDs) from 2001 to 2012 and to identify which sports and recreational activities and demographic groups are at higher risk for these injuries. Design:Data on initial ED visits for an SRR-TBI from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for 2001-2012 were analyzed. Setting:NEISS-AIP data are drawn from a nationally representative sample of hospital-based EDs. Participants:Cases of TBI were identified from approximately 500 000 annual initial visits for all causes and types of injuries treated in EDs captured by NEISS-AIP. Main Outcome Measure(s):Numbers and rates by age group, sex, and year were estimated. Aggregated numbers and percentages by discharge disposition were produced. Results:Approximately 3.42 million ED visits for an SRR-TBI occurred during 2001-2012. During this period, the rates of SRR-TBIs treated in US EDs significantly increased in both males and females regardless of age (all Ps < .001). For males, significant increases ranged from a low of 45.8% (ages 5-9) to a high of 139.8 % (ages 10-14), and for females, from 25.1% (ages 0-4) to 211.5% (ages 15-19) (all Ps < .001). Every year males had about twice the rates of SRR-TBIs than females. Approximately 70% of all SRR-TBIs were reported among persons aged 0 to 19 years. The largest number of SRR-TBIs among males occurred during bicycling, football, and basketball. Among females, the largest number of SRR-TBIs occurred during bicycling, playground activities, and horseback riding. Approximately 89% of males and 91% of females with an SRR-TBI were treated and released from EDs. Conclusion and Relevance:The rates of ED-treated SRR-TBIs increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Preventions Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.

Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network

IMPORTANCE Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained. OBJECTIVE To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury. DESIGN, SETTING, AND PARTICIPANTS In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Childrens Hospital of Philadelphias (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected. MAIN OUTCOMES AND MEASURES Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion. RESULTS A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]). CONCLUSIONS AND RELEVANCE The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.

Life Expectancy after Inpatient Rehabilitation for Traumatic Brain Injury in the United States

This study characterized life expectancy after traumatic brain injury (TBI). The TBI Model Systems (TBIMS) National Database (NDB) was weighted to represent those ≥16 years of age completing inpatient rehabilitation for TBI in the United States (US) between 2001 and 2010. Analyses included Standardized Mortality Ratios (SMRs), Cox regression, and life expectancy. The US mortality rates by age, sex, race, and cause of death for 2005 and 2010 were used for comparison purposes. Results indicated that a total of 1325 deaths occurred in the weighted cohort of 6913 individuals. Individuals with TBI were 2.23 times more likely to die than individuals of comparable age, sex, and race in the general population, with a reduced average life expectancy of 9 years. Independent risk factors for death were: older age, male gender, less-than-high school education, previously married at injury, not employed at injury, more recent year of injury, fall-related TBI, not discharged home after rehabilitation, less functional independence, and greater disability. Individuals with TBI were at greatest risk of death from seizures; accidental poisonings; sepsis; aspiration pneumonia; respiratory, mental/behavioral, or nervous system conditions; and other external causes of injury and poisoning, compared with individuals in the general population of similar age, gender, and race. This study confirms prior life expectancy study findings, and provides evidence that the TBIMS NDB is representative of the larger population of adults receiving inpatient rehabilitation for TBI in the US. There is an increased risk of death for individuals with TBI requiring inpatient rehabilitation.

Service delivery in the healthcare and educational systems for children following traumatic brain injury: gaps in care

Objective: To provide a review of evidence and consensus-based description of healthcare and educational service delivery and related recommendations for children with traumatic brain injury. Methods: Literature review and group discussion of best practices in management of children with traumatic brain injury (TBI) was performed to facilitate consensus-based recommendations from the American Congress on Rehabilitation Medicines Pediatric and Adolescent Task Force on Brain Injury. This group represented pediatric researchers in public health, medicine, psychology, rehabilitation, and education. Results: Care for children with TBI in healthcare and educational systems is not well coordinated or integrated, resulting in increased risk for poor outcomes. Potential solutions include identifying at-risk children following TBI, evaluating their need for rehabilitation and transitional services, and improving utilization of educational services that support children across the lifespan. Conclusion: Children with TBI are at risk for long-term consequences requiring management as well as monitoring following the injury. Current systems of care have challenges and inconsistencies leading to gaps in service delivery. Further efforts to improve knowledge of the long-term TBI effects in children, child and family needs, and identify best practices in pathways of care are essential for optimal care of children following TBI.

Unmet Rehabilitation Needs After Hospitalization for Traumatic Brain Injury

In this multicenter study, we investigate dysfunction and unmet need for rehabilitation and educational services in children after hospitalization for TBI. OBJECTIVES: In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry). METHODS: Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point. RESULTS: Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs. CONCLUSIONS: Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.

Improving Primary Care Provider Practices in Youth Concussion Management

Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care–based intervention including an electronic health record–based clinical decision support tool (“SmartSet”) and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.

Variations in Mechanisms of Injury for Children with Concussion

Objectives To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. Study design All patients, age 0‐17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Childrens Hospital of Philadelphias electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion‐related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. Results Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0‐4 were sports related, compared with greater proportions for older children (67% for age 5‐11, 77% for age 12‐14, and 73% for age 15‐17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). Conclusions Sports‐related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one‐third of concussions were from non–sports‐related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.

Acute Ischemic Stroke after Moderate to Severe Traumatic Brain Injury

Background and Purpose— Traumatic brain injury (TBI) leads to nearly 300 000 annual US hospitalizations and increased lifetime risk of acute ischemic stroke (AIS). Occurrence of AIS immediately after TBI has not been well characterized. We evaluated AIS acutely after TBI and its impact on outcome. Methods— A prospective database of moderate to severe TBI survivors, admitted to inpatient rehabilitation at 22 Traumatic Brain Injury Model Systems centers and their referring acute-care hospitals, was analyzed. Outcome measures were AIS incidence, duration of posttraumatic amnesia, Functional Independence Measure, and Disability Rating Scale, at rehabilitation discharge. Results— Between October 1, 2007, and March 31, 2015, 6488 patients with TBI were enrolled in the Traumatic Brain Injury Model Systems National Database. One hundred and fifty-nine (2.5%) patients had a concurrent AIS, and among these, median age was 40 years. AIS was associated with intracranial mass effect and carotid or vertebral artery dissection. High-velocity events more commonly caused TBI with dissection. AIS predicted poorer outcome by all measures, accounting for a 13.3-point reduction in Functional Independence Measure total score (95% confidence interval, −16.8 to −9.7; P<0.001), a 1.9-point increase in Disability Rating Scale (95% confidence interval, 1.3–2.5; P<0.001), and an 18.3-day increase in posttraumatic amnesia duration (95% confidence interval, 13.1–23.4; P<0.001). Conclusions— Ischemic stroke is observed acutely in 2.5% of moderate to severe TBI survivors and predicts worse functional and cognitive outcome. Half of TBI patients with AIS were aged ⩽40 years, and AIS patients more often had cervical dissection. Vigilance for AIS is warranted acutely after TBI, particularly after high-velocity events.

682 Novel use of electronic health records to advance research and management of paediatric concussions

Background While our understanding of concussion as an important public health issue among children has grown, broad description of paediatric concussions is limited to high school sports or those treated in an emergency department (ED). Further, non-specialist providers report inadequate training and infrastructure to systematically diagnose and manage these patients. To address these gaps, CHOP and CDC have initiated a novel collaborative effort to examine whether electronic health records (EHRs) can expand traumatic brain injury (TBI) surveillance and research–with a focus on concussion–and to assess whether EHR-based initiatives can improve TBI management. Methods All patients, age 0–17 years, with at least one clinical encounter with an ICD-9-CM diagnosis of concussion in the CHOP EHR system (7/2010−6/2014) were selected and their initial concussion-related encounter identified. Results 14,054 patients were included (average age: 12.1 years). Initial analyses indicate that: 50% of patients had their first encounter within primary care and 27% within specialty care; half of all concussions among 5–11 year olds were sports/recreation-related; and introduction of a concussion clinical support tool substantially improved documentation of concussion-specific assessment in the EHR (2% before vs. 70% after implementation in July 2012). Conclusions This collaborative program leverages the strength of a linked EHR system throughout a large healthcare network (>1 million annual visits) to provide a comprehensive system-wide assessment of paediatric concussion across the developmental age spectrum beyond the ED setting. This is the first such US assessment that included a diverse demographic and socioeconomic sample. This work highlights the potential of EHRs to guide clinical management and facilitate research that can lead to improved concussion prevention and diagnosis.

Prevalence of Parent-Reported Traumatic Brain Injury in Children and Associated Health Conditions

Importance Traumatic brain injury (TBI) in children results in a high number of emergency department visits and risk for long-term adverse effects. Objectives To estimate lifetime prevalence of TBI in a nationally representative sample of US children and describe the association between TBI and other childhood health conditions. Design, Setting, and Participants Data were analyzed from the 2011-2012 National Survey of Children’s Health, a cross-sectional telephone survey of US households with a response rate of 23%. Traumatic brain injury prevalence estimates were stratified by sociodemographic characteristics. The likelihood of reporting specific health conditions was compared between children with and without TBI. Age-adjusted prevalence estimates were computed for each state. Associations between TBI prevalence, insurance type, and parent rating of insurance adequacy were examined. Data analysis was conducted from February 1, 2016, through November 1, 2017. Main Outcomes and Measures Lifetime estimate of TBI in children, associated childhood health conditions, and parent report of health insurance type and adequacy. Results The lifetime estimate of parent-reported TBI among children was 2.5% (95% CI, 2.3%-2.7%), representing over 1.8 million children nationally. Children with a lifetime history of TBI were more likely to have a variety of health conditions compared with those without a TBI history. Those with the highest prevalence included learning disorders (21.4%; 95% CI, 18.1%-25.2%); attention-deficit/hyperactivity disorder (20.5%; 95% CI, 17.4%-24.0%); speech/language problems (18.6%; 95% CI, 15.8%-21.7%); developmental delay (15.3%; 95% CI, 12.9%-18.1%); bone, joint, or muscle problems (14.2%; 95% CI, 11.6%-17.2%); and anxiety problems (13.2%; 95% CI, 11.0%-16.0%). States with a higher prevalence of childhood TBI were more likely to have a higher proportion of children with private health insurance and higher parent report of adequate insurance. Examples of states with higher prevalence of TBI and higher proportion of private insurance included Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming North Dakota, South Dakota, and Colorado. Conclusions and Relevance A large number of US children have experienced a TBI during childhood. Higher TBI prevalence in states with greater levels of private insurance and insurance adequacy may suggest an underrecognition of TBI among children with less access to care. For more comprehensive monitoring, health care professionals should be aware of the increased risk of associated health conditions among children with TBI.