Initial Emergency Department Visit and Follow-Up Care for Concussions among Children with Medicaid
Tarimala A, Singichetti B, Yi H, Huang L, Doerschuk R, Tiso M, Yang J. J Pediatr. 2019 Mar;206:178-183
Take Home Message: Ohio’s concussion law may have increased the rate of concussion diagnosis and follow-up care among young patients with Medicaid.
Patients need a swift diagnosis and proper care to lessen the potential long-term negative effects of a concussion. Hence, every state passed a concussion law that included 3 main core tenets: 1) immediate removal, 2) written clearance from a health care professional to return to play, and 3) concussion education. These laws have increased the recognition of a concussion; however, it is unclear if these laws impacted the needed follow-up care after a concussion diagnosis. Therefore, the authors aimed to describe the rates of initial emergency department encounters and follow-up care for concussions among children with Medicaid before and after Ohio enacted a concussion law in 2013. The study team analyzed Ohio’s concussion-related claims data from 2008 to 2017, which they obtained from (an organization affiliated with Children’s Hospitals). The authors included patients between the ages of 0 to 18 years who were diagnosed with a concussion (based on ICD9/ICD10 codes) and actively enrolled with Partners for Kids. Patients with co-occurring severe brain injury diagnosis codes or those who had an emergency department visit less than 30 days before the concussion visit were excluded. The authors collected data on 11,813 unique patients, 12,512 unique concussions (36% female), 21,967 total encounters, and 48,238 total medical claims. Patients between 10 to 18 years of age accounted for 70% of concussion-related emergency department visits. Visits post-law increased from 2.8 (2008) to 4.9 (2014) per 10,000 patient-visits, with a slight decline to 4.2 per 10,000 patient-visits in 2016. Nearly 50% of the patients had no follow-up care after an initial emergency department visit. Still, there was greater follow-up rates after the law was enacted (after: 58% vs. before: 44%). Meanwhile, there was less use of radiology and ambulances after the concussion law. Lastly, the authors found that there was no change for claims among sports medicine providers from pre to post-law.
This is an important study because the authors demonstrated the possible impact of Ohio’s concussion law with both initial and follow-up concussion care. The increase in initial concussion visits could be attributed to improved education and better on-field concussion recognition. However, we are unable to say for sure that the law led to this improvement because during this time there was also greater media attention on concussions. The increased media attention could have also resulted in more concussion diagnoses. The increase in follow-up visits is uplifting; however, improvement is needed. It would be interesting to know if these athletes were followed-up and returned to play by athletic trainers or other relevant medical professionals, where this type of follow-up is unlikely listed in the claims data. Furthermore, it would be interesting to know how the law impacted children never sent to the emergency department because they received care from a healthcare professional where the concussion occurred (e.g., athletic trainer). It is also interesting to note that ambulance and radiology claims decreased, which suggests that medical professionals, parents, and coaches started to handle a concussion without an ambulance and understood that traditional imaging studies fail to identify a concussion. Again, we are unable to definitively say that the law led to this change since other factors could have contributed to this change (e.g., new treatment guidelines). Despite the limitations of this study, medical professionals should understand the intricacy of his/her state law since every state’s concussion law is slightly different, and continue to educate athletes, coaches, and parents on concussion recognition and the need for continued follow-up care.
Questions for Discussion: Do you feel your state’s concussion law is helpful? If so, in what way? If not, what are the barriers you are encountering?
Written by: Jane McDevitt
Reviewed by: Jeffrey Driban