'Stunning' Lack of Follow-up Care for Concussion Patients

Pauline Anderson

June 07, 2018

Less than half of patients with mild traumatic brain injury (mTBI) receive related educational material at hospital discharge or see a medical practitioner within 3 months of their injury, new research shows.

The percentage of patients seeing a health professional in the weeks after an injury increases only slightly among those with more severe injuries and psychological distress.

The analysis also uncovered wide disparities in follow-up care for mTBI patients at recognized academic centers of excellence.

"Even in these settings, we find that there's no consistent pattern of care after the injury," author Étienne Gaudette, PhD, a researcher at the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, told Medscape Medical News.

One of the problems may lie in labeling the injury "mild," he added.

Longitudinal Study

Researchers used data from Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI), an ongoing, prospective, longitudinal observational study of patients with TBI who present to the emergency department of 1 of 11 level 1 US trauma centers.

The study focused on mTBI, so in addition to having an acute head trauma necessitating CT, study participants had to have a Glasgow Coma Scale (GCS) score of 13 to 15, loss of consciousness for less than 30 minutes, and posttraumatic amnesia lasting less than 24 hours.

Study participants were surveyed at 2 weeks and 3 months. They were asked whether they received TBI educational materials at hospital discharge and whether they had seen a healthcare practitioner since discharge and, if so, which type of practitioner.

At 3 months, they were also assessed with the Rivermead Post Concussion Questionnaire (RPQ), which measures severity of headaches, dizziness, nausea, cognitive problems, mood, and sleep disturbances, and the Brief Symptom Inventory-18 (BSI-18), which measures depression, anxiety, and somatization symptoms.

The analysis included 831 TRACK-TBI patients aged 17 years or older who completed follow-up at both 2 weeks and 3 months. About 35% of the sample was female, and 58% was non-Hispanic white; the mean age was 40.3 years.

Results showed that only 42% of participants received TBI educational material at discharge, 27% had a follow-up call from the hospital by 2 weeks, 41% had seen a practitioner by 2 weeks, and 44% had seen a practitioner by 3 months.

Follow-up care varied widely among the different sites. The rate of receiving educational material at discharge (adjusted for patient characteristics) ranged from 19% to 72% and the adjusted rate of having seen a practitioner at 3 months after injury ranged from 22% to 58%.

The sites with specialty TBI clinics had the highest rates for both receiving educational materials and seeing a practitioner.

Of patients who indicated they had seen a medical practitioner and revealed the type of practitioner, most (52%) reported seeing a general practitioner while 38% saw a neurologist.

Influence of Injury Severity

Injury severity was associated with receiving follow-up care. For example, compared with a GCS score of 15, a score of 13 or 14 was associated with a greater likelihood of seeing a medical practitioner (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.10 - 2.58).

Compared to no lesion on head CT, a scan consistent with TBI was also associated with greater likelihood of seeing a practitioner (OR, 2.95; 95% CI, 1.90 - 4.60).

Certain patient characteristics were also associated with follow-up care. Women were more likely than men, and non-Hispanic whites more likely than other racial groups, to have seen a practitioner by 3 months.

At 3 months after injury, 34% of patients had three or more moderate or severe postconcussive symptoms on the RPQ. But such patients were only somewhat more likely to receive follow-up care: Only 52% reported having seen a practitioner. Gaudette described this result as "troubling."

Similarly, for the 17% with BSI-18 scores meeting the definition of psychological distress, less than half (47%) had seen a practitioner by 3 months.

Gaudette believes the gaps in care for patients with mTBI may in part be influenced by the term "mild."

"It's only mild relative to a more severe brain injury. In reality, it's not mild; a lot of these patients will get postconcussive symptoms a long time after their injury."

Systemic Problems

Patient income and insurance status were not associated with receipt of follow-up care, which Gaudette found surprising.

"We expected people who were poorer and didn't have private insurance to get worse care, but we found that it's actually not even those factors that prevent people from getting care."

Instead, Gaudette pointed to "systemic problems," such as lack of clear guidelines on appropriate management of patients with mTBI after discharge.

"We need more research into what are the best patterns of care to treat patients, and we need to establish guidelines that will be followed by these trauma centers," he said.

Meanwhile, although patients with mTBI who have symptoms should seek medical attention, trauma centers, too, should take some responsibility for follow-up care, said Gaudette.

"A large number of patients don't receive educational materials on discharge; the onus can't be on patients if they aren't properly prepped for what's to come."

The relatively small number of study sites and the fact that they were all university-affiliated level 1 trauma centers may limit the generalizability of the results.

Also, follow-up care and receipt of educational materials were self-reported, and patients with concussion and memory problems might have had trouble accurately recalling details.

"Stunning" Finding

The study reveals a "stunning" lack of follow-up care for patients with mTBI, Mary Iaccarino, MD, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, Boston, writes in an accompanying editorial.

In an interview with Medscape Medical News, Iaccarino said that while in many cases, concussions have a "natural history" and many people fully recover, a growing number, for whatever reason, don't.

"We're recognizing that there's a growing number of people with persistent symptoms," with estimates of that number ranging from 10% to 40%, depending on what groups are examined, said Iaccarino.

She noted that the study cohort potentially had more severe mTBI because the injury was considered severe enough to warrant not only a trip to the emergency department but also a CT scan.

There has been had a "real shift" in the type of education that patients with mTBI receive. Whereas they used to be told to rest until they felt better, now they're urged to get back to their usual daily activity after just a few days, even if they have some symptoms.

"A lot of people aren't getting that message," said Iaccarino. "It's a message that needs to be clarified at a follow-up visit."

Resting too long may actually make a patient feel worse, said Iaccarino. "There is this sweet spot of activity level and that follow-up visit really guides that."

In her editorial, Iaccarino notes some study limitations, including the heterogeneity of the sites, lack of multiyear longitudinal follow-up, and the small sample size.

"Thus, the benefits of follow-up care and education on outcomes can only be inferred," she writes.

Another limitation, she said, is lack of cost data. She said such information is important, not just the costs to the healthcare system but also to patients themselves. Gaudette said his team is investigating economic costs of treating patients with mTBI.

Gaudette and Iaccarino have disclosed no relevant financial relationships.

JAMA Network Open. Published online May 25, 2018. Full text, Editorial

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