More than three-quarters of children with concussions saw their primary care physician for treatment first, rather than making a trip to the emergency department (ED), according to a large retrospective review.

An analysis of electronic health record (EHR) data at one institution found that, overall, 81.9% (95% CI 81.1%-82.8%) of patients had their first concussion-related healthcare visit within the primary care department while 11.7% (95% CI 11.0%-12.4%) were seen in the ED, reported Kristy B. Arbogast, PhD, of Children's Hospital of Philadelphia (CHOP), and colleagues.

From 2010 to 2014, there was a 13% increase in pediatric patients first seeking concussion treatment within the primary care department (72.4% to 81.7%), with a corresponding 16% decline in these patients first seeking treatment in the ED (15.4% to 13.0%), the authors wrote in JAMA Pediatrics.

Natalie Muth, MD, a pediatrician at Children's Primary Care Medical Group in Vista, Calif., said that these results did not surprise her, as a pediatrician knows the family and child best. A strong relationship with a pediatrician can help increase the likelihood that the family follows the necessary guidelines for return to play and school, she added.



"Most pediatrics offices work hard to have availability for same-day and urgent visits, making the patient's pediatric medical home not only the most cost effective place to seek medical care, but also the most accessible and preferred by patients," Muth told MedPage Today via email.

"The realization that most kids with concussions see their pediatrician first will hopefully help guide further attention and supports to primary care pediatricians to optimally manage these patients," added Muth, who was not involved in the study.

Arbogast's group pointed out the results highlight the "critical importance" of primary care clinicians in concussion care, and signal to healthcare networks that these clinicians are in need of augmented training or increased resources.

"For primary care clinicians, these data provide evidence they can use to advocate for concussion clinical decision support tools in their health care system," they wrote. "Because specialized equipment is not currently needed for diagnosis, primary care clinicians can be well positioned to provide the initial evaluation for most patients with concussion."

They examined data from 8,083 patients, ages 0-17 years, who had one or more in-person clinical visits for concussion at CHOP's network. Concussion visits in the EHRs were defined by ICD-9 codes. The median age of patients was 13 years, and 70.9% were non-Hispanic white.

Age played a role in where a patient's family sought care, with a larger portion of patients 0 to 4 years seeking initial evaluation for concussion in the ED compared with a primary care doctor (51.9% versus 42.9%). By age 5, however, more than 80% of children first went to their primary care physician for concussion treatment.

Race/ethnicity was also a factor, with a little less than half (42.9%) of non-Hispanic black patients seeking treatment via the ED compared with 4.9% of non-Hispanic white patients.

Finally, insurance coverage influenced the pattern of healthcare use, with more Medicaid patients using the ED for concussion care (37%) versus privately insured patients (7%) and self-pay patients (24%).

The authors noted that concussion literature tends to focus on high school students and teenagers, but about one-third of examined patients were younger than 12 years (30.8% were 5-11 years).

"Our findings underscore future research ensuring validated, age-appropriate diagnostic and treatment strategies are available across the entire pediatric age range," they wrote.

Study limitations included the use of data from a single healthcare network's EHR system, so visits outside that network would not be included. Also, children who did not seek care for their concussion were not included in the analysis. Finally, only the initial visit was identified for each patient and the EHR was not set up to separate multiple concussions within the record.

The authors suggested that increased use of EHRs may "provide an opportunity to leverage health records for research into the natural history of concussion that may lead to improvements in ... prevention, diagnosis and management," of concussions.