Research In Action

Recently, I had the honor of speaking at CHOP’S Department of Pediatrics Summer Grand Rounds Series on “The Healthcare Landscape of Philadelphia.” It gave me an opportunity to reflect on lessons learned from the past year and a half—of dealing with a global pandemic, and how stay-at-home orders impacted access to healthcare, and more generally, how we as clinicians provide care to families across race, ethnicity, and socioeconomic status. Inequities in healthcare, specifically in access to healthcare, have always been present, but the fallout from the pandemic has highlighted to us areas for opportunity and growth. I’d like to share some of these lessons within the field of pediatric concussion, and how we might create more equitable access to concussion care for children in our community.

Current Disparities in Concussion Care

On a national level, previous work has shown that black and Hispanic children are less likely than their non-Hispanic white peers to receive a concussion diagnosis when presenting to emergency departments (EDs) with head trauma, and that black children are more likely to sustain their head injuries due to non-sports related mechanisms.

Here at CHOP, the demographic breakdowns at the locations where our concussion patients seek care is quite disparate. In our ED and at our primary care sites in the city, approximately 70% of concussed youth are black or Hispanic, 50% have public insurance, and 55% sustain their injuries through non-sport related mechanisms.

However, when we look at those patients evaluated for concussion in our specialty sports medicine clinics, we see a very different breakdown: 70% of these patients are non-Hispanic white, 80% possess private insurance, and 75% sustain their injuries through sport-related mechanisms.

Access To Care Impacts Concussion Recovery

These differences matter. Consider the following:

• Earlier access to specialists impacts recovery. We and others have found that, of those who are seen by concussion specialists, the patients whose first visit occurs within 7 days of injury have shorter recovery times.

• Recovery times are different across sex, but modifiable factors may underlie these differences. We have also found that female adolescents have a longer time from injury to first specialist visit and also take longer than males to recover in multiple ways. When controlling time to first specialist visit, several of the recovery differences disappear. 

• Concussion injury mechanism can impact care and recovery. Children who are evaluated with assault-related concussion are significantly less likely (2.8 times less likely) to receive concussion-specific physical examination techniques upon diagnosis, and ultimately have different recovery trajectories (including longer recovery times) when compared with children who sustain their injuries due to sport-related mechanisms.

A Role for Digital Health

While the reasons underlying these differences in care and recovery are likely multifactorial, we think that by improving care access for the concussed youth in our community, we can help remedy some of these disparities.

Particularly promising in this area is the field of digital health. We recently completed a study that used remote digital monitoring via a measurement technique called ecological momentary assessment (EMA) to track concussion patients from the ED. EMA is a measurement approach that allows patients to report their symptoms in real time within their real-life settings, with the potential for increased access by healthcare providers to a patient’s symptoms and activity levels in the days and weeks following a concussion. In a pilot study utilizing EMA to track symptoms and activity from the ED, we found a significant improvement in our ability to ascertain recovery 3 weeks after injury compared with traditional follow-up models. These techniques have the potential to increase our understanding of the detailed symptom trajectories in youth concussion.

With over 1 million concussions diagnosed each year in pediatric patients in our country, we have a lot of work to do to ensure that all children receive equitable and state-of-the-art care. As we learn more about recovery and access patterns, we are very excited about the potential for novel methods of diagnosis and monitoring to ultimately reduce disease burden for the concussed youth in our community.