Postconcussion Academic Support in Children Who Attend a Primary Care Provider Follow-up Visit after Presenting to the Emergency Department.

OBJECTIVE: To examine whether a primary care provider (PCP) follow-up visit after emergency department evaluation of concussion improved the children's likelihood of receiving academic support. STUDY DESIGN: This was a prospective cohort study. Concussed children, aged 8-18 years, presenting to a regional pediatric trauma center emergency department (n = 160) were contacted 7 and 30 days after injury to gather data on PCP follow-up, symptoms, quality of life, and receipt of academic support instituted after and because of the concussion. Bivariate comparisons of demographics, concussion characteristics, quality of life, and symptoms were made between children who did and did not receive support using independent samples t tests, Wilcoxon rank sum tests, or χ2 tests. ORs and 95% CIs were calculated using multivariable logistic regression with backwards elimination to test the association between attending an outpatient follow-up visit and the receipt of academic support for variables where P < .2 in bivariate comparisons. RESULTS: Overall, 51.3% (n = 82) received academic support; of these, 84.2% attended a follow-up visit compared with 71.8% of 78 children who attended a follow-up visit but did not receive support (P = .06). Children who received support were more likely to have commercial insurance; experience a sports-related injury mechanism; have parents whose primary language was English; suffer from learning disabilities and migraines; and be non-Hispanic (P < .05). There was no association between attending a follow-up visit and receipt of academic support (adjusted OR 1.83; 95% CI 0.75-4.45). CONCLUSIONS: Although the majority of children received academic support postconcussion, accommodations were associated with several demographic, medical history, and injury characteristics, but not attending a PCP follow-up visit.

Quality Improvement in Concussion Care: Influence of Guideline-Based Education.

OBJECTIVE: To evaluate the potential impact of a concussion management education program on community-practicing pediatricians. STUDY DESIGN: We prospectively surveyed 210 pediatricians before and 18 months after participation in an evidence-based, concussion education program. Pediatricians were part of a network of 38 clinically integrated practices in metro-Atlanta. Participation was mandatory for at least 1 pediatrician in each practice. We assessed pediatricians' self-reported concussion knowledge, use of guidelines, and comfort level, as well as self-reported referral patterns for computed tomography (CT) and/or emergency department (ED) evaluation of children who sustained concussion. RESULTS: Based on responses from 120 pediatricians participating in the 2 surveys and intervention (response rate, 57.1%), the program had significant positive effects from pre- to postintervention on knowledge of concussions (-0.26 to 0.56 on -3 to +1 scale; P < .001), guideline use (0.73-.06 on 0-6 scale; P < .01), and comfort level in managing concussions (3.76-4.16 on 1-5 scale; P < .01). Posteducation, pediatricians were significantly less likely to self-report referral for CT (1.64-1.07; P < .001) and CT/ED (4.73-3.97; P < .01), but not ED referral alone (3.07-3.09; P = ns). CONCLUSIONS: Adoption of a multifaceted, evidence-based, education program translated into a positive modification of self-reported practice behavior for youth concussion case management. Given the surging demand for community-based youth concussion care, this program can serve as a model for improving the quality of pediatric concussion management.

Pediatric primary care provider practices, knowledge, and attitudes of human immunodeficiency virus screening among adolescents.

OBJECTIVES: To evaluate pediatric primary care provider (PCP) HIV screening practices, knowledge, and attitudes. STUDY DESIGN: Anonymous cross-sectional, internet-based survey of pediatric PCPs from 29 primary care practices. Survey items assessed current HIV screening practices and knowledge, attitudes, and perceived barriers towards screening. Provider demographics and practice characteristics were analyzed for associations with screening through logistic regression. RESULTS: Of 190 PCPs, there were 101 evaluable responses (response rate: 53.2%). PCPs reported a screening rate for HIV of 39.6% ("most" or "all of the time") during routine adolescent visits compared with violence (60.4%), substance abuse (92.1%), and depression (94.1%) (P < .001). Less than 10% of PCPs correctly answered questions related to Centers for Disease Control and Prevention and state HIV screening recommendations. Of 20 potential HIV screening barriers assessed, mean number of reported barriers was 4.8 (SD ± 2.9); with most concerns related to confidentiality, time for counseling, and follow-up. In a multivariable model, the only factor significantly associated with HIV screening "most" or "all of the time" during routine adolescent visits was urban practice site (aOR 9.8, 95% CI 2.9, 32.9). Provider type, sex, years since training, HIV screening guideline knowledge, and endorsing ≤5 barriers were not associated with HIV screening. CONCLUSIONS: Although providers practicing in urban areas were more likely to report screening adolescents for HIV than those in suburban areas, overall self-reported screening rates were low, and several barriers were identified commonly. Future interventions should target increasing providers' knowledge and addressing concerns about confidentiality, requirements and counseling time, and follow-up of results.

Predictors of 30-day readmission and association with primary care follow-up plans.

OBJECTIVE: To test the hypothesis that missing primary care follow-up plans in the discharge summary is associated with higher 30-day readmissions. STUDY DESIGN: This retrospective cohort study included pediatric patients discharged from Mattel Children's Hospital, University of California, Los Angeles between July 2008 and July 2010. Exclusions included deaths, transfers, neonatal discharges, stays under 24 hours, and patients over 18 years of age. Bivariate and propensity weighted multivariate logistic regressions tested relationships between 30-day readmission and patient demographics, illness severity, and documentation of primary care provider (PCP) follow-up plans at discharge. RESULTS: There were 7794 index discharges (representing 5056 unique patients), with 1457 readmissions within 30 days (18.7%). Average length of stay was 6.3 days. Being 15-18 years old, (OR 1.42 [1.02-1.96]), having public insurance (OR 1.48 [1.20-1.83]), or having higher All-Patient Refined Diagnosis-Related Group severity scores (for severity = 4 vs 1, OR 6.88 [4.99-9.49]) was associated with increased odds of 30-day readmission. After adjusting for insurance status, Asian (OR 1.46 [1.01-2.12]) but not Black or Hispanic, race/ethnicity was associated with greater odds of readmission. Fifteen percent of 172 medical records from a randomly selected month in 2010 documented PCP follow-up plans. After adjusting for demographics, length of stay and severity, documenting PCP follow-up plans was associated with significantly increased odds of 30-day readmission (OR 4.52 [1.01-20.31]). CONCLUSION: Readmission rates are complex quality measures, and documenting primary care follow-up may be associated with higher rather than lower 30-day readmissions. Additional studies are needed to understand the inpatient-outpatient transition.