Improving outcomes and reducing disparities through integrated primary care-specialty care implementation of the CDC Pediatric Mild TBI Guideline

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Mild traumatic brain injury (mTBI) is a common injury in childhood with the potential to have a substantial impact on function in the school and sports setting. Early recognition, followed by up-to-date mTBI care, has been demonstrated to improve outcomes, reducing the incidence of persistent post-concussive symptoms (PPCS). The current best evidence for mTBI care has been brought together in the CDC’s Pediatric mTBI Guideline, poised to be translated into clinical care via rigorous, planned implementation. The Minds Matter Concussion Program at the Children’s Hospital of Philadelphia (CHOP) has demonstrated a track record of positively impacting the care of children with mTBI via the implementation of electronic clinical decision support (eCDS) embedded in the network-wide electronic health record. The goal of this project is to build on that experience to improve the outcomes of children with mTBI and reduce the disparities in those outcomes by translating the current Guideline into standard care. The first aim will be directed at understanding the specific roots of the current disparities in pediatric mTBI outcomes for over 8000 children by examining the Minds Matter Concussion Registry, a census of children seen for mTBI across the CHOP healthcare network. In addition, we will evaluate school outcomes through our partnership with BrainSTEPS, a program administered by the Brain Injury Association of Pennsylvania. In the second aim, through our ongoing successful partnership with the CHOP Primary Care Network, we will implement Guideline-informed eCDS utilizing a validated clinical prediction score (5P risk score) and targeted mTBI physical examination (visio-vestibular examination) in selected urban and suburban primary care practices in a stepped-wedge trial. This effort will quantify the direct impact of the Guideline on improving pediatric mTBI outcomes, including the identification of children at high risk of PPCS in need of referral for specialized care, and by including diverse practices, the effectiveness of the intervention in reducing disparities. As part of the trial design, an urban and suburban primary care practice will also participate in the novel implementation of a mobile health (mHealth) intervention using a smartphone application to perform ecological momentary assessment of symptoms to identify those in the moderate risk category who would benefit from earlier referral. The third aim will investigate and address barriers to accessing specialized mTBI care from alternative points of entry into the healthcare system, namely urban schools and youth club sports organizations by conducting qualitative semi-structured interviews and providing mTBI education to those personnel based on the Guideline. We will implement an innovative telehealth athletic training consultation service line and examine its impact on clinical outcomes and reducing disparities. This project, when completed, in addition to generating new knowledge about outcomes and disparities in pediatric mTBI, will also produce the deliverables of eCDS for clinical implementation of the Guideline, including novel mHealth and telehealth approaches to improving outcomes and reducing disparities in mTBI, impacting the lives of children broadly.