Bridging the gap in paediatric concussion management

Concussion can be devastating; among children and adolescents it is a silent epidemic and a serious public health concern. Recognizing the impact of concussion, stakeholder organizations have committed resources to develop educational supports regarding appropriate care in the form of clinical practice guidelines and position statements. The purpose of these documents, which include the Ontario Neurotrauma Foundation’s recently released Guidelines for Diagnosing and Managing Pediatric Concussion (1), and the Canadian Paediatric Society’s position statement on sport-related concussion (2), is to clarify and standardize recommendations for the clinical management of concussion based on empirical evidence. Practice guidelines have the ability to educate and influence health care providers, as well as to inform consumers about the care they should receive for a particular health problem (3). They have been demonstrated to improve health care providers’ decision-making, as well as consistency of care. It is also believed that practice guidelines demonstrate the commitment of the health care system to providing quality care, and may even improve efficiency of care (3), all of which can lead to improved patient health outcomes. However, while practice guidelines can be beneficial, they also have important limitations that should be recognized. Despite the increasing number of practice guidelines for concussion management, practice variations continue to exist for several reasons. To begin to address this issue, we advocate for a multimethod approach for physician education to optimize learning and, thereby, improve clinical practice and patient health outcomes. Wide practice variation exists in the management of concussion, bringing into question physicians’ knowledge of concussion management recommendations, and causing concern for premature return to play and learn in paediatric populations. A study from the Children’s Hospital of Philadelphia (Pennsylvania, USA) determined that the majority of paediatric primary care providers (PCPs) were aware of cognitive rest as part of concussion management; however, only 2% were able to translate that knowledge to clinical practice (4). Moreover, a study involving American Academy of Pediatrics’ Emergency Medicine Section members revealed that 53% of respondents were not comfortable counselling patients and their families about concussion sequelae and return to play instructions (5). Zonfrillo et al (6) similarly demonstrated that PCPs tended to refer concussion patients because they were not comfortable with management. They also found that 6% to 17% of respondents did not identify a variety of more subtle signs as being related to concussion. Studies have also brought to light the inconsistent use of concussion management recommendations. A survey of 115 Canadian paediatric emergency medicine (EM) physicians’ knowledge of concussion management showed wide practice variation for cognitive rest recommendations. Importantly, 35% of respondents did not recommend reduction of time in front of a screen and 63% did not recommend complete cognitive rest (7). An Ontario survey of paediatric PCP’s concussion management practices showed that both return to play and learn recommendations were insufficient, with only 37% and 53% of respondents correctly applying the graduated guidelines, respectively (8). Another survey examining the concussion management practices of PCPs in Ontario, similarly found that the participants did not consistently recommend physical or cognitive rest (9). In their retrospective chart review of sport-related concussions, Carson et al (10) found that patients returned to play prematurely in 43.5% of cases and returned to school prematurely in 44.7% of cases. A survey of 809 Canadian paediatricians also indicated some practice variation, including 16% of patients being returned to activity immediately and 21% after >14 days of rest (11). Clinical practice guidelines are useful for clarifying appropriate practice when knowledge of management practices for a particular health problem, such as concussion, is lacking; however, other important barriers to consider pertain to the dissemination and adoption of practice guidelines. Practice variation may also be attributed to physicians’ lack of awareness and use of available resources. Christakis and Rivara (12) found that only 16% to 66% of paediatricians were aware of four different widely publicized and distributed clinical practice guidelines on various paediatric health problems. Of those who were aware of the practice guidelines, only 19% to 28% reported changing their practice behaviour. Practice guidelines and position statements have become a popular strategy for researchers and health care providers to move available knowledge into active use for concussion management. However, Stoller et al (9) determined that 49% of family physicians, 52% of EM physicians and 27% of paediatricians were unaware of the consensus statements on concussion published by the Concussion in Sport Group. Similarly, Lebrun et al (13) revealed that only 9.4% of United States physicians who participated in their study reported using the most recent consensus statement on concussion for diagnosis and management. Mercuri et al (14) recently proposed that factors such as patient context may lead to physicians’ intentional deviation from clinical practice guideline recommendations. Their study revealed that when a contextual factor relating to patients’ social history (eg, living situation, parental anxiety) was present in a clinical scenario, both expert and novice EM physicians were less likely to adhere to the practice guideline recommendations than when one was not present (56% and 67% versus 80% and 79%, respectively). They also found that a physician’s decision to deviate from practice guidelines may depend on their level of experience; expert EM physicians were more likely to deviate from practice guideline recommendations than novice physicians when a contextual variable was present (14). These findings support the argument that multiple factors can influence physicians’ adherence to practice guidelines beyond those of knowledge and awareness, and that educational initiatives are required in combination with the dissemination of practice guidelines to effectively educate physicians and change practice. Knowledge translation experts have questioned the effectiveness of solely relying on clinical practice guidelines and position statements to educate physicians. Grimshaw et al (15) demonstrated that printed educational materials are limited in their standalone effectiveness for changing practice behaviours. Researchers have also recognized the role that the quality of the resources may play in practice variations, especially when the rigour of development has been compromised. Woolf et al (3) proposed that recommendations presented in practice guidelines may potentially be inaccurate for a multitude of reasons (eg, findings misinterpreted, use of poorly designed studies, use of outdated recommendations). The authors further argued that recommendations can be influenced by the experiences and opinions of development group members, and that patient needs may not always be the only factor considered when making recommendations (eg, cost, societal needs) (3). Flaws in the development of practice guidelines (known or unknown) can compromise their rigour and quality, and lead to harm for patients, health care providers and the health care system (3), therefore, underlining the significance of following rigourous practice guideline development processes, such as the Practice Guidelines Evaluation and Adaptation Cycle (16), and implementing continuous updates. Recognizing the importance of proper concussion management practices, we advocate for a multimethod approach for physician education to optimize learning. The growing evidence base demonstrating both a knowledge and practice gap in concussion management has led to calls for educational and training opportunities for physicians that are specific to the management of concussion (13). When planning educational strategies to affect change, there are several critical factors to consider, including the type of strategy, the target group(s) and the intervention(s) to be used. Dissemination and implementation strategies, as defined by Grimshaw and Russell (17), each carry a targeted purpose. Educational strategies for dissemination target awareness, knowledge and attitudes toward clinical practice guideline recommendations, while implementation strategies seek practice change by improving adherence to recommendations. The distinct difference between these two types of educational strategies is that one is primarily informational while the other is action oriented. Recognizing that the effectiveness of educational interventions can vary according to provider type, it is important to consider physicians’ learning styles and determine which educational interventions can best impact their knowledge and practice behaviours. The literature also shows that standalone interventions are limited in their effectiveness for initiating practice change, and that educational strategies are more effective when they involve two or more interventions (18). As organizations explore various ways to disseminate their clinical practice guidelines, sufficient time and resources must be allocated for planning and up-taking implementation strategies in conjunction with dissemination strategies. The above-discussed difficulties with practice guidelines highlight that physicians need opportunities to practice using and incorporating them into their everyday practice. Ideally, these practice opportunities should closely mirror realistic clinical situations and can include role-playing, patient simulators and discussions of clinical case examples (19). Such interventions are well suited to physicians’ learning styles and can increase the rate of use of practice guidelines for concussion and their recommendations (18,19). These interactive interventions would offer physicians opportunities to critically evaluate the practice guidelines and apply the recommendations among peers before widespread use with patients. Pham and Zemek’s (20) practice article provides an example of how clinical case examples can be used for this exact purpose. These interventions would also enable the intersection of research evidence, varying clinical situations and patient contextual factors (14). Finally, active participation in educational interventions for concussion management would promote further research to determine the effectiveness of these educational interventions, and how the consideration of patient contextual factors influences adherence to practice guidelines for concussion and impacts patient health outcomes. Concussion is a major health concern in the paediatric population. The present article represents a starting point for improving knowledge acquisition and practice changes in regard to concussion management. It also stimulates questions on how a multimethod approach to physician learning can be used as a mechanism for improving knowledge, clinical practice and patient health outcomes in this area.

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