Trajectories of Daily Postconcussion Symptoms in Children.

OBJECTIVES: To identify trajectories of daily postconcussion symptoms (PCS) from the acute postinjury period to symptom resolution among concussed children and examine demographic factors and acute PCS associated with the identified symptom trajectories. SETTING AND PARTICIPANTS: Seventy-nine participants with a concussion were enrolled within 72 hours of injury and completed a daily survey that assessed PCS from enrollment until symptom resolution. DESIGN: This was a prospective cohort study among concussed children aged 11-17 years. MAIN MEASURES: Children rated their concussion symptoms daily using the Post-Concussion Symptom Scale. Symptom duration was assessed using participants' date of symptom resolution and coded as a dichotomous variable: (1) PCS duration 14 days or less or (2) PCS duration longer than 14 days. RESULTS: Of the 79 participants, most were male ( n = 53, 67%), injured during a sporting activity ( n = 67, 85%), or had PCS that persisted for more than 14 days post-injury ( n = 41, 52%). Group-based trajectory modeling yielded 4 trajectory groups: (1) low acute/resolved PCS ( n = 39, 49%), (2) moderate/persistent PCS ( n = 19, 24%), (3) high acute/persistent PCS ( n = 13, 16%), and (4) high acute/resolved PCS ( n = 8, 10%). No significant associations were found between demographic factors and the trajectory group. A higher symptom burden at injury was associated with an increased odds of being in the high acute/resolved or high acute/persistent recovery groups than being in the low acute/resolved group (odds ratio [OR] 1.39, 95% CI = 1.11-1.74; OR = 1.33, 95% CI = 1.11-1.60, respectively), as was a higher symptom severity at injury (OR = 1.09, 95% CI = 1.03-1.15; OR = 1.06, 95% CI = 1.02-1.11, respectively). CONCLUSION: Our findings may help clinicians identify concussed children on slower recovery trajectories, and implement early, individualized treatment plans that foster optimal recovery for concussed children.

Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years.

OBJECTIVE: As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS: This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS: Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION: In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.

Changes in Physician Recommendations for Early Physical Activity After Pediatric Concussion: A Retrospective Study.

OBJECTIVES: This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations. DESIGN: Retrospective observational study. SETTING: Concussion clinics associated with a pediatric hospital. PATIENTS: Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed. INDEPENDENT VARIABLES: The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities). MAIN OUTCOME MEASURES: Physician PA recommendations. RESULTS: From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% ( P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury ( P < 0.05). A significantly increased odds of recommending "light activity" (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and "noncontact PA" (OR = 2.21, 95% CI, 1.28-2.05), compared with "no activity" within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending "light activity" or "noncontact PA." CONCLUSIONS: Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted.

Child Safety Seat‒Use Behavior Among Parents of Newborns: A Trans-Theoretical Model‒Guided Intervention in Shantou, China, 2021.

We evaluated the effect of a trans-theoretical model-based intervention on child safety seat (CSS)‒use behaviors among parents of newborns in Shantou, China. Parents' knowledge, attitude, and self-efficacy scores on CSS use were significantly higher at one, three, and six months after the intervention compared with scores at baseline. Parents' stage of CSS use also advanced as the intervention progressed. The trans-theoretical model‒based intervention and evidence generated from this study may provide guidance for future individualized interventions to improve CSS use. (Am J Public Health. 2023;113(12):1271-1275. https://doi.org/10.2105/AJPH.2023.307415).

Change in health-related quality of life and functional disability over time post-concussion in youth.

PURPOSE: Concussions can have detrimental on children's cognitive, emotional, behavioral, and/or social functioning. We sought to examine changes in health-related quality of life (HRQOL) and functional disability from pre-injury to 1-week post-concussion, and to symptom resolution among youth ages 11-17 with a concussion. METHODS: In this prospective, longitudinal cohort study, 83 concussed youth, ages 11-17, self-reported post-concussion symptoms daily as well as HRQOL and functional disability at baseline (pre-injury, retrospective), 1-week post-concussion, and symptom resolution. We modeled changes in overall and sub-scale HRQOL and functional disability scores over time from pre-injury to 1-week post-concussion and from 1-week post-concussion to symptom resolution using a piecewise linear mixed model, adjusting for potential covariables. Estimated fixed effects with a corresponding adjusted coefficient (beta), along with their 95% confidence intervals are presented. RESULTS: Overall HRQOL worsened from pre-injury to 1-week post-injury (ß = - 5.40, 95%CI - 9.22, - 1.58) but did not change from 1-week post-injury to symptom resolution. Physical HRQOL worsened from pre-injury to 1-week post-injury (ß = - 9.90, 95%CI - 14.65, - 5.14) but improved from 1-week post-injury to symptom resolution (ß = 1.64, 95%CI 0.50, 2.78), while psychosocial HRQOL showed no change over time. Functional disability worsened from pre-injury to 1-week post-injury (ß = 8.36, 95%CI 5.93, 10.79) but with no change from 1-week post-injury to symptom resolution. Youth with symptom duration > 14 days reported worse HRQOL and functional disability than those who recovered in ≤ 14 days and greater daily post-concussion symptom scores were associated with worse HRQOL and functional disability. CONCLUSION: Concussions have a negative impact on overall and physical HRQOL and functional disability in youth acutely post-injury. Ratings of HRQOL could be used to inform clinical treatment decisions to assist with the recovery process.

Direct medical charges of all parties in teen-involved vehicle crashes by culpability.

BACKGROUND: Motor vehicle crashes among teen drivers often involve passengers in the teen's vehicle and occupants of other vehicles, and the full cost burden for all individuals is largely unknown. This analysis estimated direct hospitalisation and emergency department charges for teen-involved crashes by teen culpability, comparing charges for the teen driver, passengers and occupants of other vehicles. METHODS: Probabilistic linkage was performed to link the Iowa police crash reports with Iowa emergency department and Iowa hospital inpatient data. Teen drivers aged 14-17 involved in a crash from 2016 through 2020 were included. Teen culpability was determined through the crash report and examined by teen and crash characteristics. Direct medical charges were estimated from charges through linkage to the Iowa hospital inpatient and the Iowa emergency department databases. RESULTS: Among the 28 062 teen drivers involved in vehicle crashes in Iowa between 2016 and 2020, 62.1% were culpable and 37.9% were not culpable. For all parties involved, the inpatient charges were $20.5 million in culpable crashes and $7.2 million in non-culpable crashes. The emergency department charges were $18.7 million in teen culpable crashes and $6.8 million in teen non-culpable crashes. Of the $20.5 million total inpatient charges in which a teen driver was culpable, charges of $9.5 million (46.3%) were for the injured teen driver and $11.0 million (53.7%) for other involved parties. CONCLUSIONS: Culpable teen-involved crashes lead to higher proportions of injury and higher medical charges, with most of these charges covering other individuals in the crash.

Pediatric Dance-Related Injuries Treated in Emergency Departments in the United States, 2000-2020.

OBJECTIVE: This study investigated the characteristics and trends of children aged 3 to 19 years treated in US emergency departments for dance-related injuries. METHODS: Retrospective analysis of data from the National Electronic Injury Surveillance System from 2000 through 2020 was conducted. RESULTS: An estimated 489,119 children received emergency treatment for a dance-related injury, averaging 23,291 children annually, and the rate of injury increased 68.1% during the 21-year study period. Girls accounted for 80.3% and children aged 15 to 19 years accounted for 46.5% of cases. Sprains/strains were the most frequent diagnosis (44.4%), and lower extremities were the most commonly injured body region (56.4%). Compared with other body regions, patients aged 3 to 10 years were more likely to sustain head/neck injuries (odds ratio, 3.94, 95% confidence interval, 3.42-4.52) than 11- to 19-year-olds. Falls and noncontact mechanisms of injury accounted for 35.6% and 32.1% of injuries, respectively. Unstructured dance activity was associated with 30.8% of dance-related injuries overall and 67.0% among children aged 3 to 5 years. Ballet/pointe dancers frequently sustained lower extremity sprains/strains (39.2%). Compared with other dance types, break dancing was more commonly associated with injuries to an upper extremity than other body regions (odds ratio, 4.76, 95% confidence interval, 3.66-6.19). CONCLUSIONS: The rate of pediatric dance-related injuries treated in US emergency departments is increasing. Unstructured dance activity was an important source of dance-related injury, especially among children aged 3 to 5 years. The injury diagnosis and body region injured varied by child age and type of dance. Additional targeted prevention efforts should be implemented that address the injury characteristics of dancer subgroups.

Risk factors for prolonged recovery from concussion in young patients.

OBJECTIVES: For young patients sustaining concussion, assessing recovery is vital in determining safe return to play. Identifying risk factors may aid clinicians in recognising patients at risk for prolonged recovery. The study objective is to identify risk factors for prolonged (>28 days) and extended (>90 days) recovery (defined as symptom duration) and analyse how these risk factors differ between the two groups. METHODS: We retrospectively analysed electronic health record data (n=4937) among patients aged 10-18 years collected at Nationwide Children's Hospital Sports Medicine concussion clinics between 1 July 2012 and 30 June 2019. Data collected included patient demographics, comorbidities (eg, prior psychiatric diagnoses, prior concussions) and injury characteristics (eg, loss of consciousness, injury setting). We examined patient risk factors for prolonged (>28 days) and/or extended (>90 days) recovery using modified Poisson regression models. RESULTS: Factors associated with increased risk of prolonged recovery from concussion included prior concussions (adjusted risk ratio (ARR) 1.19, 95% CI 1.02 to 1.38) for two concussions (ARR 1.36, 95% CI 1.14 to 1.61), for >3, and higher initial symptom score (ARR 2.57, 95% CI 2.34 to 2.83) for postconcussion symptom (PCS) scores 21-60 (ARR 2.89, 95% CI 2.54 to 3.29), for PCS>60. Risk factors for extended recovery included history of concussion (ARR 1.50, 95% CI 1.09 to 2.06) for two concussions (ARR 1.75, 95% CI 1.17 to 2.62), for >3 and older age (15-18 years, ARR 1.11, 95% CI 1.05 to 1.18). Additionally, comorbid attention deficit hyperactivity disorder increased risk of prolonged recovery (ARR 1.14, 95% CI 1.01 to 1.29) while anxiety increased risk for extended recovery (ARR 1.47, 95% CI 1.10 to 1.95). CONCLUSION: Overall, risk factors for prolonged recovery differ somewhat from risk factors for extended recovery. For patients who present to clinic with concussion, mental health is an important consideration which may impact the timeline for symptom recovery.

Fair Play as an Injury Prevention Intervention: Do Yellow Card Accumulation Policies Reduce High School Soccer Injuries?

OBJECTIVES: Evaluate yellow card policies' (YCPs) effectiveness in reducing competition contact injuries (CCIs). DESIGN: Retrospective cohort. SETTING: High schools. PARTICIPANTS: Soccer players from High School (HS) Reporting Information Online participating schools, 2005/06 to 2017/18. INDEPENDENT VARIABLES: Athlete exposure (AE), CCIs from HS competitions collected from states with/without YCPs. MAIN OUTCOME MEASURES: Rate and rate ratio (RR) of athlete-athlete CCIs recorded by athletic trainers were compared between states with/without YCPs and pre-YCPs/post-YCPs among the states with YCPs using Poisson regressions. Proportions of severe athlete-athlete CCIs were also described in states with/without YCPs. RESULTS: Fifteen states implemented YCPs between 2005/06 and 2017/18; 901 athlete-athlete CCIs occurred during 352 775 competition AEs in states with YCPs, and 3525 injuries during 1 459 708 competition AEs in states without YCPs. There was no significant difference in injury rates between schools in states with/without YCPs (RR 1.07; 95% confidence interval [CI]: 0.97-1.17). Among state with YCPs, injury rates were not significantly different between pre-YCP and post-YCP implementation (RR 1.15; 95% CI: 0.98-1.34). Although a significantly lower proportion of injuries resulting in >3 weeks' time loss (TL) occurred in states with YCPs (injury proportion ratio 0.81; 95% CI: 0.66-0.997), no significant differences were observed in proportions of other severe athlete-athlete CCIs between states with/without YCPs. CONCLUSIONS: Yellow card policies were ineffective in lowering HS soccer athlete-athlete CCI rates, although injuries resulting in >3 weeks' TL were less prevalent in states with YCPs. Implementation of YCPs alone, without proper enforcement, may not be a sufficient injury prevention strategy.

Quantifying Cognitive Workload Using a Non-Contact Magnetocardiography (MCG) Wearable Sensor.

Quantifying cognitive workload, i.e., the level of mental effort put forth by an individual in response to a cognitive task, is relevant for healthcare, training and gaming applications. However, there is currently no technology available that can readily and reliably quantify the cognitive workload of an individual in a real-world environment at a seamless way and affordable price. In this work, we overcome these limitations and demonstrate the feasibility of a magnetocardiography (MCG) sensor to reliably classify high vs. low cognitive workload while being non-contact, fully passive and low-cost, with the potential to have a wearable form factor. The operating principle relies on measuring the naturally emanated magnetic fields from the heart and subsequently analyzing the heart rate variability (HRV) matrix in three time-domain parameters: standard deviation of RR intervals (SDRR); root mean square of successive differences between heartbeats (RMSSD); and mean values of adjacent R-peaks in the cardiac signals (MeanRR). A total of 13 participants were recruited, two of whom were excluded due to low signal quality. The results show that SDRR and RMSSD achieve a 100% success rate in classifying high vs. low cognitive workload, while MeanRR achieves a 91% success rate. Tests for the same individual yield an intra-subject classification accuracy of 100% for all three HRV parameters. Future studies should leverage machine learning and advanced digital signal processing to achieve automated classification of cognitive workload and reliable operation in a natural environment.

Association of Self-Paced Physical and Cognitive Activities Across the First Week Postconcussion With Symptom Resolution in Youth.

OBJECTIVE: To examine the association of objectively measured, self-paced physical and cognitive activities across the first week postconcussion with symptom resolution in youth. SETTING: Emergency department or concussion clinics. PARTICIPANTS: Youth aged 11 to 17 years with physician-confirmed concussion. DESIGN: Prospective cohort with repeated measures. MAIN MEASURES: Days from injury to symptom resolution, based on daily ratings by youth on the Post-Concussive Symptom Scale. Physical and cognitive activities were assessed using an ActiGraph and a Narrative Clip, respectively. RESULTS: A total of 83 youth participants were included (n = 54 [65%] males; mean age = 14.2 years, SD = 1.9). While self-paced daily physical and cognitive activities increased across the first week postinjury, daily postconcussion symptoms decreased. Increased daily step count was associated with an increased likelihood of early symptom resolution (hazard ratio [HR] = 1.17; 95% confidence interval [CI], 1.02-1.34). However, this association was not statistically significant after adjusting for acute postconcussion symptoms and other covariates. Greater school attendance time was associated with earlier symptom resolution (adjusted HR = 1.14; 95% CI, 1.02-1.27). CONCLUSION: Self-paced physical and cognitive activities across the first week postinjury alone neither hastened nor prolonged concussion recovery. Youth with concussion may have some latitude to determine their activity levels.

Influence of insurance type on rate and type of initial concussion-related medical visits among youth.

BACKGROUND: A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth. METHODS: We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children's Hospital's (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses. RESULTS: Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients' average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011). CONCLUSIONS: Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Steering Teens Safe: translation to a workplace wellness program in the USA.

Parent-based teen driving interventions have been shown to increase safe teen driving but few have been translated beyond the research setting. As employers focus more on total worker health, the workplace offers a unique opportunity to implement a safe teen driving program into a workplace wellness program. The aim of this study was to adapt the evidence-based, parent-focused teen safe driving program Steering Teens Safe (STS) into workplace wellness programs, and to evaluate the implementation process and effect on parent-teen communication. The Replicating Effective Programs framework was used to modify STS to fit the workplace setting. The implementation process of the STS workplace wellness program was measured using direct observation and recordings of parent communication trainings while the effectiveness was measured by parent questionnaires. Forty-five parent employees across three businesses participated in the study. STS trainers were skilled in training parents in effective communication, including using open-ended questions and reflections. Parents reported increased success in conversations with their teens regarding safe driving through increased affection, receptivity, trust and equality in conversations. Workplaces may play a key role in assisting parents with teaching their children about safe driving.

Current health status and history of traumatic brain injury among Ohio adults.

INTRODUCTION: Lifetime history of traumatic brain injury (TBI) with loss of consciousness (LOC) is prevalent in 21% of adult, non-institutionalised residents of Ohio. Prior history has been associated with lower incomes, inability to work and disability. The current study sought to evaluate the relationship between lifetime history and adverse health conditions. METHODS: Data came from the 2014 Ohio Behavioral Risk Factors Surveillance System, which included a state-specific module eliciting lifetime history of TBI. RESULTS: Non-institutionalised adults living in Ohio who have had at least one TBI with LOC were more likely to report fair or poor health, more days of poor health, more days when poor health limited activities, being diagnosed with a chronic condition and having less than 7 hours of sleep per night. The relationship with increasing number of TBIs was monotonic, with the likelihood of adverse health increasing as the number increased. A similar relationship was observed for increasing severity of the worst lifetime TBI. Experiencing a first TBI before age 15 was associated with poorer health but was not statistically different than incurring a first after age 15. CONCLUSIONS: Adults who have experienced TBI with LOC in their lifetime are two to three times more likely to experience adverse health conditions when compared with same age-matched, sex-matched and race-matched adults without such history. These findings support re-examining the public health burden of TBI in light of lifetime exposure and not just the consequences of an index injury.

Lifetime History of Traumatic Brain Injury and Behavioral Health Problems in a Population-Based Sample.

OBJECTIVE: To investigate the relationships between indices of lifetime history of traumatic brain injury (TBI) exposure and measures of behavioral health status among Ohioans. PARTICIPANTS: A random sample (n = 6996) of Ohioans contacted to complete the 2014 Ohio Behavioral Risk Factors Surveillance System (BRFSS). DESIGN: A cross-sectional survey. MAIN MEASURES: The Ohio State University TBI Identification Method adapted for BRFSS module and BRFSS behavioral indicators. RESULTS: After demographic adjustment, lifetime history of TBI was found to be associated with increased odds of binge drinking, heavy drinking, smoking, a depressive disorder, or mental health not being good (≥2 days and ≥14 days in last 30 days). Mixed findings across behavioral indicators were observed in regard to number and severity of injury. Age at first injury showed no remarkable associations with the behavioral health indicators. CONCLUSIONS: Ohioans who have sustained at least one TBI with loss of consciousness in their lifetime are at increased risk for poor behavioral health, including alcohol misuse, smoking, and depression. The findings underscore the need for community-based mental health treatment programs to screen for TBI history in their intake evaluations, and to train clinicians on the provisions of accommodations for cognitive and behavioral deficits.

Prevalence of child passenger restraint use in Shantou, China from 2012 to 2017.

BACKGROUND: Child passenger safety is an important public health problem in China. This study aimed to examine the prevalence of child passenger restraint use while riding in a car in the city of Shantou in China from 2012 to 2017. METHODS: Three large-scale cross-sectional observational studies were conducted in 2012, 2015 and 2017, respectively. The observation sites included randomly selected hospitals, kindergartens, and primary and secondary schools. The outcome measures included the changes in percentages of seating position (e.g., front vs. rear), whether sitting on lap, and use of child restraint systems (CRS) or seat belts by year and by age group. Descriptive statistics, Chi-square tests and logistic regression were used to address the study aims. RESULTS: A total of 9858 commuting children aged 17 and younger were observed in passenger cars in Shantou, China during the study. The proportion of children aged 0-5 sitting on adult's lap decreased from 26.6% in 2012 to 24.6% in 2017, while the proportion of CRS use among the children sitting in the rear row increased among children aged 0-5 (from 0.7% in 2012 to 14.2% in 2017) and children aged 6-11 (from 0.7% in 2012 to 2.4% in 2017). Comparing children aged 0-11 in 2012, children in the same ages were less likely to sit in the front row in 2015 (OR = 0.42, 95%CI = 0.37, 0.48) and in 2017 (OR = 0.27, 95%CI = 0.23, 0.31). Children aged 0-11 were more likely to sit in the rear row with CRS use in 2015 (OR = 8.50, 95%CI = 5.44, 13.28) and in 2017 (OR = 10.95, 95%CI = 7.02, 17.08) comparing with children in the same ages in 2012. As for children aged 12-17, they were more likely to use seat belt in 2017 (OR = 1.40, 95%CI = 1.06, 1.85) compared with those children in 2012. CONCLUSIONS: While child passenger safety behaviors improved from 2012 to 2017 in Shantou, China, more efforts are needed to protect child passengers from injuries.

Analyzing the impact of a state concussion law using an autoregressive integrated moving average intervention analysis.

BACKGROUND: Existing studies analyzing the impact of state concussion laws have found an increase in concussion-related medical encounters post-law, in some instances, such increases were observed during the pre-law period due to a potential "spillover" effect. This study assessed the effects of Ohio's concussion law, while accounting for such a "spillover" effect, on the trends in monthly rates of concussion-related medical encounters in Medicaid insured children using autoregressive integrated moving average (ARIMA) analysis. METHODS: We analyzed claim data obtained from the Partners For Kids database, a pediatric accountable care organization in Ohio. Concussion-related medical encounters for Medicaid-insured children (ages 0-18 years) treated between April 1, 2008 to December 31, 2016 were selected and analyzed. We assessed pre- and post-law trends in concussion-related medical encounters using an ARIMA intervention model. We also used traditional regression methods to validate the study results. RESULTS: A total of 16,943 concussion-related medical encounters sustained by 15,545 unique patients were included. Monthly rates of concussion-related medical encounters significantly increased from 4.64 per 10,000 member months during the pre-law period to 6.69 per 10,000 member months in the post-law period (P < 0.0001). Three upward breaks in the monthly rates of concussion-related medical encounters were observed between 2009 and 2016, with two breaks observed during the pre-law period. Specifically, the increased breakpoint observed in July 2011 (P = 0.0186) was significantly associated with an estimated 7.3% increase (95% CI: 1.1-13.7) in the rate of concussion-related medical encounters. This finding was confirmed in the Poisson regression and curve fitting models. Furthermore, a seasonal trend in concussion-related medical encounters was observed with the highest rates in September and October of each year. CONCLUSIONS: Two of the three upward breaks identified in the monthly rate of concussion-related medical encounters occurred before the enactment of Ohio's concussion law, suggesting a potential "spillover" effect. Further research is needed to confirm such an effect in children with other types of medical insurance.

Differences in Postinjury Psychological Symptoms Between Collegiate Athletes With Concussions and Orthopedic Injuries.

OBJECTIVE: To describe the differences in postinjury psychological symptoms among Division I collegiate student athletes who sustained concussions versus orthopedic injures and to examine the effects of injury type on postinjury psychological symptoms during the course of recovery. DESIGN: A prospective cohort study with repeated measures. SETTING: Two Big 10 Conference universities. PARTICIPANTS: Student athletes who were at least 18 years old and participated in one of 9 National Collegiate Athletic Association (NCAA) Division I-sponsored sports during the 2007 to 2011 seasons. MAIN OUTCOME MEASURES: Baseline depressive symptoms and anxiety were measured at enrollment. On identification of an eligible injury, follow-up surveys were conducted among injured athletes at multiple intervals until the injured athlete returned to play. Depressive symptoms, anxiety, fear of return-to-play, and fear of reinjury were measured at the postinjury follow-ups. RESULTS: The concussion group had significantly lower scores of fear of return-to-play (B = -0.94, P = 0.0278) and fear of reinjury (B = -1.11, P = 0.0152) compared with the orthopedic injury group. The concussion group scored higher on depressive symptoms than the orthopedic injury group at 1 month after injury (P = 0.0264), although both groups scored similarly at baseline (P = 0.9729) and at 1 week after injury (P = 0.1475). CONCLUSIONS: Patterns of psychological disturbance differ after concussions and orthopedic injures. Further research is warranted to identify the factors contributing to these differences and to develop effective intervention programs to prevent these symptoms.

Putting Policy Into Practice: School-Level Compliance With and Implementation of State Concussion Laws.

CONTEXT: Each year, approximately 2 million US children 18 years or younger sustain a concussion, a type of mild traumatic brain injury (TBI). Concussions can have detrimental effects on physical, cognitive, emotional, or sleep health. POLICY: Between 2009 and 2014, all 50 US states and Washington, District of Columbia, enacted state concussion laws aimed to increase awareness about concussion and reduce the prevalence and severity of this injury. Most state laws include the following core tenets: (1) immediate removal from play after an actual or suspected concussion; (2) medical clearance before an athlete can return to play (RTP); and (3) concussion education for athletes, parents, and coaches. IMPLEMENTATION: State concussion laws allow for substantial interpretation at the school level, resulting in considerable variation in the content of school written concussion policies and the level of implementation of state law requirements at the school level. EVALUATION: We assessed the degree of high school written concussion policy compliance with the respective state law and examined the relationship between concussion policy compliance and school-level implementation of concussion laws. Seventy-one school officials completed a semistructured telephone interview and submitted their school's written concussion policy. Of the 71 policies analyzed, most complied with the removal-from-play, RTP, and concussion education tenets (90.1%, 97.2%, and 76.1%, respectively). The majority of participants reported that their school implemented the removal-from-play (91.5%), RTP (93.0%), and concussion education (80.6%) tenets well or very well. No significant relationships were found between researcher-rated school policy compliance and school-reported implementation of state law requirements at the school level. DISCUSSION: Our findings suggest that most participating schools complied with their state concussion law and implemented law requirements well or very well. Future studies should identify facilitators and barriers to the implementation of state concussion laws at the school level.

Initial Emergency Department Visit and Follow-Up Care for Concussions among Children with Medicaid.

OBJECTIVE: To describe the rates and patterns of initial emergency department (ED) encounters and follow-up care for concussions among Medicaid-insured children before and after the 2013 enactment of Ohio concussion law. STUDY DESIGN: Using a time-series design, this study analyzed concussion claim data obtained from Partners for Kids, a pediatric accountable-care organization in Ohio. A total of 12 512 concussions and 48 238 associated claims for services between January 1, 2008, and June 30, 2017, with an initial ED encounter among Medicaid-insured children (ages 0-18 years) were analyzed. The effect of the law on the odds of follow-up care were assessed using generalized estimating equations models, adjusted for sex, age group, and residence location. RESULTS: Of the total 12 512 concussions, 63.9% occurred in male patients, 70.1% in patients ages 10-18 years, and 65.2% in patients from urban areas. The rate of initial ED encounters for concussions increased from 2008 to 2014 (2.8 to 4.9 per 10 000 members), followed by a decrease in 2016 (4.2 per 10 000 members). A significant increase in follow-up care after the initial ED encounter was observed from pre-law to post-law (OR 1.73, 95% CI 1.61, 1.86). A shift in follow-up care was observed from radiology and ambulance services in pre-law to primary care providers in post-law. CONCLUSIONS: The Ohio concussion law may have influenced the patterns of initial ED visit and follow-up care for concussions among Medicaid-insured children. Future studies evaluating the impact of the law should analyze the utilization patterns among children with various insurance/payment types.