Abstract
Objective
To understand pediatricians’ attitudes, knowledge and behaviors about the care of children with complicated mild traumatic brain injury (TBI).
Setting and participants
3500 pediatricians randomly selected from the American Medical Association master file.
Design
Cross-sectional survey
Main measures
Pediatricians were asked about their attitude toward following children with complicated mild TBI for cognitive and behavioral sequelae; their knowledge of TBI sequelae; and, their usual evaluation and management of children following TBI.
Results
There were 576 (16.5%) completed responses. Most pediatricians (51%) see one or two patients with complicated mild TBI annually. Most pediatricians do not think that pediatricians are the correct clinician group who should by primarily responsible for following children with complicated mild TBI for cognitive (74%) or behavioral sequelae (54%). Pediatricians report difficulty referring children for cognitive (56%) and behavioral (48%) specialty services. Pediatricians have good knowledge of short-term complications of complicated mild TBI.
Conclusion
Pediatricians do not think they are the correct clinical group to primarily care for children after hospitalization for complicated mild TBI; yet, other clinicians are frequently not accessible. Pediatricians need educational and referral support to provide surveillance for injury sequelae in this group of children.
Keywords: traumatic brain injury, pediatrics, knowledge attitude beliefs model
Traumatic brain injury (TBI) occurs in approximately 300 per 100,000 children in children under 17 years of age annually.1 Mild TBI is more frequent than severe injury among children, and thus while it has less morbidity than severe TBI, it constitutes a larger population burden of disease. Mild TBI is defined by any period of transient confusion, disorientation, or impaired consciousness; any period of amnesia that lasts < 24 hours; or, loss of consciousness for < 30 minutes; or signs of other neurologic or other neuropsychological dysfunction and a Glasgow Coma Scale (GCS) score of 13-15 as a result of an injury to the head.2,3 Some children with mild TBI have an intracranial abnormality such as an intracranial hemorrhage or contusion and recommended care includes observation or surgical care in the hospital.3,4 Children with mild TBI and intracranial pathology are often sub-classified as complicated mild TBI and have greater risk for worse longer-term health related quality of life and more persistent behavioral and cognitive problems than children with mild injury without an intracranial hemorrhage.5-9
Although children with complicated mild TBI have risk for TBI related physical, cognitive and behavioral issues, they are frequently discharged from hospital without a plan for routine surveillance for the development of these TBI related sequelae. In a retrospective study of insured children hospitalized because of an intracranial injury, approximately half of children 7 years of age and older did not have a pediatric visit in the year after hospital discharge or subspecialty care.10 Slomine and colleagues studied medical needs post hospitalization for TBI among children 5 – 15 years of age. Their study found that in comparison to children with moderate or severe TBI, children hospitalized with mild injury defined as a head Abbreviated Injury Score (AIS) of 2, had greater unmet and unrecognized cognitive, behavioral and physical health care needs.11,12 The AIS classifies severity of injury according to its associated threat to life on an ordinal scale of 1 (minor) to 6 (unsurvivable) for six body regions.13 Generally, head injury refers to any injury to the head region, which may or may not include a brain injury. The head AIS refers to injury to the cranium and the brain (not the scalp or other soft tissue injury). The AIS uses anatomically based descriptors of injury to the intracranial arteries, the nerves, the brain and the cranial bones. A child with a head AIS 2 injury could have a closed skull fracture and less than 15 minutes loss of consciousness while a child with a head AIS of 4 might have an epidural or subdural hematoma. Over half of the children who had sustained a head AIS 2 injury received no health care services related to the injury in the first 3 months after injury and nearly 60 percent did not have any physician visits. This lack of health services is especially concerning as a third of all children hospitalized after TBI in the study had unmet or unrecognized physical, cognitive, or socio-emotional medical needs assessed one year following injury. Medical needs were more prevalent among those children with less severe injury.12 Together these studies suggest that a system for routine surveillance of children after hospitalization for the sequlae of complicated mild TBI would improve the medical care of this group of children.
Pediatricians are well placed to care for children who have been hospitalized with a TBI, but who are not prescribed inpatient or outpatient rehabilitation services on discharge from hospital. Pediatricians are accessible and frequently know the child and family, as well as available medical, school and community resources if children require referral. However, it is not known whether pediatricians have the desire or the knowledge to care for this patient group. We designed and deployed a survey of pediatricians using a knowledge, attitudes and behaviors framework. Our goals were to ask who pediatricians thought should primarily care for children with complicated mild TBI, and to assess their knowledge of short and longer-term outcomes of complicated mild TBI, and their usual practice behaviors in caring for this group of children. Information from primary care pediatricians is important to inform the medical community about how to build a system of care for children with TBI after discharge to home from hospital.
Methods
This research was approved by the University of Utah Institutional Review Board.
Sampling frame
Using the American Medical Association (AMA) Master File, we recruited a national sample of general pediatricians from November 2013 to January 2014. The AMA Master File is considered to be the most inclusive list of practicing physicians in the country as it is neither limited to members of the AMA nor to board certified physicians. We requested a random sample of 3,500 general pediatricians who were between the ages of 30 and 65 years, who had a listed email address, and who were listed as currently in practice.
We used a mixed-mode survey design including postal mail and electronic mail using methods developed by Dillman.14 Pediatricians received a pre-survey letter, then a paper survey with a $2 incentive and a prepaid return envelope. A postal card reminder and a second survey were sent to non-respondents. Non-respondents were offered the opportunity to respond to the survey via the web by electronic mail 3 weeks and 6 weeks after the original mailing, also.
We estimated the number of surveys that we would need to send to achieve a 4-point margin of error using the assumptions of a 20% response rate and 15% ineligible rate of physicians from the Master File. We estimated that we would need to mail 3,500 surveys to achieve a sample size of 594 respondents.
Survey development
The survey was developed to understand pediatricians’ attitudes toward who should care for this group of patients, knowledge about the short and longer-term consequence of complicated mild TBI, and usual practice in caring for this group of children. Survey development was a multi-stage process that included development of knowledge questions that encompassed a review of the literature about complicated mild TBI and cognitive interviews with experts; focus groups with local pediatricians and interviews with national pediatricians to understand their nomenclature, usual practice, and to review the survey; and, finally piloting of the survey to check length and wording.15 In order to develop the knowledge questions, we performed 7 cognitive interviews with experts from neuropsychology (n=2), pediatric physical medicine and rehabilitation (PM&R) (n=3) and pediatric neurology (n=2). Cognitive interviews ask the interviewee to elaborate on the information provided by thinking out loud about the topic and allow additional questions or probes about the basis of their response.16 Experts were recruited via snowball sampling starting with local experts and extending to national experts. Conversations were recorded and then transcribed. Experts were interviewed about the following domains in regard to caring for children after a complicated mild TBI: (1) what should pediatricians know about the consequences of complicated TBI in the short and longer terms; (2) what should pediatricians screen for early after injury and late after injury. Two authors reviewed the transcriptions and grouped the responses by frequency of occurrence among the experts.
We then performed both a focus group (n = 6 participants) and interviews with pediatricians (n = 8) to ask about their general experience in caring for this group of patients using a facilitator guide to insure the survey content had face validity to pediatricians.17 Specifically, pediatricians were asked about their usual practice including how commonly they see children after hospitalization for TBI, how they find out their patient has been hospitalized, how soon and frequently they see children after injury, and the types of formal and informal screens they use to assess children after TBI. Pediatricians were asked also about to whom they refer children with TBI sequelae and barriers to referrals. At the end of the focus group, pediatricians were asked to comment on the survey in terms of content and clarity. The adapted survey was then tested for length and understandability by a small, separate group of pediatricians (n = 5).
Survey content
Demographics
The survey requested information about physician and practice demographics including years in practice, board certification, region (inner city urban, urban, suburban, and rural), type of practice, and percent of practice panel of publicly insured and non-English speaking children patterned from a survey by Lewis.18 To be eligible for the study, pediatricians needed to practicing at least 50% time and to care for general pediatric patients.
Attitudes
Pediatricians’ attitudes toward caring for children with complicated mild TBI were assessed by asking which clinicians or school personnel should primarily be responsible for follow-up care of this group after discharge from the hospital. Pediatricians were specifically asked about follow-up care of learning or behavioral problems. Pediatricians were then asked about their usual referral patterns for children for whom there was a concern about learning problems or behavioral problems.
Knowledge
Pediatricians’ knowledge of complicated mild TBI sequelae was assessed by asking question about three scenarios that differed primarily by time from injury. Abbreviated scenario stems are shown in Figure 1. Possible sequelae were chosen from those most frequently suggested by the experts as important for pediatricians to know and included motor, learning, behavioral, emotional and growth sequelae. Examples of possible sequelae at 3 months post-injury included items such as headaches, clumsiness at sports, tiring quickly, and sleep problems. Examples of possible sequelae one and three years post-injury included items such as depressive symptoms, inattention to details, over reacting to small things, and inability to concentrate at school. Pediatricians were asked to respond using a Likert type scale: strongly agree, agree, unsure, disagree or strongly disagree that symptoms might by related to the child’s complicated mild TBI. Two potential sequelae not suggested by any expert (appetite and heat intolerance) were listed in order to insure true negative responses for survey validity.
Figure 1.
Three scenarios abbreviated from the survey used to assess pediatricians’ knowledge of post-TBI sequelae.
Behaviors
Pediatricians were asked about their usual anticipatory guidance for a child who is discharged to home without rehabilitation from an overnight stay or longer in hospital after a TBI. Anticipatory guidance in pediatrics involves counseling and educating children and parents about potential future concerns. Pediatricians were asked if they always, usually, about half the time, occasionally, or never provided types of anticipatory guidance for children who were symptomatic 2 – 3 days after discharge from the hospital for a TBI.
Statistical analysis
Descriptive statistics were used to examine demographic variables. Chi-squared analysis was used to compare categorical variables and Student’s t-test was used to compare means of continuous variables. Responses to the knowledge questions were grouped into positive (strongly agreed and agreed) or negative (unsure, disagree and strongly disagree). Responses to the anticipatory guidance questions were grouped into always and usually versus half the time, occasionally, or never.
Results
There were 3,500 surveys mailed and 765 responses (21.8%) received of which 167 (4.7%) were ineligible and 22 incomplete. This left 576 (16.5%) completed surveys for analysis. Pediatricians were geographically diverse, represented a variety of practice locations, and were primarily in private practice. Pediatricians’ practice panels were primarily English speaking and approximately 30% publicly insured (Table 1). Pediatricians infrequently encountered children who had been hospitalized after a TBI. Most physicians (51%) estimated that they treated children with an over-night stay in the hospital or longer who did not receive inpatient rehabilitation services and were discharged to home to follow-up with their general pediatrician after TBI in their practice every 6 months to a year, while a smaller number estimated once a month (5%) or every few years to never (44%). Many pediatricians had received no formal training in caring for children with TBI (43%) or had received only a few didactic lectures (50%) about caring for children with TBI.
Table 1. Physician and practice characteristics of 576 respondents.
| Physician demographics | N | % |
|---|---|---|
| Years in practice | Median 17.0 years IQR 10, 25 | |
| Board certified in pediatrics | 552 | 95.8 |
| Practice region | ||
| Northeast | 149 | 25.9 |
| Southeast | 118 | 20.5 |
| Midwest | 117 | 20.3 |
| Southwest | 75 | 13.0 |
| West | 111 | 19.3 |
| Missing | 6 | 1.0 |
| Practice location | ||
| Urban, inner city | 68 | 11.8 |
| Urban, non-inner city | 127 | 22.1 |
| Suburban | 299 | 51.9 |
| Rural | 74 | 12.8 |
| Missing | 8 | 1.4 |
| Practice type | ||
| Private | 425 | 73.8 |
| Health maintenance organization |
31 | 5.4 |
| University affiliated practice | 20 | 3.5 |
| Community clinic | 29 | 5.0 |
| Hospital clinic | 50 | 8.7 |
| Other | 20 | 3.5 |
| Missing | 1 | 0.2 |
| Practice patient characteristics | ||
| Publicly insurance | Median 30% IQR 10, 60 | |
| Non-English speaking | Median 5% IQR 1, 15 |
Attitudes
Pediatricians were asked what group of clinicians should primarily follow children for the development of learning and behavioral problems after a TBI. For learning problems, respondents replied: general pediatricians (36.6%), followed by neuropsychology (21.5%), and pediatric neurology (15.6%). Small percentages of pediatricians felt that this responsibility belonged to the school (5.2%), behavioral medicine (4.5%), developmental pediatrics (3.8%), or physical medicine and rehabilitation (PM&R) (2.1%). When asked to whom they preferred to refer children who appeared to have a learning problem, most pediatricians preferred to refer to neuropsychology (50.2%) followed by developmental pediatrics (14.6%), behavioral medicine (12.7%), or neurology (12.3%). For the 56% of pediatricians who stated that they were not able to refer to their preferred subspecialist, the most frequently identified barriers included that there was too long of a wait (27.4%), the subspecialist was not available (19.6%), and that insurance did not cover the service (15.1%).
When asked about who should monitor children for behavioral problems that might arise following a TBI, the respondents replied: general pediatrics (46.5%), followed by behavioral medicine (26.6%), and neuropsychology (12.7%). Only 1.6% of pediatricians thought that PM&R should follow children for this potential complication. When asked to whom they would prefer to refer children with behavioral issues, pediatricians primarily endorsed behavioral medicine (60.1%), neuropsychology (20.7%), neurology (7.1%), and PM&R (0.7%). Half of pediatricians (51.7%) were able to refer children to their preferred provider. For the remainder of pediatricians, the most frequently cited reasons for not referring to their preferred provider were too long of a wait for an appointment (25.5%), the provider was not available in their area (13.9%) or insurance would not cover the service (13.9%).
Knowledge
Pediatricians were knowledgeable about short-term consequences of complicated mild TBI. Pediatricians recognized that headache, sleep disturbances, problems with fine and large motor control, learning and behavior problems, and fatigue were all possible symptoms that a child might experience 3 months after TBI. Over a third of pediatricians (35.1%) were unsure about whether attention problems might result from the brain injury. Most pediatricians correctly disagreed that heat intolerance was a likely consequence of TBI (Table 2).
Table 2.
Pediatricians knowledge of possible TBI sequelae at 3 months, 15 months, and 3 years following injury.
| Strongly agree, agree |
Strongly disagree, disagree, unsure |
Missing | ||||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Scenario 1: How strongly do you agree or disagree that the following issues are likely to be related to his head injury at 3 months post-injury? | ||||||
| Headaches | 559 | (97.1) | 14 | (2.4) | 3 | (0.5) |
| Difficulty falling asleep | 492 | (85.4) | 78 | (13.5) | 6 | (1.0) |
| Difficulty writing with a pen of pencil at school | 506 | (87.6) | 66 | (11.5) | 4 | (0.7) |
| Difficulty learning new information at school | 536 | (93.1) | 36 | (6.2) | 4 | (0.7) |
| Intolerant of heat | 126 | (21.9) | 444 | (77.1) | 6 | (1.0) |
| Clumsy at sports | 481 | (83.5) | 93 | (16.1) | 2 | (0.4) |
| Tires quickly at school | 442 | (76.7) | 131 | (22.7) | 3 | (0.3) |
| Interrupting or speaking out of turn in conversations | 371 | (64.4) | 202 | (35.1) | 3 | (0.5) |
| More arguments with siblings | 424 | (73.6) | 149 | (25.9) | 3 | (0.5) |
| Scenario 2: How strongly do you agree or disagree that the following issues are likely to be related to his head injury at 15 months post-injury? | ||||||
| Gets more upset than he used to about little things, but gets over it quickly |
327 | (56.8) | 242 | (42.0) | 7 | (1.2) |
| Seizures | 431 | (74.8) | 142 | (24.7) | 3 | (0.5) |
| Poor appetite | 110 | (19.1) | 459 | (76.7) | 7 | (1.2) |
| Teachers say he doesn’t stay on task well | 417 | (72.4) | 155 | (26.9) | 4 | (0.7) |
| Dropped out of team sports | 332 | (57.6) | 238 | (41.3) | 6 | (1.0) |
| Height below expected on his growth chart | 48 | (8.3) | 520 | (90.3) | 8 | (1.4) |
| Grades not as good as last year | 419 | (72.7) | 153 | (26.6) | 4 | (0.7) |
| Fewer friends than last year | 271 | (47.1) | 299 | (51.9) | 6 | (1.0) |
| Needs lots of reminders to complete his homework | 424 | (73.6) | 148 | (25.7) | 4 | (0.7) |
| Intolerant of heat | 75 | (13.0) | 499 | (86.6) | 2 | (0.3) |
| Less energy, seems sad, less interested in activities | 357 | (62.0) | 217 | (37.7) | 2 | (0.3) |
| Scenario 3: How strongly do you agree or disagree that the following issues are likely to be related to his head injury at 3 years post-injury? | ||||||
| Gets more upset than he used to about little things, but gets over it quickly |
306 | (53.1) | 264 | (45.8) | 6 | (1.0) |
| Seizures | 422 | (73.3) | 151 | (26.2) | 3 | (0.5) |
| Poor appetite | 121 | (21.0) | 449 | (78.0) | 6 | (1.0) |
| Teachers say he doesn’t stay on task well | 398 | (69.1) | 174 | (30.2) | 4 | (0.7) |
| Dropped out of team sports | 278 | (48.3) | 292 | (50.7) | 6 | (1.0) |
| Height below expected on his growth chart | 72 | (12.5) | 495 | (85.9) | 9 | (1.6) |
| Grades not as good as last year | 345 | (59.9) | 227 | (39.4) | 4 | (0.7) |
| Fewer friends than last year | 248 | (43.0) | 323 | (56.1) | 5 | (0.9) |
| Needs lots of reminders to complete his homework | 386 | (67.0) | 187 | (32.5) | 3 | (0.5) |
| Seems more anxious | 329 | (57.1) | 244 | (42.4) | 3 | (0.5) |
Many pediatricians were unaware of the longer-term consequences of TBI that required an overnight hospital stay (Table 2). At 15 months post-injury, approximately 40 – 50% of the pediatricians did not agree that emotional lability, depression and social problems (fewer friends and less participation in team sports) could be consequences of complicated mild TBI. Most recognized that children could have problems with attention and seizures. Very few pediatricians at 15 months or 3 years post injury (8.3%, 12.5% respectively) recognized that pituitary dysfunction leading to decreased growth velocity could be a rare consequence of complicated mild TBI.19 At 3 years post-injury many pediatricians were not aware that decreased learning velocity (grades not as good as last year), emotional problems (lability or anxiety), or social problems (fewer friends and less participation in team sports) could be attributed to the TBI.
Behaviors
Pediatricians were asked about their usual practice when assessing a child after an overnight stay or longer in the hospital for complicated mild TBI. Reflecting their knowledge of early TBI consequences, most pediatricians advised parents of a child who was symptomatic after discharge from hospital to tell the school about the child’s injury, advised gradual return to school with no physical education (PE) and no contact sports. Most pediatricians reported counseling parents about potential learning and behavioral problems. About 80% of pediatricians stated that they scheduled a follow-up visit in one month as opposed to telling parents to return only if the child remained symptomatic (Table 3).
Table 3.
Pediatricians’ usual practice during a follow-up visit 2 – 3 days after discharge from hospital for TBI
| Usually or always | Half time, occasionally, never |
Missing | ||||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| Tell school that child had a head injury | 553 | (96.0) | 18 | (3.1) | 5 | (0.9) |
| Advise gradual return to school | 534 | (92.7) | 37 | (6.4) | 5 | (0.9) |
| Advise no physical education | 559 | (97.1) | 13 | (2.3) | 4 | (0.7) |
| Advise no contact sports | 569 | (98.8) | 4 | (0.7) | 3 | (0.5) |
| Advise the family about potential learning problems |
436 | (75.7) | 136 | (23.6) | 4 | (0.7) |
| Advise the family about potential behavioral problems |
399 | (69.3) | 171 | (29.7) | 6 | (1.0) |
| Schedule a follow-up visit in 1 month | 462 | (80.2) | 108 | (18.8) | 6 | (1.0) |
| Schedule a follow-up visit in one month only if child still symptomatic |
190 | (33.0) | 375 | (65.1) | 11 | (1.9) |
Discussion
Children with complicated mild TBI are a group at risk for unmet and unrecognized physical, behavioral and cognitive health care needs, yet they do routinely receive medical care after discharge from hospital.10,12 We wanted to understand pediatricians’ attitudes, knowledge and behaviors in caring for children with complicated mild TBI children in order to decide whether efforts to improve detection and treatment of post-TBI sequelae should be concentrated on referring children back to their pediatrician after their hospital stay or whether children should be referred to an alternate clinician type or program.
We found that less than half of pediatricians feel that they should be primarily responsible for following children who have a complicated mild TBI for learning and behavioral problems. These findings concur with a Pennsylvania state survey examining pediatric practice.20 The Pennsylvania study showed that most pediatricians (89%) identify themselves as the correct physician group to provide follow-up for children with mild TBI; however; fewer pediatricians (61%) felt that they were the correct group to care for children who had sustained a loss of consciousness with the mild TBI.
Pediatricians’ knowledge about complicated mild TBI differed by whether they were asked about early or late effects of complicated mild TBI. Pediatricians tended to recognize the consequences of complicated mild TBI that overlap with concussion symptoms. Pediatricians’ knowledge of these complicated mild TBI sequelae may reflect the success of the concussion educational campaigns by the Centers for Disease Control and the American Academy of Pediatrics.21,22 In further support of this, pediatricians report following these guidelines in counseling families and children about avoiding sport and physical education early after a complicated mild TBI, following recommendations for cognitive rest and gradual return to sports, and are proactive about follow-up of symptomatic children.
Pediatricians were less well informed about the potential longer-term learning and behavioral consequences of complicated mild TBI. Specifically, pediatricians may not recognize that as the expectations for higher-level problem solving, behavior regulation, and self-monitoring increase with age, children with complicated mild TBI may experience more challenges in school. Knowledge of social, behavioral, emotional and learning problems that may not be recognized until one or two years after injury is important because they may go unrecognized by parents. Parents may assume that children’s social or school problems are transient developmental issues and not injury sequelae that need to be addressed.
When pediatricians do recognize learning and behavioral problems as a consequence of complicated mild TBI, they have difficulty in referring children for evaluation and treatment secondary to clinician availability and lack of insurance coverage. These are barriers that have been previously recognized as impeding the management of other pediatric psychosocial problems.23 Interestingly, only 1 to 2% of pediatricians recognized pediatric PM&R physicians as a resource in caring for children with complicated mild TBI. This may be because pediatric PM&R is a recent subspecialty and there are large regional variations in the availability of pediatric PM&R physicians.24,25 The availability of PM&R physicians who specialize in caring for children with TBI may also vary by region.
Who then should care for this of group of children when they return to the community? We would suggest that in many areas of the country pediatricians are the only viable clinical option to care for these children in the community. Many families cannot return to a tertiary care center due to distance, and other clinicians such as pediatric neuropsychology and psychology are frequently unavailable in the community or not covered through insurance plans. Schools frequently do not have the resources to recognize and treat children with severe TBI making it less likely that children with complicated mild TBI will receive services.26
While in this survey, many pediatricians reported that following children with complicated mild TBI for the development of behavioral and cognitive problems was not within their scope of practice, general pediatricians do screen uninjured children for both learning and behavioral health problems.27 In a recent survey, approximately 75% of general pediatricians who exclusively practice general pediatrics reported managing or co-managing children for ADHD, depression, anxiety, and behavioral management problems.28 However, pediatricians need support to care for children with complicated mild TBI as a child with complicated mild TBI is a low frequency event for any single pediatrician.
We suggest a multi-pronged approach to insure surveillance of children discharged from the hospital after a complicated mild TBI. This approach could be delivered through the trauma system and would need to include both education of parents and pediatricians. Parents need education about possible complicated mild TBI sequelae and provision of an appointment to their pediatrician or primary care physician at the time of discharge. A recent study of parent ability to recognize concussion symptoms after receiving verbal and written instructions in the emergency department showed that most parents were unable to identify concussion symptoms in their children.29 This suggests that more robust discharge education is necessary. Prior work has shown that making an appointment for parents at the time of discharge increases family attendance at follow-up visits.30 Pediatricians need to be supported in their care of this group of children with ‘just in time’ education. Just in time education provides education tailored to the individual needs of the clinician in a timely manner and could be delivered via links to evidenced based medicine through the electronic medical record or in the child’s hospital discharge packet.31 Finally, pediatricians need to be able to refer children who are having cognitive or behavioral sequelae. Telehealth has been shown to improve access to needed psychological resources in other settings, and is a possible way of making behavioral.32,33 If pediatricians and parents are able to recognize later symptoms of complicated mild TBI, they may be able to better advocate for services for children within the school system.
This survey should be viewed in light of its limitations. Similar to many surveys of physicians, the response rate was low although we implemented most suggested methods of increasing response rates.34 This low response rate limits generalizability. If physicians interested in TBI were more likely to respond than those who were not interested, then we likely overestimate pediatricians’ knowledge. Our group of respondent pediatricians was more likely to be suburban, private practice physicians with a lower percent of publicly insured patients compared to the 2014 AAP Periodic Survey of Fellows.35 This comparison would suggest that the respondent group may have more access to resources for their patients than some others. Finally, pediatricians self-reported their practice patterns. It is possible that pediatricians systematically reported desirable behavior as opposed to actual behavior; however, as this survey was anonymous there was no incentive to do so.
Conclusion
Pediatricians do not believe that they are the appropriate physician group to provide surveillance of children with complicated mild TBI for the development of potential learning and behavioral sequelae. However, there is a paucity of other clinician types such as PM&R, behavioral health, and neuropsychology in the community to provide surveillance. Trauma systems should develop supports for pediatricians and families to insure that children with complicated TBI receive surveillance for TBI related cognitive and behavioral sequelae of injury.
Supplementary Material
Acknowledgments
Funding Source: This project was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development under award number K24HD072984. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funder had no involvement in the study design, collection, analysis or interpretation of the data, or the decision to submit the manuscript for publication.
Footnotes
Conflicts of Interest: No author has a conflict of interest to declare.
Contributor Information
Heather T. Keenan, Department of Pediatrics, University of Utah, P.O. Box 581289, Salt Lake City, Utah 84158, phone: 801.587.7611 FAX: 801.581.8686 heather.keenan@hsc.utah.edu.
Susan L. Bratton, Department of Pediatrics, University of Utah.
Rebecca R. Dixon, Department of Pediatrics, University of Utah.
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