PM1077: Investigating Disparities in Adherence to Clinical Care Recommendations in a Specialty Care Pediatric Concussion Population

Background: Studies describe socio-demographic disparities in concussion care and recovery; however, little is known about disparities in treatment plan adherence, which could give insight into recovery differences. Our goal was to characterize socio-demographic differences in adherence to care recommendations among a pediatric population in a specialty concussion clinic.

Methods: Patients aged 5-18 years who presented with a concussion to any primary care site of a children’s hospital network from 9/26/2019-12/31/2019 and had at least 1 specialty care follow-up visit in the network were included. We assessed adherence to care recommendations of: (1) aerobic exercise, defined as participation in physical activity; (2) participation in a home exercise program (HEP) of visio-vestibular tasks (both based on provider documentation/interpretation of patient self-report); and (3) attendance at formal vestibular therapy, if referred. Adherence was determined from electronic medical record abstraction using a combination of patient self-report and provider documentation; charts with conflicting or missing adherence documentation were excluded from analysis. Fisher’s exact test was used to compare adherence to care recommendations by race/ethnicity (non-Hispanic (NH) White vs. NH Black), insurance status (private vs. public/self-pay), sex, age ( < 14 years old vs. 14+), and mechanism of injury (sport or recreation-related vs. non-sport or recreation-related).

Results: A total of 140 patients met inclusion criteria; patients with recommendations were further excluded from analyses of aerobic (n=46), HEP (n=19), and vestibular therapy recommendations (n=5) due to incomplete documentation (see table 1 for characteristics of final cohort). Of the recommendations made, NH White patients were significantly more likely to adhere to the HEP than NH Black patients (96.9% vs. 66.7%, p=0.002), and there was a trend toward significant differences between private and publicly insured/self-pay patients (94.5% vs. 80.0%, p = 0.09). Of those referred to formal vestibular therapy, patients with private insurance were significantly more likely to adhere to the referral than patients with public insurance/self-pay (75.0% vs. 47.1%, p=0.04), and there was a trend toward significant differences between NH White patients and NH Black patients (76.1% vs. 46.2%, p=0.08). There were no significant differences in adherence to aerobic exercise recommendations for any of the comparisons, nor among age, sex, or injury mechanism for the HEP or vestibular therapy.

Conclusion: This study highlights disparities in adherence to concussion specialty recommendations with a lower percentage of NH Black patients and patients with public insurance/self-pay following care recommendations for HEP and vestibular therapy. These demographic features often serve as proxies for the socio-cultural constructs that give rise to overall care disparities influencing recovery trajectories among these populations. Future studies should aim to more objectively measure adherence to concussion clinical recommendations and further elucidate what systemic barriers hinder adherence to care, to ultimately work towards equity in both clinical care and outcomes.