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| Journal of the New Zealand Medical Association,
31-March-2006, Vol 119 No 1231
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An analysis of referees and referrals to a specialist
concussion clinic in New Zealand
Deborah Snell, Lois Surgenor
Mild traumatic brain injury (MTBI) is a common injury with
diverse patterns of physical, cognitive, and psychosocial disability; MTBI
accounts for 70–90% of traumatic brain injuries presenting to hospitals
and outpatient clinics.1–3 While recovery from MTBI is mostly uneventful,
it has been consistently demonstrated that a minority of MTBI patients
experience long-term symptoms and disability.4–6 The reasons are not fully
understood and may relate to multiple physiological and psychological factors,
with compensation and litigation issues consistently highlighted as being
associated with poorer outcomes.1,7–9
Whether early intervention makes any difference to outcome
has been debatable, with only equivocal empirical support evident for early
intervention models of rehabilitation.4 Nevertheless, early limited educational
intervention, reassurance, and support regarding symptom management; and
guidance regarding resumption of pre-injury roles; is
beneficial.4,5,8–11
The Burwood Hospital Concussion Clinic is a new service
initiated on a background of uncertainty regarding the benefits of early and
time-limited rehabilitation in the MTBI group. Accordingly, we aimed to more
closely examine the characteristics of cases referred, their subsequent
management, and their crude outcomes.
As patient non-attendance results in significant costs in
terms of administrative and clinical time,12–14 frequency and
characteristics of non attendance to initial appointments were reviewed to
identify any variables that may improve management of non-attendance issues.
Likewise, the Clinic is aware that some cases have required longer follow-up
than planned for in the service specifications, which emphasise short-term
intervention.
Accordingly, this study also sought to investigate the
demographic and clinical characteristics of cases remaining on the caseload
longer than 7 months after initial assessment.
MethodsPatients—Responding
to the high incidence and prevalence rates of MTBI (and the related costs of
rehabilitation in New Zealand), Accident Compensation Corporation (ACC) recently
invited tenders for services for provision of time-limited assessment and
interdisciplinary intervention for MTBI.
The Burwood Concussion Clinic obtained ACC funding and
‘went live’ in November 2001. Referrals are accepted directly from
the local hospital emergency department, primary health care providers (e.g.,
General Practitioners), ACC Case Managers, and other approved sources such as
neurological services.
Following an initial triage, patients are generally
accepted into the Clinic if they are aged 16 years or over and have suffered
from a MTBI within the last 6 to 12 months. Acceptance decisions are based on
diagnostic indicators that include period of loss of consciousness for less than
30 minutes; Glasgow Coma Scale (15) score of ≥13, and 15 within 6 hours of
injury; post-traumatic amnesia for less than 24 hours; and no past history of
severe traumatic brain injury (TBI).3,16–18
Despite being the practice of some services, patients
are not necessarily excluded from the Clinic when there is evidence of
intracranial complications.11,19 Consistent with studies reporting on MTBI
symptoms,3,11,20 Table 1 outlines common presenting symptoms of MTBI in our
patient group.
Table 1. Common presenting symptoms of mild traumatic
brain injury (MTBI)
During the course of assessment and rehabilitation,
patients may be seen by a range of rehabilitation disciplines depending on their
assessed needs. The clinic aims to complete assessments and initiate
rehabilitation (where indicated) within 3 to 6 weeks post-injury. Intervention
any earlier following injury is not considered useful given that the literature
has consistently indicated that a high proportion of MTBI cases demonstrate
spontaneous recovery during the first few weeks.1,7,8
Data
collection—All files (n=357) generated by the Concussion Clinic in
the 2-year period ending in October 2004 were manually reviewed to gather data
on source of referral; age and gender of case; cause of MTBI; time delay between
MTBI and first clinic contact; type and number of assessments and treatments
conducted by the clinic; time period of clinic follow-up; and estimated outcome
of the MTBI at point of discharge.
Long-term cases were categorised as patients requiring
follow-up for longer than 7 months. This category was chosen as it represented
the top quartile of the four follow-up time categories. Outcome was categorised
as “good” if the MTBI symptoms had resolved and the patient was
deemed to have returned to premorbid functioning; a “fair” outcome
was defined as remaining symptomatic but having resumed pre-injury roles such as
employment; while “poor” outcome was defined as persisting
post-concussion symptoms and failure to resume pre-injury roles at time of
discharge from the clinic.
A further outcome category (“undetermined”)
was defined as those referred on to other agencies (e.g. psychiatric services)
for significant clinical problems interfering with rehabilitation (e.g.
depression). Of those referrals that never resulted in an initial assessment,
the reasons for this were categorised as either patient or referrer cancelling
the referral, or ‘did not arrive’ (DNA).
Ethical clearance and approval from the relevant
organisations was obtained prior to undertaking the audit.
Statistical
analysis—The association between continuous and categorical
variables was analysed using correlation, ANOVA, independent sample t-tests and
Chi-squared respectively. Logistic regression (‘Enter’) was
performed on statistically significant univariate variables to estimate the
independent contribution to risk of DNA and risk of being a long-term case. An
alpha level of 0.05 was used on all tests.
ResultsTables 2, 3, and 4 (in the PDF version)
summarise the demographic and clinical features of cases referred to the
Concussion Clinic. The mean age of people referred was 33.8 years (SD=13.8),
with a slightly higher frequency (57%) of males.
MTBI
cause was significantly associated with gender (χ2=20.5, df=7,
p=0.005) and age (F [7–342]=6.2, p=0.000). In particular, females were
significantly under-represented in those presenting with assault-related MTBIs,
whereas those presenting with fall-related MTBIs were significantly older
(M=41.9; SD=15.2 years) than all other categories apart from those with
work-related, medically-related, and other miscellaneous causes.
Excluding those patients whose referral was cancelled
(n=27), 10% of booked-in cases did not attend (DNA) the initial assessment
appointment. Age (t [45.6]=3.4,
p=0.002) and source of
referral (χ2=15.6, df=5, p=0.008) were significantly associated with
DNA. In particular, those not turning up were significantly younger (M=28.4
years, SD=8.7) than those who did (M=34.5, SD=14.1).
The Emergency Department at Christchurch Hospital was the
referring service with the largest percentage (19.5%) of DNAs, which was at
least twice the rate of any other service (see Table 4). Logistic regression
(‘Enter’) determined that both age and referral source remained
significant independent contributors to risk of DNA.
Forty-five percent of the 300 patients were seen for a
one-off assessment appointment; almost all (99%) of these assessments were
conducted by a specialist medical practitioner in neuropsychiatry or
rehabilitation medicine. However, more typically (56%), the assessments also
involved other health practitioners (number of assessing practitioners M=2.1,
SD=1.1), with neuropsychology being the most likely second discipline involved
(43%), followed by occupational therapy (34%) and physiotherapy (25%).
164 patients were offered follow-up treatment over several
months (M=22.2 weeks, SD=17.7). Treatment follow-up mostly (57%) involved a
single health practitioner (an occupational therapist or physiotherapist in 51%
and 23% of the cases respectively). Twenty-two percent of the patients offered
treatment were categorised as “long-term cases” (i.e. they were
followed up for more than 7 months).
Three variables were associated with the probability of
being a long-term case:
Logistic regression (‘Enter’)
determined that all three variables made an independent contribution to the
probability of being a long-term case.
At point of discharge from the service, 70.2% of cases were
classified as having a good outcome, with others classified as fair (11.8%) or
poor (6.2%) outcome. A small number (11.8%) were referred on to additional
health providers for further rehabilitation or treatment, and thus their outcome
was undetermined. No demographic, clinical, assessment or treatment variables
were associated with those cases classified as having a good outcome. The small
number with a poor outcome precluded any exploration of factors associated with
this.
Turning to referee characteristics (see Table 4), source of
referral was significantly
associated with type
of MTBI (χ2=67.3, df=42, p=0.008). In particular, ACC referred
significantly more MVA-related but significantly less assault-related MTBIs than
expected. Source of referral was significantly associated with the elapsed time
between the MTBI and being seen by the Concussion Clinic (F [5,266]=4.3,
p=0.001). Post-hoc analysis indicated that those referred by Christchurch
Hospital-based services (Emergency Department, Occupational Therapy,
Neurological Services) were seen with more recently-incurred MTBIs than those
referred by others.
DiscussionAs the Burwood Hospital Concussion Clinic is a new service,
we hoped to derive information that would inform future service development and
referrers. As expected, cases represented a reasonably young group of adults,
although the age range was broad.
In contrast to the known greater incidence of men
experiencing MTBIs,2,21,22 our overall sample was reasonably gender balanced,
and this suggests possible under-referral of men. Closer perusal of gender mixes
across injury cause reveals that females were less likely to present with
assault or following worksite injuries, but more likely to present with MTBI
secondary to a medical condition, such as a fall resulting from syncope or a
seizure. Rates of assault presenting to the Clinic were twice that usually cited
in other countries.1,17,21
More than half of our sample required the involvement of
more than one type of health practitioner, with a neuropsychological screen
being the most likely assessment-event accompanying any medical review. While
the value of neuropsychological assessment in this population has been
debatable,18,23 a screening assessment is completed if subjective cognitive
problems persist for longer than 3 months post-injury; and in our observation,
usually provides reassurance regarding absence of significant neuropsychological
impairment.
In addition, a neuropsychological screen is completed for
all patients involved in cognitively-demanding roles such as study, teaching,
law, and medicine. Indeed, the fact that occupational therapy provides the most
frequent form of treatment follow-up reiterates the perceived value of providing
educational support, symptom management, and guidance regarding resumption of
pre-injury roles.
Specific additional treatments are also initiated as
clinically indicated, such as physiotherapy treatment for vestibular
disturbances, or medication for mood disorder. Although most cases achieved full
return of functioning at discharge, the high proportion requiring follow-up
beyond 7 months is concerning.
Why women may be over-represented in this group is unclear,
but speculations include better ability to communicate treatment needs, or even
that woman may be more likely to develop prolonged post-concussion symptoms
following MTBI.1,3,7
It is unclear why the greater time-lag between injury and
clinic contact also contributed to risk of long-term follow-up, although it is
clinically known that difficult complications impacting on recovery from MTBI
may take time to be declared, and this in turn contributes to later referrals.
Rates of non attendance in our sample appear modest and
consistent with other reports on non-attendance to hospital outpatient
clinics.12,14,24 Even though the numbers are small, identification of variables
associated with non attendance in our sample has been helpful in terms of
managing this issue.
Patients may not attend because their symptoms have improved
and they do not feel they need to attend, or they have returned to work and do
not wish to take time off for such an appointment. These intuitively appear
particularly relevant to referrals made by the Emergency Department given that
patients seen in this setting may well experience considerable improvement
between discharge and the Concussion Clinic appointment. The fleeting
therapeutic engagement with patients in such settings may also play a part in
poor follow-through by the patient. Whatever the case, encouraging referrers in
such settings to reiterate rehabilitation needs with MTBI patients is likely to
be beneficial.
As with any retrospective analysis, this study is limited by
the completeness of records available. Likewise, cause-and-effect relationships
between variables cannot be drawn. While any bias as a result of chance
variation is ameliorated by our relatively large sample size, the small numbers
of cases in some of the categories still precluded further exploration.
Furthermore, the Burwood Concussion Clinic is a new service and this raises the
possibility of bias through an influx of ‘old’ or difficult cases
being referred, which in turn affected the clinic’s activities. For these
reasons, a repeated study is planned, and future studies should consider other
issues such as the frequently highlighted risk for iatrogenic disability in this
patient group,3,4,18 the impact of alcohol use, and previous history of MTBI.
We also intend to focus on continuing research activity in
the clinic: development and/or validation of relevant outcome measures for
systematically evaluating outcomes of our patients. Likewise, providing
unnecessary and routine follow-up (in a patient group where spontaneous recovery
rates are likely to be high) is costly, and may over medicalise the condition.
Thus, for these collective reasons, further research is
required to identify MTBI patients who can most benefit from the Clinic’s
services. Limitations aside, this study has identified important issues for the
Concussion Clinic—it may increase awareness of its functions among
referrers so they become more aware of the function of the Concussion Clinic as
well as the various rehabilitation needs of this population.
Author information:
Deborah L Snell, Neuropsychologist, Brain Injury Rehabilitation Service, Burwood
Hospital, Canterbury District Health Board; Lois J Surgenor, Senior Lecturer,
Department of Psychological Medicine, Christchurch School of Medicine,
University of Otago; Christchurch
Correspondence:
Deborah Snell, Brain Injury Rehabilitation Service, Burwood Hospital, Canterbury
District Health Board, PO Box 4708, Christchurch. Fax: (03) 383 6868; email: deborah.snell@cdhb.govt.nz
References:
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