September 16, 2021, Kitchener, Ontario
Posted by: Robert Deutschmann, Personal Injury Lawyer
Neurology Today released a review of the New AAN (American Academy of Neurology) Quality Measures for Concussion. The article is written by Susan Fitzgerald and is based on an interview with the lead author of the study Sean Rose, MD, co-director of the complex concussion clinic and assistant professor of pediatric neurology at Nationwide Children's Hospital in Columbus and focusses on the highlights of the clinical takeaways about evaluation, clinical examination, and return-to-play protocols.
This post will highlight some of article.
“Concussion remains a clinical diagnosis, inevitably involving some degree of subjectivity and uncertainty,” the document, published in the July 28 edition of Neurology, stated. The measure set also includes a third component of concussion care: documentation of a return-to-play strategy or protocol.
Concussion measurement sets are over arching tools that allow physicians to judge the quality of care that they are providing patients with concussion. The measurement sets are different from guidelines which are designed to inform specific diagnostic and treatment decisions. The study focussed on the importance of a quality measurement set for concussion.
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Why was it time to develop a quality measurement set for concussion?
While there is evidence to guide the clinical diagnosis and management of concussion, there remains significant variability in care practices. We developed this measure set to support high-quality care for individuals with concussion and to improve patient outcomes. A previous set did not exist.
What evidence is the new measurement set based on?
The work group used evidence-based and consensus guidelines from several professional medical organizations, such as the Centers for Disease Control and Prevention, the AAN, and the American Academy of Pediatrics. We also included evidence from systematic reviews and individual research studies to identify elements of patient care that are considered key to quality medical care. While 19 measures were initially proposed, three measures were ultimately included after data review, group discussion, and public comment.
What are the key points in the new concussion document?
The first two measures highlight that concussion remains a clinical diagnosis based on history and neurologic exam. To meet these quality measures, history includes tracking symptoms during recovery, and exam includes a thorough neurologic physical exam.
• Concussion symptoms evaluation: The measurement set does not tell clinicians which specific tools to use to do a symptoms evaluation, but does list some assessment tools to consider, such as the child or adult versions of the Sport Concussion Assessment Tool and the Post-Concussion Symptom Scale. Most of them free and available online.
“These tools are a springboard for the caregiver to discuss patient symptoms and track them over time,” the document says. “Symptom evaluation tools should not be used by themselves to manage concussion but should be used to make treatment decisions. Treatment for concussion varies widely and we cannot recommend a treatment follow-up component for this measure at this time.”
• Appropriate neurologic exam: The measurement set is not intended to change the way someone is trained to complete a neurologic exam. But the neurologic exam should include at least seven key components: cervical assessment, cognitive function, vestibular function, extraocular movement, gait, balance, and coordination. The measure notes that “A general neuro exam to exclude spine and brain injury should be completed as part of the initial evaluation.”
• Documentation of return-to-play strategy or protocol: The third measure affirms the consensus recommendation that a patient should complete and tolerate a progression of physical activities prior to being cleared for contact sports or other “at-risk” activities. The measure set includes a common six-step protocol as an example, beginning with physical activities that do not worsen symptoms, progressing to light aerobic activity, and ultimately arriving at normal game play. For example, a soccer player might start with light jogging, then more intense running and sprints, then basic soccer footwork and ball handling, then non-contact practice, then full scrimmage, then game competition.
How might this measurement set help clinicians improve the consistency and quality of concussion care they deliver?
It could be used by individual physicians to track whether they are performing key elements of care for every patient with concussion. It could also be used by organizations or funding agencies potentially to identify whether physicians are meeting basic quality measures.
It is important to recognize these three quality measures are considered foundational to the diagnosis and management of concussion. But they do not represent the only things that providers should do to provide high-quality care for patients with concussion. The three measures we picked were all practice-based rather than outcomes-based. Because concussion overall needs more research, it is not known conclusively what interventions result in better outcomes.
What measures were not included in the final document?
The workgroup held multiple meetings to identify proposed measures that have well-documented evidence. We explored other measures but determined that there is not currently enough evidence to support them or there is not a feasible way to track their completion. A single study with a handful of patients is not adequate.