Objective: The objective of this study was to assess whether primary care professionals' self-reported concussion management practices are consistent with clinical guideline recommendations from leading health organizations. Setting: 2023 DocStyles online national market research survey of US primary care professionals. Participants: One thousand three hundred eighteen primary care professionals who see patients with concussion. Design: Cross-sectional. Main measures: Primary care professionals' self-reported practices related to return to activity (physical, cognitive, social), work/school accommodations, provision of follow-up instructions, and screening for risk factors for persistent symptoms. All data were analyzed using SAS and differences were examined using χ 2 tests. Results: Among the 1318 primary care professionals who saw a patient with a concussion in the past 12 months, about one-third of participants self-reported that they do not provide recommendations or provide recommendations on return to physical (42.6%), cognitive (33.5%), and social (38.5%) activities that do not align with clinical recommendations. Most (78.0%) provided follow-up instructions more than 75% of the time. Only about half of participants self-reported providing work/school accommodations (52.0%) and screening for risk factors of persistent symptoms (54.6%) more than 75% of the time; findings varied by specialty, years of medical practice, and urbanicity of healthcare facility. Conclusion: This study found that many participants' self-reported concussion management practices do not align with clinical recommendations from the Centers for Disease Control and Prevention and others. Use of clinical care pathways, and other promising strategies to improve adherence to guideline recommendations, may be beneficial.
Objective: To characterize postdischarge opioid prescription patterns in the year after traumatic brain injury (TBI) hospitalization and examine whether early demographic, injury, and hospital-level factors predict long-term or high-risk opioid use. Setting: Harborview Medical Center, a high-volume Level I trauma center serving the WWAMI region (Washington, Wyoming, Alaska, Montana, Idaho). Participants: A total of 9647 adults admitted to Harborview Medical Center with a TBI diagnosis between January 1, 2012 and December 31, 2019 who survived their hospitalization. Design: Retrospective cohort study linking 3 data sources: the Harborview Trauma Registry, the University of Washington Medicine electronic health record system, and the Washington State Department of Health Prescription Drug Monitoring Program. Main Measures: Postdischarge opioid prescription fills were characterized using 4 Bree Collaborative metrics measured quarterly over 364 days after discharge: any opioid prescription, chronic opioids (≥60-day supply), chronic high-dose opioids (≥60-day supply and ≥50 mg/d morphine equivalent dose [MED]), and chronic opioids with concurrent sedatives. Demographic, injury, and inpatient opioid administration variables were examined as potential predictors. Results: Approximately 12% of participants filled an opioid prescription within 90 days of discharge. Among those who did, 26% had refills reflecting chronic use (≥60-day supply), of whom 54% continued filling prescriptions through 1 year postinjury. Neither demographic characteristics nor inpatient opioid administration variables, including average MED, maximum MED, or average MED in the final 48 hours of hospitalization, were significant predictors of postdischarge opioid use across any metric or quarter. Conclusion: Although most individuals with TBI do not fill opioid prescriptions after discharge, among those who do, 1 in 4 follow trajectories consistent with chronic use. The absence of identifiable demographic or hospital-level predictors suggests that routine electronic health record–derived variables are insufficient for risk stratification in this population and highlights the risk of relying on unvalidated demographic proxies in clinical prescribing decisions.
Objective: To examine the association between duration of repeated exposure to low-level blast and alteration in brain structure. Setting: Data were collected at 2 neuroimaging facilities. Participants: Canadian Armed Forces breachers ( n = 30) and snipers ( n = 31) with a history of repeated exposure to low-level blast (average years = 9.70, SD = 4.57) and sex- and age-matched active military controls ( n = 57). Design: MRI and neurocognitive data from breachers and snipers were collected prospectively at baseline (time 1) and after a training exercise involving a concentrated regimen of blast exposure (time 2) (time gap = 80.56 days, SD = 36.90). Time 1 and time 2 data were used to assess the chronic and training-related effects of blast exposure, respectively. MRI and neurocognitive data from controls were collected twice with a comparable time gap. Main measures: High-resolution magnetic resonance imaging (MRI) scans, plus neurocognitive measures. Results: Voxel-based morphometry conducted on MRI data collected at time 1 demonstrated that compared with controls, there was lower regional gray matter volume in left inferior frontal gyrus in snipers, and bilaterally in parahippocampal gyrus (bordering on amygdala) in breachers. Regional gray matter volume in left inferior frontal gyrus in snipers predicted neurocognitive function. We did not observe any difference in regional white matter volume between groups at time 1, nor any changes in regional gray or white matter volume between time 1 and time 2. Conclusion: Chronic but not training-related low-level blast exposure was associated with dissociable patterns of regional gray matter volume reduction in snipers and breachers, and regional gray matter volume predicted neurocognitive function in snipers. The differential pattern of structural alteration between breachers and snipers and its relationship with neurocognitive function in snipers can inform health monitoring programs for diagnosis and treatment of blast-exposed service members and Veterans.
