Health Care Navigation of Black and White Adolescents After Sport-Related Concussion: A Path Toward Health Equity

We completed a retrospective cohort study using data from the Vanderbilt Sports Concussion Center (VSCC) registry. The institutional review board (No. 192033) determined the study to be exempt and waived the requirement for consent. Patients seen by VSCC providers between November 1, 2017, and October 1, 2020, for concussion were screened for eligibility (n = 1504). A concussion diagnosis was defined based on the International Classification of Diseases, 9th and 10th editions, codes for concussion (ie, 850.*, S06.0X**) and variants as well as postconcussion syndrome (eg, 310.2, F07.81). Patients aged 12 to 23 years were included in the registry if they had presented to a VSCC provider within 3 months of injury and the provider confirmed an SRC diagnosis based on the most recent Concussion in Sport Group guidelines.¹⁶  Notably, those with acute intracranial findings (hemorrhage or fracture) on imaging were excluded (n = 8). In total, 868 (57.7%) met the criteria and were included in the registry. Given that our focus was on racial differences, those patients with missing or unknown race (n = 107) and those belonging to another minoritized racial group for which n < 20 (n = 23) were excluded. Additionally, only the first concussion of the study period was analyzed for any particular athlete to maintain independence of observations (n = 79 repeat concussions). Finally, we limited this study to middle and high school athletes, as the treatment pathway for collegiate athletes at the center was considerably different (n = 77). A patient-flow diagram detailing all exclusion criteria is provided in Figure 1.

A joint venture between Vanderbilt University Sports Medicine (VUSM) and the Vanderbilt Medical Center (VUMC) Neurosurgery and Orthopaedics Departments, the VSCC is a multidisciplinary center involving health care providers from a variety of specialties (neuropsychology, neurology, neurosurgery, pediatrics, sports medicine, emergency medicine, physical therapy, occupational therapy, speech therapy, and psychiatry). Vanderbilt University Sports Medicine provides athletic training outreach services to 26 high schools in the Nashville, Tennessee, area. Those schools are a mixture of city, county, and private schools. The ATs in the VUMC system are given direct access to all VSCC health care providers and services. The VSCC providers have also established relationships with ATs at high schools outside of the VUSM relationships. Referrals flow to the VSCC from the ED, ATs, and community providers. The VSCC provides baseline concussion testing and postinjury concussion management for patients with acute or complex SRCs.

We performed a manual chart review, extracting data from provider notes to a secure REDCap (Vanderbilt University) database. Loss of consciousness (LOC), amnesia, or both were noted as present if mentioned in the initial concussion visit note or on an athlete-completed intake form. On-field evaluation was defined by an explicit mention that the athlete was evaluated or not evaluated for a concussion at the time of injury. If there was no explicit mention, on-field evaluation was recorded as unknown.

We used 4 primary outcomes: (1) time from injury to the first health system contact, (2) location of the first contact, (3) time to the SRC clinic visit, and (4) whether the athlete established care (>1 visit), was lost to follow-up, or was released immediately to an AT termed disposition. The first health system contact was defined as the location of the first non-AT health care provider seen after the injury (eg, ED or urgent care, SRC clinic, other clinic). The SRC clinic referred to any provider (ie, sports medicine, orthopaedics, neuropsychology) who saw patients under the VSCC umbrella. Those who first presented to either an in-system or outside ED, urgent care, or other walk-in clinic were coded as ED/urgent care. Those who presented first to general pediatrics, neurosurgery, or another scheduled clinic outside of VSCC were coded as other. We operationally defined ED orders as either a treatment (ie, medication, intravenous fluids) or diagnostic procedure (ie, imaging). The ED orders were recorded from provider notes, medication administration records, and outside medical records for those who first presented to ED/urgent care. The time to first contact was defined as the number of days from injury to the first health care provider contact, not including on-field evaluations. The time to the clinic visit was defined as the days from injury to presentation at VSCC. The time to the first VSCC follow-up was defined as the number of days from the first VSCC visit to the second VSCC visit and was calculated only for those who had follow-up. Disposition of the athlete after the first VSCC visit was coded as established care (ie, >1 follow-up visit at VSCC), lost to follow-up, or released to AT. Lost to follow-up was defined as the follow-up being requested but not completed. If the VSCC provider indicated that the athlete was being released to the school-based AT for further monitoring and a protocol for the return to activity, then that athlete was considered released to the AT.

The data were grouped by race, Black or White, as a dichotomous variable. Race was self-reported by the patient on intake forms. Descriptive analyses were performed with categorical data reported as frequencies and proportions. Continuous data except for age were presented as the median and interquartile range, given the nonnormal distribution. Age was presented as the mean ± SD. Group comparisons were conducted using χ² statistics, Mann-Whitney U, or independent-samples t tests, as appropriate. Statistical significance was set a priori at P < .05.

The final cohort consisted of 582 athletes, of whom 16.5% were Black (n = 96) and 83.5% were White (n = 486). Full demographic and past medical history data are presented in Table 1. No racial differences in patient age were present (t_1,580 = 1.286, P = .199). More White athletes attended private schools (24.0%) compared with their Black counterparts (9.5%, P = .002), and more White athletes than Black athletes were privately insured (86.0% versus 71.9%, P = .003). Race was associated with concussion history (P = .013): White athletes more frequently reported ≥1 prior concussion (45.0% versus 22.9%). The 2 groups were otherwise similar in terms of past medical and family histories.

Black athletes more frequently reported LOC than White athletes (21.9% versus 11.8%, P = .008), whereas amnesia (retrograde and anterograde) was reported similarly by the 2 groups (14.6% versus 19.3%, respectively, P = .273). The health care navigation pathways of the 2 groups of athletes are presented diagrammatically in Figure 2. Black and White athletes demonstrated no difference in the prevalence of on-field evaluation (39.6% versus 28.8%, P = .099) postinjury or time to the first health system contact (U = 22 209.50, P = .595; Table 2). The type of initial health system contact setting was not dependent on race (P = .723). Most Black and White athletes sought care initially in the concussion clinic (61.5% versus 62.3%, P = .723), followed by the ED/urgent care (30.2% versus 27.2%, P = .723).

Overall, Black athletes reporting to the ED received similar ED orders as their White counterparts. Looking at the breakdown of individual ED orders, 50.8% of White athletes received diagnostic head imaging compared with 37.9% of Black athletes, but this was not statistically significant (P = .211). Also, ED orders that included pain or nausea medication administration did not differ (P = .559 and P = .128, respectively). Furthermore, the rates of hospital admission between the groups were not different (P = 1.000). In summary, of those who initially presented to the ED, 66.7% of White athletes received 1 or more ED orders, compared with 55.2% of Black athletes (P = .241); 25.7% of White athletes and 13.8% of Black athletes received at least 2 ED orders (P = .169).

Both Black (median = 4 days; interquartile range = 2.5–7.5 days) and White (median = 5 days; interquartile range = 2.0–12.0 days) athletes presented to the concussion clinic within similar time frames (U = 22 757.50, P = .704; Table 2). After the initial evaluation in the concussion clinic, Black and White athletes demonstrated similar dispositions (P = .138), with low rates of loss to follow-up (4.2% versus 6.4%), and the majority established care (56.3% versus 64.0%). For those who established care, follow-up occurred at a median of 13 days for both Black and White athletes (U = 8565.50, P = .0558).

Health care disparities often emerge through the interactions among race, SES, and access to care. Thus, disentangling these factors can be challenging, and without data that include minoritized groups, the scientific, scholarly, and clinical communities cannot actively advance equitable health policy or health care. In an effort to contextualize racial disparities in SRC management, we compared initial care, referral pathways, and timelines for SRC management in Black and White adolescent athletes within a regional health care network. Nearly two-thirds of Black and White athletes sought SRC care initially at the concussion clinic versus the ED or other medical clinic. However, of those who first went to the ED, a greater proportion of White athletes received 1 or more ED orders compared with Black athletes (67% versus 55%). Moreover, 26% of White athletes received at least 2 ED orders compared with only 14% of Black athletes. Otherwise, referral patterns and care timelines did not differ between Black and White athletes. A minimal percentage of patients was lost to follow-up, and no differences were observed by race. These findings suggest that racial disparities may be appropriately minimized within an established regional SRC care network by facilitating health care navigation.

Contextualizing the importance of understanding race within a framework of health equity addresses key social concerns in the process of reducing US health disparities. The health care infrastructure that includes the organization, financing, and availability of services has historically been unequal between the Black and White communities.¹⁷  Before the 1964 Civil Rights Act, Black and White people were mandated by national law to seek care in separate facilities or on separate floors within a facility.^17,18  Consequently, health inequity and inequality resulting from structural racism have produced unequal access to medical care, provider-level challenges and disparities, and disparities in health outcomes.^11,17,18  Greater perceived racial discrimination has also been associated with delayed care seeking among Black individuals.^7,17  Within our sample, a notable disparity was that fewer Black athletes had private insurance compared with White athletes. Previous analyses have shown that individuals with public insurance, or particularly a lack of private insurance, were less likely to seek care in a tertiary specialty concussion clinic¹⁹  and more likely to initiate point of entry at the ED⁴  or present >14 days postinjury.²⁰  These disparities may be related to barriers in the referral process or providers not participating in Medicaid. Notably, despite insurance differences between Black and White athletes in this study, we saw no differences between groups in the direct care path to the SRC clinic or in loss to follow-up. Although we hypothesized that anticipated racial differences in insurance status might result in differences in access or delays in care, we found that being within the SRC clinic referral network at the time of injury appeared to mitigate the effect of socioeconomic differences, promote health equity, and optimize continuity of care. Possible reasons for accepting the null hypothesis may be that adolescent athletes have better access to health care because of the scholastic-sponsored nature of their injury, whereas individuals playing in non–school-sanctioned sports may have a harder time establishing care.

The ED is frequently the first health system contact, and ED use for SRC can lead to unnecessary imaging, inefficient patient handoffs, or fragmented care.²¹  Emergency department physicians were marginally aware of concussion consensus statement recommendations and return-to-play protocols,²²  which can interfere with care trajectories and timelines for recovery. In our study, ED use for SRC was similar by race. An explanation could be the presence of ATs within the concussion center network who recognize on-field symptoms or diagnose concussions and assist with referrals directly to the concussion clinic. However, these results contrast somewhat with the previous literature,^2,3  which illustrated that Black children and adolescents seeking care at the ED after a head injury were less likely to be diagnosed with a concussion than their White counterparts. Notably, though, these prior findings are not incompatible with ours, as Black patients who were seen and discharged without a concussion diagnosis would not have been included in the present study. Yet we may expect some portion of these patients who were not initially diagnosed to later present in delayed fashion,²³  though we found no evidence of this phenomenon (ie, longer times to clinic). Seeking initial care at the ED could be a symptom of not having a primary care relationship or could be related to those who experienced LOC or persistent or delayed nausea and vomiting, as those patients are more likely to recognize their injury as a concussion and present to the ED.²⁴  More than 20% of Black athletes and nearly 12% of White athletes experienced LOC, values that are inflated compared with previously published estimates.¹⁶  These specific symptoms may have increased the rate of appropriately diagnosing SRC, whereas those with mild symptoms may have been discharged without a diagnosis or diagnosed and not referred to the concussion center. Given the sampling methods, we cannot exclude the possibility that Black athletes without LOC were disproportionately discharged without a diagnosis of SRC after head injury, which would explain the racial differences in LOC. Unfortunately, aside from LOC, whether the athletes may have experienced any other on-field symptoms, leading to either a referral to the ED or a family decision to seek care at the ED, is unknown.

Despite similarities in presentation to the ED between Black and White athletes, inconsistent diagnostic procedures and treatments provided to Black and White athletes raise questions and suggest room for improvement in providing equitable care. Fifty percent of Black athletes who sought care at the ED were sent home without a single ED order. In contrast, White athletes received more ED orders overall, including head imaging, pain medication, nausea medication, and intravenous fluids. For example, over 50% of White athletes who sought care at the ED received imaging, compared with 36% of Black athletes. Although these measures were not statistically significant, we believe the raw data are a more robust and transparent indicator of health equity. This difference in imaging as a diagnostic procedure also aligns with previous cross-sectional research²⁵  using nationally representative data with nonhospitalized patients from 52 tertiary children's hospitals. Imaging was performed during 33.5% of ED visits by White patients in contrast to 24.1% of Black patients. Despite stratification by insurance status, Black patients were 31% less likely to receive diagnostic imaging as part of their ED evaluation compared with White patients.²⁵  Although these findings suggest that race may be independently associated with imaging decisions in the ED, more research using nationally representative ED data is needed to understand the imaging and other services provided specifically for patients with concussion.

Racial disparities have been documented along the spectrum of clinical care; however, representation of Black people or other minoritized groups is often missing in published SRC studies, making this factor difficult to discern. Although previous investigators demonstrated disparities in access to ATs,¹⁰  accessible baseline neurocognitive testing,²⁶  use of subspecialty concussion care,¹⁹  and concussion symptom knowledge,⁹  understanding care paths among groups can help to answer questions regarding recovery timelines and treatment pathways. Bretzin et al²⁷  showed that the median time to medical clearance after an SRC varied by health care provider and medical facility. These results did not address racial diversity, but those who sought initial care at the ED or urgent care facility were cleared sooner than those who sought initial care with a team physician or specialist.²⁷  Our outcomes illustrated that timelines and pathways to care were similar between Black and White athletes for on-field evaluation, time to the first health system contact, time to the concussion clinic visit, and time to the first follow-up visit. On-field evaluation is most often conducted by an AT, and earlier authors²⁷  showed that an AT was one of the initial examiners in 72% of SRC cases across a large statewide epidemiologic study. The presence of an AT may promote direct referrals and allow for more proximal SRC services (ie, at the athlete's school rather than requiring travel to a clinic for follow-up), thereby helping to reduce disparities. Moreover, 40% and 30% of Black and White athletes, respectively, were released to the AT to carry out return-to-play protocols as a final sequence of care.

The limitations of this study warrant discussion. First, these results are bound by disproportionate numbers of Black and White athletes that reflect regional demographics; beyond attendance at a private or public school, the patients' school-based demographics are unknown. These demographics could include the degree of AT access (eg, full- or part-time staffing) and SES of the school population. Second, this study was limited to patients who received care at our SRC clinic. Thus, it may not have fully captured all patients who sustained an SRC and either did not present at all or presented only to an outside provider, AT, or outside ED. Therefore, we are unable to comment on whether diagnosis and access to care were equitably distributed in the community at large other than to note that patients who were seen followed similar referral patterns, timelines, and dispositions. Specifically, disparate care paths and health care use for mild traumatic brain injury have been exacerbated by geographic disparities for patients in rural locations,²⁸  who may not have been included in this analysis. Similarly, we do not know the full community or neighborhood characteristics for the patients, which may explain variations in health system navigation better than race alone. Moreover, these data were limited to a single regional health care system, and the results may not be generalizable to other US health care systems. Future researchers would benefit from expanding care-path patterns to communities or geographic regions not well represented in this study to better understand care paths and timing-related outcomes related to care seeking. However, these results can serve as a care-path example to networks looking to expand in order to provide more equitable care. Finally, not all SRC guidelines advocate sending individuals with SRC to a specialty center such as the one in this study; however, previous literature^29,30  suggested that a concussion center visit within the first week postinjury improved the odds of a more rapid recovery. Thus, a multidisciplinary network that includes ATs and ED physicians who can make a quick referral to the SRC clinic for patients with uncomplicated SRC can equitably expedite care and recovery.

Equitable SRC care is possible when similar resources are provided to diverse communities. With established relationships that include a network of schools, ATs, and a concussion clinic, it can be easier for patients to navigate medical spaces and be provided a path to care and treatment for SRC. The direct field-to-clinic care path was responsible for 62% of SRC patients in our regional SRC center over 3 years. Despite school type and insurance differences between Black and White athletes, no significant racial disparities were apparent in the time from injury to the first health system contact, location of the first contact, time to the SRC clinic visit, and whether the athlete established care (>1 visit), was released immediately to an AT, or was lost to follow-up. Furthermore, although this finding was not statistically significant, Black athletes received fewer ED orders compared with White athletes. Our care-path results offer a health-equity–focused example of a health care network model that can reduce disparities and facilitate the continuity of care for SRC. A care path can optimize resource use, value-based care, interdisciplinary communication, and equitable outcomes. However, we are mindful that these outcomes reflected only patients who sought care at the SRC center and did not capture the care paths of patients who did not receive care, nor did they address possible disparities in access or care for those who never presented to the health system.