Emory Study Finds that Underdiagnosis of Mild Traumatic Brain Injury is a Pervasive Problem in the Emergency Setting
An article published in April, 2020 by the American College of Emergency Physicians reports on evidence that underdiagnosis of Mild Traumatic Brain Injury (mTBI) “is a pervasive problem in the emergency setting,” and that even patients who receive a diagnosis are unlikely to receive appropriate discharge education and are therefore at risk of missing opportunities for treatment, referral and improvement in outcomes. Koval et. at., Concussion Care in the Emergency Department: A Prospective Operational Brief Report, Annals of Emergency Medicine 2020 Apr;75(4):483-490. The evidence comes from a prospective observational study performed at an academic Level 1 trauma and emergency care center. The study subjects included 98 patients admitted to the ER over a four week period who responded affirmatively to two questions based on the CDC’s clinical definition of mTBI:
- Was there a blunt force trauma to the head or did the head move back and forward with a lot of force? and
- Was there a change in mental status or level of consciousness as a result of the event (including fogginess, confusion, disorientation, stunned)?
All of these patients were therefore considered “at high risk for mTBI.” Less than 50% of these high risk patients were evaluated on the issues recommended by the CDC, the Department of Defense/Veterans Affairs, or the 5th International Conference on Concussion in Sport. MTBI was documented as a differential diagnosis in only 45.9% of these high risk patients. Only 6.1% of these high risk patients received a mTBI-specific ICD-10 code. (Many insurers will contest a mTBI diagnosis absent such a code.) Among the patients who received a diagnosis of mTBI only 41.5% received mild traumatic brain injury discharge education.
From a medical perspective these results document that many victims of mild traumatic brain injury are not being properly evaluated or diagnosed and are not getting the information they need to achieve the best recovery. Failure to properly evaluate mTBI (and to use the proper diagnostic codes) also has legal consequences impacting the ability of mTBI patients to receive fair compensation for their injuries. How many times have we heard insurers say that they will not compensate for a diagnosis not reflected in the medical records?
The authors of the study outline their plan, based on the study outcome, to increase provider education related to diagnosis and discharge for patients with mTBI. Let’s hope that happens in other institutions as well.