The Leaky Pipeline of Injury: Disparities at Multiple Junctures for Children with Head Trauma

OBJECTIVE: To assess disparities in both individual and neighborhood measures of opportunity across multiple critical junctures in the health care system journey of pediatric head trauma patients. STUDY DESIGN: Using the Minds Matter Registry, which includes all patients evaluated for head trauma across emergency department and outpatient locations in a tertiary care pediatric health care network, we evaluated disparities by age, sex, race, ethnicity, and insurance status, and both the overall and domain scores of the neighborhood Child Opportunity Index among: (1) patients presenting to the emergency department with head trauma and diagnosed with concussion, (2) patients diagnosed with concussion referred to specialty care, and (3) patients referred to specialty care for concussion and attending at least one appointment. RESULTS: Overall, we included 22 344 patients, 5998 diagnosed with concussion, 1142 referred to specialty care, and 504 attending a specialty visit. Across the 3 junctures, we saw stepwise increase in age (median 7.0 years overall sample vs 12.0 diagnosed with concussion vs 13.0 referred to specialty care vs 14.0 attending a specialty visit), race and ethnicity (% identifying as non-Hispanic White 33% vs 40% vs 43% vs 48%), insurance (% possessing private insurance 46% vs 53% vs 56% vs 61%), and overall Child Opportunity Index (median 40 vs 55 vs 63 vs 74). CONCLUSIONS: We identified a "leaky pipeline of injury," with multiple increasing disparities present at each juncture along the health care journey of children with head trauma. Although our findings are specific to head injury, this study likely applies to other injuries and disease processes in the pediatric population, helping to identify key targets for future interventions.