Analyzing the effect of state legislation on health care utilization for children with concussion

JAMA Pediatr. 2015 Feb;169(2):163-8. doi: 10.1001/jamapediatrics.2014.2320.


Importance: In 2009, Washington State enacted legislation outlining the medical care of children and adolescents with concussion (ie, the Lystedt Law), with all other states and Washington, DC passing legislation by January 2014.

Objective: To evaluate the effect of concussion laws on health care utilization rates from January 1, 2006, through June 30, 2012, in states with and without legislation.

Design, setting, and participants: For commercially insured children aged 12 to 18 years from all 50 states and DC from January 1, 2006, through June 30, 2009, we examined the following: (1) prelegislation trends in concussion-related health care utilization from January 1, 2006, through June 30, 2009, (2) postlegislation trends in states without concussion legislation, and (3) the effect of state concussion laws on trends in states with concussion legislation in effect by means of negative binomial multivariable estimation with state and time fixed effects.

Exposures: Concussion diagnosis.

Main outcomes and measures: Emergency department and related health care utilization rates for concussion.

Results: Between academic school years 2008-2009 and 2011-2012, states with legislation experienced a 92% increase in concussion-related health care utilization, while states without legislation had a 75% overall increase in concussion-related health care utilization during the same period. In the multivariable fixed-effects models, controlling for differences across states, rates of treated concussion in states without legislation were 7% higher in the 2009-2010 school year, 20% higher in the 2010-2011 school year, and 34% higher in the 2011-2012 school year compared with the prelegislation trends (2005-2009) (all P < .01). During the same period, states with concussion laws demonstrated a 10% higher concussion-related health care utilization rate compared with states without laws (P < .01).

Conclusions and relevance: Increased health care utilization rates among children with concussion in the United States are both directly and indirectly related to concussion legislation. A portion of the increased rates (60%) in states without legislation is attributable to an ongoing upward trend demonstrated before enactment of the first state law in 2009. The remaining 40% increase in these states is thought to have resulted from elevated awareness brought about by heightened local and national media attention. Concussion legislation has had a seemingly positive effect on health care utilization, but the overall increase can also be attributed to increased injury awareness.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Ambulatory Care / statistics & numerical data
  • Athletic Injuries / epidemiology
  • Athletic Injuries / prevention & control*
  • Brain Concussion / epidemiology
  • Brain Concussion / prevention & control*
  • Child
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Male
  • Neurology
  • Office Visits / statistics & numerical data
  • Patient Admission / statistics & numerical data
  • Physical Education and Training / legislation & jurisprudence*
  • School Health Services / legislation & jurisprudence*
  • State Government*
  • Tomography, X-Ray Computed / statistics & numerical data
  • United States / epidemiology