Sports Medicine Staffing Across National Collegiate Athletic Association Division I, II, and III Schools: Evidence for the Medical Model

CONTEXT

The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown.

OBJECTIVE

To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department).

DESIGN

Cross-sectional study.

SETTING

Collegiate sports medicine programs.

PATIENTS OR OTHER PARTICIPANTS

Representatives of 325 universities.

MAIN OUTCOME MEASURE(S)

A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined.

RESULTS

Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers.

CONCLUSIONS

In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.

Staffing, Financial, and Administrative Oversight Models and Rates of Injury in Collegiate Athletes

CONTEXT

Structural features of health care environments are associated with patient health outcomes, but these relationships are not well understood in sports medicine.

OBJECTIVE

To evaluate the association between athlete injury outcomes and structural measures of health care at universities: (1) clinicians per athlete, (2) financial model of the sports medicine department, and (3) administrative reporting structure of the sports medicine department.

DESIGN

Descriptive epidemiology study.

SETTING

Collegiate sports medicine programs.

PATIENTS OR OTHER PARTICIPANTS

Colleges that contribute data to the National Collegiate Athletic Association (NCAA) Injury Surveillance Program.

MAIN OUTCOME MEASURE(S)

We combined injury data from the NCAA Injury Surveillance Program, sports medicine staffing data from NCAA Research, athletic department characteristics from the United States Department of Education, and financial and administrative oversight model data from a previous survey. Rates of injury, reinjury, concussion, and time loss (days) in NCAA athletes.

RESULTS

Compared with schools that had an average number of clinicians per athlete, schools 1 standard deviation above average had a 9.5% lower injury incidence (103.6 versus 93.7 per 10000 athlete-exposures [AEs]; incidence rate ratio [IRR] = 0.905, P < .001), 2.7% lower incidence of reinjury (10.6 versus 10.3 per 10000 AEs; IRR = 0.973, P = .004), and 6.7% lower incidence of concussion (6.1 versus 5.7 per 10000 AEs; IRR = 0.933, P < .001). Compared with the average, schools that had 1 standard deviation more clinicians per athlete had 16% greater injury time loss (5.0 days versus 4.2 days; IRR = 1.16, P < .001). At schools with sports medicine departments financed by or reporting to the athletics department (or both), athletes had higher injury incidences (31% and 9%, respectively).

CONCLUSIONS

The financial and reporting structures of collegiate sports medicine departments as well as the number of clinicians per athlete were associated with injury risk. Increasing the number of sports medicine clinicians on staff and structuring sports medicine departments such that they are financed by and report to a medical institution may reduce athlete injury incidence.

A Comparison of Emergency Preparedness Between High School Coaches and Club Sport Coaches

CONTEXT

Recent studies suggested that a large population of high school-aged athletes participate on club sport teams. Despite attempts to document emergency preparedness in high school athletics, the adherence to emergency and medical coverage standards among club sport teams is unknown.

OBJECTIVE

To determine if differences in emergency preparedness and training existed between coaches of high school teams and coaches of high school-aged club teams.

DESIGN

Cross-sectional survey.

SETTING

Online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

A total of 769 coaches (females = 266, 34.6%) completed an anonymous online questionnaire regarding their emergency preparedness and training.

MAIN OUTCOME MEASURE(S)

The questionnaire consisted of (1) demographics and team information, (2) emergency preparedness factors (automated external defibrillator [AED] availability, emergency action plan [EAP] awareness, medical coverage), and (3) emergency training requirements (cardiopulmonary resuscitation/AED, first aid).

RESULTS

High school coaches were more likely than club sport coaches to be aware of the EAP for their practice venue (83.9% versus 54.4%, P < .001), but most coaches in both categories had not practiced their EAP in the past 12 months (70.0% versus 68.9%, P = .54). High school coaches were more likely to be made aware of the EAP during competitions (47.5% versus 37.1%, P = .02), but the majority of coaches in both categories indicated that they were never made aware of EAPs. High school coaches were more likely than club coaches to (1) have an AED available at practice (87.9% versus 58.8%, P < .001), (2) report that athletic trainers were responsible for medical care at practices (31.2% versus 8.8%, P < .001) and competitions (57.9% versus 31.2%, P < .001), and (3) be required to have cardiopulmonary resuscitation, AED, or first-aid training (P < .001).

CONCLUSIONS

High school coaches displayed much greater levels of emergency preparedness and training than coaches of high school-aged club teams. Significant attention and effort may be needed to address the lack of emergency preparedness and training observed in club coaches.

Injury Surveillance and Evaluation of Medical Services Utilized During the 2016 Track and Field Olympic Trials

Background:

Injury surveillance systems have been implemented at world championships, yet no previous work has determined the burden of injuries during the United States Track and Field Olympic Trials. Additionally, the type of medical service providers utilized throughout the meet has not been reported, leaving it unclear whether optimal staffing needs are being met.

Purpose:

To describe the incidence of injuries presenting to the medical team at the 2016 US Track and Field Olympic Trials (Eugene, Oregon) by event type and competitor demographics.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective review was performed of all documented injuries and treatments recorded from June 28 through July 10, 2016. Descriptive statistics and the prevalence of newly incurred injuries were calculated for registered athletes and nonathlete (ie, support) staff. The incidence of acute injuries was analyzed for registered athletes, as stratified by athlete sex and event type.

Results:

A total of 514 individuals were seen during the trials: 89% were athletes and 11% were supporting staff. Physicians treated 71 injuries and 14 illnesses. Of diagnosed injuries, 85% (n = 60) occurred among athletes, with hamstring strains (16.7%, n = 10) being the most prevalent. A mean of 124 medical services (median, 137; interquartile range, 65.5-179.5) were provided each day of the trials. Among medical services, 41.8% were attributed to massage therapists for athletes, while chiropractic services were the most utilized service (47.1%) by the support staff. There was an overall incidence of 59.7 injuries per 1000 registered athletes, with jumpers (109.4 per 1000) and long-distance athletes (90.4 per 1000) being the most commonly seen athletes.

Conclusion:

Throughout the trials, athletes participating in jumping and long-distance events were the most commonly seen by physicians, creating the potential need for an increase in staffing of physicians during meet periods when these events occur. The provided medical services appeared to follow the number of athletes competing during the trials and the need for recovery treatments after competition. Findings from this study should inform future strategy for staffing and policy development at Olympic Trials and other elite-level track and field events in the United States.

The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (OR_adj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (OR_adj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (OR_adj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.

Athletic Trainer Services in Public and Private Secondary Schools

CONTEXT

 The presence of athletic trainers (ATs) in secondary schools to provide medical care is crucial, especially with the rise in sports participation and resulting high volume of injuries. Previous authors have investigated the level of AT services offered, but the differences in medical care offered between the public and private sectors have not been explored.

OBJECTIVE

 To compare the level of AT services in public and private secondary schools.

DESIGN

 Concurrent mixed-methods study.

SETTING

 Public and private secondary schools in the United States.

PATIENTS OR OTHER PARTICIPANTS

 A total of 10 553 secondary schools responded to the survey (8509 public, 2044 private).

MAIN OUTCOME MEASURE(S)

 School administrators responded to the survey via telephone or e-mail. Descriptive statistics depict national data. Open-ended questions were evaluated through content analysis.

RESULTS

 A greater percentage of public secondary schools than private secondary schools hired ATs. Public secondary schools provided a higher percentage of full-time, part-time, and clinic AT services than private secondary schools. Only per diem AT services were more frequent in the private sector. Regardless of the extent of services, reasons for not employing an AT were similar between sectors. Common barriers were budget, school size, and lack of awareness of the role of an AT. Unique to the public sector, remote location was identified as a challenge faced by some administrators.

CONCLUSIONS

 Both public and private secondary schools lacked ATs, but higher percentages of total AT services and full-time services were available in the public sector. Despite differences in AT services, both settings provided a similar number of student-athletes with access to medical care. Barriers to hiring ATs were comparable between public and private secondary schools; however, remote location was a unique challenge for the public sector.

Athletic Trainer Services in US Private Secondary Schools

CONTEXT

Availability of athletic trainer (AT) services in US secondary schools has recently been reported to be as high as 70%, but this only describes the public sector. The extent of AT coverage in private secondary school settings has yet to be investigated and may differ from the public secondary school setting for several reasons, including differences in funding sources.

OBJECTIVE

To determine the level of AT services in US private secondary schools and identify the reasons why some schools did not employ ATs.

DESIGN

Concurrent mixed-methods study.

SETTING

Private secondary schools in the United States.

PATIENTS OR OTHER PARTICIPANTS

Of 5414 private secondary schools, 2044 (38%) responded to the survey.

MAIN OUTCOME MEASURE(S)

School administrators responded to the survey via telephone or e-mail. This instrument was previously used in a study examining AT services among public secondary schools. Descriptive statistics provided national data. Open-ended questions were evaluated through content analysis.

RESULTS

Of the 2044 schools that responded, 58% (1176/2044) offered AT services, including 28% (574/2040) full time, 25% (501/2042) part time, 4% (78/1918) per diem, and 20% (409/2042) from a hospital or clinic. A total of 84% (281 285/336 165) of athletes had access to AT services. Larger private secondary schools were more likely to have AT services available. Barriers to providing AT services in the private sector were budgetary constraints, school size and sports, and lack of awareness of the role of an AT.

CONCLUSIONS

More than half of the surveyed private secondary schools in the United States had AT services available; however, only 28% had a full-time AT. This demonstrates the need for increased medical coverage to provide athletes in this setting the appropriate level of care. Budgetary concerns, size of the school and sport offerings, and lack of awareness of the role of the AT continued to be barriers in the secondary school setting.

Methods and Descriptive Epidemiology of Services Provided by Athletic Trainers in High Schools: The National Athletic Treatment, Injury and Outcomes Network Study

CONTEXT

Research is limited on the extent and nature of the care provided by athletic trainers (ATs) to student-athletes in the high school setting.

OBJECTIVE

To describe the methods of the National Athletic Treatment, Injury and Outcomes Network (NATION) project and provide the descriptive epidemiology of AT services for injury care in 27 high school sports.

DESIGN

Descriptive epidemiology study.

SETTING

Athletic training room (ATR) visits and AT services data collected in 147 high schools from 26 states.

PATIENTS OR OTHER PARTICIPANTS

High school student-athletes participating in 13 boys' sports and 14 girls' sports during the 2011-2012 through 2013-2014 academic years.

MAIN OUTCOME MEASURE(S)

The number of ATR visits and individual AT services, as well as the mean number of ATR visits (per injury) and AT services (per injury and ATR visit) were calculated by sport and for time-loss (TL) and non-time-loss (NTL) injuries.

RESULTS

Over the 3-year period, 210 773 ATR visits and 557 381 AT services were reported for 50 604 injuries. Most ATR visits (70%) were for NTL injuries. Common AT services were therapeutic activities or exercise (45.4%), modalities (18.6%), and AT evaluation and reevaluation (15.9%), with an average of 4.17 ± 6.52 ATR visits and 11.01 ± 22.86 AT services per injury. Compared with NTL injuries, patients with TL injuries accrued more ATR visits (7.76 versus 3.47; P < .001) and AT services (18.60 versus 9.56; P < .001) per injury. An average of 2.24 ± 1.33 AT services were reported per ATR visit. Compared with TL injuries, NTL injuries had a larger average number of AT services per ATR visit (2.28 versus 2.05; P < .001).

CONCLUSIONS

These findings highlight the broad spectrum of care provided by ATs to high school student-athletes and demonstrate that patients with NTL injuries require substantial amounts of AT services.

Staffing Levels at National Collegiate Athletic Association Football Bowl Subdivision-Level Institutions

CONTEXT

The "Appropriate Medical Coverage for Intercollegiate Athletics" (AMCIA) document was created to support assessment and calculation of athletic training personnel requirements. However, little is known regarding disparities between current and recommended staffing practices.

OBJECTIVE

To identify the staffing and employment characteristics of athletic health care services at Football Bowl Subdivision-level institutions.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

Head athletic trainers and athletic training staff members who were knowledgeable about budget and staff.

MAIN OUTCOME MEASURE(S)

The survey, Assessment of Staffing Levels at National Collegiate Athletic Association Football Bowl Subdivision-Level Institutions, was used to evaluate personal, university, and staff demographics; staffing and employment topics; and AMCIA variables and use.

RESULTS

The survey was accessed and partially completed by 104 individuals (response rate = 84.6%). A total of 79 athletic trainers (response rate = 76%) completed the entire survey. One-third of the respondents (34.2%, n = 26) met the recommended number of full-time equivalents (FTEs) for football, two-thirds of the respondents (65.7%, n = 50) failed to meet the recommendation, and 26.2% (n = 27) were missing data needed for FTE calculation. Among those who did not meet the recommended FTEs (n = 50), 38.0% (n = 19) were within 1 FTE of being compliant, 26.0% (n = 13) were within 2 FTEs, and 24.0% (n = 12) were within 3 FTEs. About one-third of respondents (35.9%, n = 37) reported not using the AMCIA, citing lack of funding (29.7%, n = 11), lack of administrative support (21.6%, n = 8), and other reasons (37.8%, n = 14).

CONCLUSIONS

The majority of institutions that used the AMCIA were able to provide justification for staffing. For most of the institutions that failed to meet their recommendation, adding 1-3 FTE athletic trainers for football would change their compliance status. A uniform definition of the term FTE within collegiate athletics is needed to allow for structured assessment and allocation of staffing and workloads.

Acute injuries in track and field athletes: a 3-year observational study at the Penn Relays Carnival with epidemiology and medical coverage implications

BACKGROUND

Few studies have examined acute injuries in track and field in both elite and subelite athletes.

PURPOSE

To observe the absolute number and relative rates of injury in track and field athletes across a wide range of competition levels and ages during 3 years of the Penn Relays Carnival to assist with future medical coverage planning and injury prevention strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Over a 3-year period, all injuries treated by the medical staff were recorded on a standardized injury report form. Absolute number of injuries and relative injury rates (number of injuries per 1000 competing athletes) were determined and odds ratios (ORs) of injury rates were calculated between sexes, competition levels, and events. Injuries were also broken down into major or minor medical or orthopaedic injuries.

RESULTS

Throughout the study period, 48,473 competing athletes participated in the Penn Relays Carnival, and 436 injuries were sustained. For medical coverage purposes, the relative rate of injury subtypes was greatest for minor orthopaedic injuries (5.71 injuries per 1000 participants), followed by minor medical injuries (3.42 injuries per 1000 participants), major medical injuries (0.69 injuries per 1000 participants), and major orthopaedic injuries (0.18 injuries per 1000 participants). College/elite athletes displayed the lowest relative injury rate (7.99 injuries per 1000 participants), which was significantly less than that of high school (9.87 injuries per 1000 participants) and masters athletes (16.33 injuries per 1000 participants). Male athletes displayed a greater likelihood of having a minor orthopaedic injury compared with female athletes (OR, 1.36 [95% CI, 1.06-1.75]; χ2 = 5.73; P = .017) but were less likely to sustain a major medical injury (OR, 0.33 [95% CI, 0.15-0.75]; χ2 = 7.75; P = .005). Of the 3 most heavily participated in events, the 4 × 400-m relay displayed the greatest relative injury rate (13.6 injuries per 1000 participants) compared with the 4 × 100-m and 4 × 200-m relays.

CONCLUSION

Medical coverage teams for future large-scale track and field events need to plan for at least 2 major orthopaedic and 7 major medical injuries per 10,000 participants. Male track and field athletes, particularly masters male athletes, are at greater risk of injury compared with other sexes and competition levels.

Injury and treatment characteristics of sport-specific injuries sustained in interscholastic athletics: a report from the athletic training practice-based research network

Background:

The inclusion of clinical practice factors, beyond epidemiologic data, may help guide medical coverage and care decisions.

Hypothesis:

Trends in injury and treatment characteristics of sport-specific injuries sustained by secondary school athletes will differ based on sport.

Study Design:

Retrospective analysis of electronic patient records.

Level of evidence:

Level 4.

Methods:

Participants consisted of 3302 boys and 2293 girls who were diagnosed with a sport-related injury or condition during the study years. Injury (sport, body part, diagnosis via ICD-9 codes) and treatment (type, amount, and duration of care) characteristics were grouped by sport and reported using summary statistics.

Results:

Most injuries and treatments occurred in football, girls’ soccer, basketball, volleyball, and track and field. Sprain or strain of the ankle, knee, and thigh/hip/groin and concussion were the most commonly documented injuries across sports. The injury pattern for boys’ wrestling differed from other sports and included sprain or strain of the elbow and neck and general medical skin conditions. The most frequently reported service was athletic training evaluation/reevaluation treatment, followed by hot/cold pack, therapeutic exercise, manual therapy techniques, electrical stimulation, and strapping of lower extremity joints. Most sports required 4 to 5 services per injury. With the exception of boys’ soccer and girls’ softball, duration of care ranged from 10 to 14 days. Girls’ soccer and girls’ and boys’ track and field reported the longest durations of care.

Conclusion:

Injury and treatment characteristics are generally comparable across sports, suggesting that secondary school athletic trainers may diagnose and treat similar injuries regardless of sport.

Clinical Relevance:

Subtle sport trends, including skin conditions associated with boys’ wrestling and longer duration of care for girls’ soccer, are important to note when discussing appropriate medical coverage and care.

Characterization of medical care at the 161-km Western States Endurance Run

OBJECTIVE

To examine the medical care at a highly competitive 161-km mountain ultramarathon.

METHODS

Encounter forms from the 2010 through 2013 Western States Endurance Run were analyzed for trends in consultation and use of intravenous fluids.

RESULTS

A total of 63 consultations (8.2% of starters) were documented in 2012 and 2013, of which 10% involved noncompetitors. Most (77%) of the consultations with competitors occurred on the course rather than at the finish line, and were generally during the middle third of the race. Of the on-course consultations, the runner was able to continue the race 55% of the time, and 75% of those who continued after consultation ultimately finished the race. Relative number of consultations did not differ among competitors within 10-year age groups (P = .7) or between men and women (P = .2). Overall, consultations for medical issues were predominant, and nausea and vomiting accounted for the single highest reason for consultation (24%). Although there was an overall decrease in finish line consultations and intravenous fluid use from 2010 through 2013 (P < .0001 for both) that was independent of maximum ambient temperature (P = .3 and P = .4), the proportion of those being treated with intravenous fluids relative to those receiving consultation at the finish line was directly related to maximum ambient temperature (r = .93, P = .037). Both 2012 and 2013 had a single medical emergency that required emergency evacuation.

CONCLUSIONS

This work demonstrates that the medical needs in a 161-km ultramarathon are mostly for minor issues. However, occasional serious issues arise that warrant a well-organized medical system.