The impact of high school athletic trainer services on medical payments and utilizations: a microsimulation analysis on medical claims

The Social Determinants of Health and Athletic Trainer Availability in Indiana Secondary Schools

CONTEXT

The social determinants of health (SDOH) are circumstances under which individuals are born, work, and live that influence health outcomes. Previous researchers have examined 1 determinant of economic stability and found disparities in socioeconomic status and athletic trainer (AT) availability.

OBJECTIVE

To examine the SDOH characteristics of Indiana secondary schools and AT availability.

DESIGN

Cross-sectional study.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

A total of 426 secondary schools.

MAIN OUTCOME MEASURE(S)

All data were collected from publicly available databases. The independent variable was AT availability, and schools were classified as having a full-time AT, a part-time AT only, or no AT. The SDOH variables were gathered for each school (at the school and county levels). Data were summarized using measures of central tendencies, 1-way analysis of variance, and Kruskal-Wallis tests.

RESULTS

School enrollment was larger in schools with greater AT availability (P< .001). The proportion of non-White students was greater in schools with more AT availability (P= .002). Greater AT availability was present in counties with higher graduation rates (P= .03). Post hoc comparisons revealed differences in graduation rates between schools with a part-time AT and those with no AT (P= .04). Schools with less AT availability were located in counties with a slightly higher percentage of the population uninsured (P= .02). Schools with greater AT availability were located in counties with a higher ratio of population to primary care physicians (P= .03). Schools with less AT availability were located in counties with a higher population experiencing severe housing problems (P= .02). No differences were found in AT availability based on the 3 social and community context variables (P> .05).

CONCLUSIONS

Differences were noted in AT availability and SDOH characteristics at the secondary school level. We observed less AT availability where high school graduation rates and the population of primary care providers were lower. Strategies should be implemented to improve access to athletic health care in underresourced communities.

Exertional Heat Illness: Adoption of Policies and Influencing Contextual Factors as Reported by Athletic Administrators

BACKGROUND

Little is known about the adoption by athletic administrators (AAs) of exertional heat illness (EHI) policies, and the corresponding facilitators and barriers of such policies within high school athletics. This study describes the adoption of comprehensive EHI policies by high school AAs and explores factors influencing EHI policy adoption.

HYPOTHESIS

We hypothesized that <50% of AAs would report adoption of an EHI policy, and that the most common facilitator would be access to an athletic trainer (AT), whereas the most common barrier would be financial limitations.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 466 AAs (82.4% male; age, 48 ± 9 years) completed a validated online survey to assess EHI prevention and treatment policy adoption (11 components), as well as facilitators and barriers to policy implementation. Access to athletic training services was ascertained by matching the participants' zip codes with the Athletic Training Locations and Services Project. Policy adoption, facilitators, and barriers data are presented as summary statistics (proportions, interquartile range (IQR)). A Welch t test evaluated the association between access to athletic training services and EHI policy adoption.

RESULTS

Of the AAs surveyed, 77.9% (n = 363) reported adopting a written EHI policy. The median of EHI policy components adopted was 5 (IQR = 1,7), with only 5.6% (n = 26) of AAs reporting adoption of all policy components. AAs who had access to an AT (P = 0.04) were more likely to adopt a greater number of EHI-related policies, compared with those without access to an AT. An AT employed at the school was the most frequently reported facilitator (36.9%).

CONCLUSION

Most AAs reported having written EHI policy components, and access to an AT resulted in a more comprehensive policy.

CLINICAL RELEVANCE

Employment of an AT within high school athletics may serve as a vital component in facilitating the adoption of comprehensive EHI policies.

Access to Athletic Trainers and Emergency Medical Services Activations for Sport-Related Injuries

CONTEXT

Having athletic trainers (ATs) employed at secondary schools is associated with improved preparedness for sport-related emergencies. The use of emergency medical services (EMS) in settings with different access to athletic training services remains unknown.

OBJECTIVE

To compare the incidence of EMS activations for patients with sport-related injuries among zip codes with various levels of access to athletic training services.

DESIGN

Descriptive epidemiology study.

SETTING

Data were obtained from the National EMS Information System and the Athletic Training Location and Services Project.

PATIENTS OR OTHER PARTICIPANTS

Zip codes where 911 EMS activations for sport-related injuries among individuals 13 to 18 years old occurred.

MAIN OUTCOME MEASURE(S)

Incidence of EMS activations, athletic training service level (no ATs employed [NONE], less than full-time employment [PARTIAL], all ATs employed full time [FULL]), and athletic training employment model (independent contractor [IC], medical or university facility [MUF], school district [SD], mixed employment models [MIX]) for each zip code.

RESULTS

The EMS activations were 2.8 ± 3.6 per zip code (range = 1-81, N = 4923). Among zip codes in which at least 1 AT was employed (n = 2228), 3.73% (n = 83) were IC, 38.20% (n = 851) were MUF, 27.24% (n = 607) were SD, and 30.83% (n = 687) were MIX. Compared with SD, MUF had a 10.8% lower incidence of EMS activations (incidence rate ratio [IRR] = 0.892; 95% CI = 0.817, 0.974; P = .010). The IC (IRR = 0.920; 95% CI = 0.758, 1.118; P = .403) and MIX (IRR = 0.996; 95% CI = 0.909, 1.091; P = .932) employment models were not different from the SD model. Service level was calculated for 3834 zip codes, with 19.5% (n = 746) NONE, 46.2% (n = 1771) PARTIAL, and 34.4% (n = 1317) FULL. Compared with NONE, FULL (IRR = 1.416; 95% CI = 1.308, 1.532; P < .001) and PARTIAL (IRR = 1.368; 95% CI = 1.268, 1.476; P < .001) had higher incidences of EMS activations.

CONCLUSIONS

Local access to athletic training services was associated with an increased use of EMS for sport-related injuries among secondary school-aged individuals, possibly indicating improved identification and triage of sport-related emergencies in the area. The difference in EMS use among employment models may reflect different policies and procedures for sport-related emergencies.

Differences in Access to Athletic Trainers in Public Secondary Schools Based on Socioeconomic Status

CONTEXT

Significant health care disparities exist in the United States based on socioeconomic status (SES), but the role SES has in secondary school athletes' access to athletic training services has not been examined on a national scale.

OBJECTIVE

To identify differences in access to athletic training services in public secondary schools based on school SES.

DESIGN

Cross-sectional study.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

Data for 3482 public high schools.

MAIN OUTCOME MEASURE(S)

Data were gathered from the Athletic Training Locations and Services (ATLAS) database, US Census Bureau, and National Center for Education Statistics. We included schools from 5 states with the highest, middle, and lowest poverty percentages (15 states total) and collected county median household income, percentage of students eligible for free or reduced-price lunch, race and ethnicity demographics, and access to athletic training services (full-time athletic trainer [AT], part-time AT only, no AT) for each school. Data were summarized in means, SDs, medians, interquartile ranges (IQRs), frequencies and proportions, 1-way analyses of variance, and Kruskal-Wallis tests.

RESULTS

Differences were present in school SES between schools with full-time, part-time-only, and no athletic training services. Schools with greater access to athletic training services had fewer students eligible for free or reduced-price lunch (full time: 41.1% ± 22.3%, part time only: 45.8% ± 24.3%, no AT: 52.9% ± 24.9; P < .001). Similarly, county median household income was higher in schools with increased access to athletic training services (full time median [IQR]: $56 026 [$49 085-$64 557], part time only: $52 719 [$45 355-$62 105], and no AT: $49 584 [$41 094-$57 688]; P < .001).

CONCLUSIONS

Disparities in SES were seen in access to athletic training services among a national sample of public secondary schools. Access to ATs positively influences student-athletes' health care across several measures. Pilot programs or government funds have been used previously to fund athletic training services and should be considered to ensure equitable access, regardless of school SES.

Effects of Athletic Trainer Direct Employment on the Management of Sports-Related Injuries in High School Athletes

BACKGROUND

Hiring athletic trainers (ATs) in high schools has attracted rising interest as a potential way of improving adolescents' health by enhancing their safety and reducing their risk of injury.

OBJECTIVE

This study aims to determine if there is a difference in the referral patterns, injury diagnoses, and injury treatments performed at a metropolitan high school when an AT is employed versus not employed by the school.

DESIGN

This is a retrospective quantitative two-period study.

SETTING

The study was conducted in the high school athletic department in Norfolk, Virginia, and the study population was high school athletes (age 14-18).

MAIN OUTCOME MEASURES

Changes in referral patterns, injury diagnoses, and injury treatments performed at a local high school when an AT is employed versus not employed by the school; specifically, we examined the number of and percent changes in yearly treatments, referrals, evaluations, and re-evaluations during the two periods.

RESULTS

Our first t-test revealed a statistically significant increase in the number of reported injuries between 2011-2015 (M = 58.00, SD = 44.86) and 2016-2020 (M = 299.00, SD = 40.93, p = 0.006. The second t-test revealed a statistically significant increase in the number of referrals between 2011-2015 (M = 249.00, SD = 353.41) and 2016-2020 (M = 1188.00, SD = 158.21), p = 0.014. The third t-test revealed a statistically significant increase in the number of treatment items between 2011-2015 (M = 150.67, SD = 175.32) and 2016-2020 (M = 636.67, SD = 211.72), p = 0.01.

CONCLUSIONS

The present study found an increased frequency of reported injuries, referrals, and treatment after ATs directly joined the staff of a large metropolitan high school. These findings suggest that direct employment of ATs is associated with greater recording of injuries and treatment of conditions. A reduction in referrals occurs with the presence of directly employed ATs, which could result in improved health for student-athletes, but this needs further study.

Evidence for Economic Evaluations of Athletic Trainer Services

OBJECTIVE

Literature suggests athletic trainers (ATs) can help address health needs in a more affordable way across a variety of settings. We aimed to assess if AT services are cost-effective when compared to no AT services or services by other health providers.

DATA SOURCES

We performed a keyword search in 5 databases: Medline (FirstSearch), PubMed, Web of Science, SPORTDiscus, and Google scholar. We also conducted a generic web search to identify any informal sources that may meet the eligibility criteria.

STUDY SELECTION

We used a comprehensive list of terms to search economic evaluation studies on ATs. We included studies that met all the following criteria: economic evaluation studies on AT services; original studies written in English; and published in the last 10 years(2011-present). we excluded studies that examined either only cost or only benefit of AT services.

DATA EXTRACTION

We extracted data using a predefined checklist that included major components of economic evaluation. We also extracted data regarding athletic training practice setting.

RESULTS

We extracted 5 articles in our review, most of which supported the use of AT services as economically viable. The practice settings studied in the articles included two high school settings, two military settings, and a community outreach program that included several practice settings. Only one of the studies used standard economic evaluation methodology and took insurance status into account.

CONCLUSION

Our review shows that AT services can be a cost-effective option for addressing health care needs. However, the literature remains sparse and there was an overall lack of consistency in outcome measures, analytical methods, and reporting practices, which reduced the comparability across studies. Future studies on this topic should address these limitations, which will provide critical economic evidence to inform decision making on investing in AT services across various settings.

Secondary School Socioeconomic Status and Athletic Training Practice Characteristics

CONTEXT

Socioeconomic status (SES) is a significant predictor of morbidity and mortality across health outcomes. Limited information exists on how school SES impacts athletic training practice when a certified athletic trainer (AT) is present at secondary schools.

OBJECTIVE

To describe contact frequencies and service rates provided by ATs for injuries among secondary school student athletes and how these differ by school SES.

DESIGN

Cross-sectional study Setting: Athletic training room (ATR) visit days and AT services were collected from 77 secondary schools. Schools were separated into three school SES groups: affluent (n=31), average (n=29), and disadvantaged (n=17).

PATIENTS OR OTHER PARTICIPANTS

Secondary school student-athletes participating in 12 boys' and 11 girls' sports who visited the ATR during the 2014-2015 through 2018-2019 academic years and received athletic or non-athletic injury care.

MAIN OUTCOME MEASURES

Contact frequencies expressed as ATR visit days per injury, AT services per injury, and AT services per ATR visit day. Rates for service type utilized were expressed as the total count over reported athlete-exposures.

RESULTS

ATs documented 1,191 services. Affluent and average SES school communities provided greater contact frequencies for injury related care compared to disadvantaged school communities, particularly by AT services/injury (7.10±13.08 versus average: 9.30±11.60 and affluent: 9.40±12.20; p=0.020). Affluent school communities provided greater rates of services in five of the eleven service groups reported. No significant differences were observed among school SES groups in therapeutic exercises.

CONCLUSIONS

Our findings reflect that AT practice characteristics may differ by school SES, but these differences do not appear to result in less medical care. Given the complexity and widespread effects of SES, future investigations should utilize a complex method to determine SES as well as aim to identify how SES may impact secondary school student athletes outside of AT practice characteristics.