Athletic Directors' Barriers to Hiring Athletic Trainers in High Schools

Epidemiology of Bone-Stress Injuries and Health Care Use in Pac-12 Cross-Country Athletes

CONTEXT

Bone-stress injury (BSI) is common in collegiate athletes. Injury rates and health care use in running athletes are not well documented.

OBJECTIVE

To describe the rate and classification of injury and associated health care use in collegiate cross-country runners with BSI.

DESIGN

Descriptive epidemiology study.

SETTING

Sports medicine facilities participating in the Pac-12 Health Analytics Program.

PATIENTS OR OTHER PARTICIPANTS

Pac-12 Conference collegiate cross-country athletes.

MAIN OUTCOME MEASURE(S)

Counts of injury and health care resources used for each injury. Injury rates were calculated based on athlete-seasons.

RESULTS

A total of 168 BSIs were reported over 4 seasons from 80 team-seasons (34 men's and 46 women's team-seasons) and 1220 athlete-seasons, resulting in 1764 athletic training services and 117 physician encounters. Bone-stress injuries represented 20% of all injuries reported by cross-country athletes. The average BSI rate was 0.14 per athlete-season. Injury rates were higher in female (0.16) than male (0.10) athletes and higher in the 2019-2020 season (0.20) than the 2020-2021 (0.14), 2018-2019 (0.12), and 2021-2022 (0.10) seasons. Most BSIs occurred in the lower leg (23.8%) and the foot (23.8%). The majority of injuries were classified as overuse and time loss (72.6%) and accounted for most of the athletic training services (75.3%) and physician encounters (72.6%). We found a mean of 10.89 athletic training services per overuse and time-loss injury and 12.20 athletic training services per overuse and non-time-loss injury. Mean occurrence was lower for physician encounters (0.70), prescription medications (0.04), tests (0.75), procedures (0.01), and surgery (0.02) than for athletic training services (10.50).

CONCLUSIONS

Bone-stress injuries are common in collegiate cross-country runners and require considerable athletic training resources. Athletic trainers should be appropriately staffed for this population, and suspected BSIs should be confirmed with a medical diagnosis. Future investigators should track treatment codes associated with BSI to determine best-practice patterns.

Neighborhood Context as a Barrier to Sport Participation for Girls: Evidence From a Sport Diversity Index

BACKGROUND

Evidence suggests neighborhood contexts play a vital role in shaping the availability and diversity of youth sport and participation rates, especially for African American or Black girls. Currently, no index captures interscholastic sport opportunities (eg, sport diversity) within and across school districts and specifically applied to African American or Black girls.

OBJECTIVE

To visualize the inequalities present in interscholastic sport opportunities for girls across school districts using a novel index in a selected study area of St Louis City and County, Missouri, and discuss the implications for African American or Black girls.

DESIGN

Cross-sectional study.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

Data for 47 public high schools in the 23 St Louis City and County school districts.

MAIN OUTCOME MEASURE(S)

We gathered data from the 2014-2018 American Community Survey and Missouri State High School Activities Association. We assessed sport diversity for girls by constructing a sport diversity index (SDI) that uses an entropy index as its foundation. Census-tract data were used to examine the association with neighborhood demographics and contributors to school district income and sport diversity. Descriptive spatial statistics were calculated to evaluate distributions in St Louis City and County, with the bivariate local indicator of spatial autocorrelation used to determine any correlations between variables of interest.

RESULTS

The St Louis City school district, which has areas with high rates of renter-occupied housing and poverty and high percentages of non-Hispanic African American or Black students, had the lowest SDI for girls, contrasted with the school districts in St Louis County, which showed an inverse pattern on average. The SDI for girls was correlated with the percentages of renter-occupied housing and poverty. The SDI for girls was also correlated with race: an increasing presence of the non-Hispanic African American or Black population was associated with decreased sport diversity for girls.

CONCLUSIONS

The SDI for girls demonstrated a spatial association with neighborhood-level determinants of sport-opportunity availability for non-Hispanic African American or Black girls in St Louis. The role of social and political determinants of health in shaping community context and resultant health in athletic training research, policy, and practice should be considered.

A Roadmap for Sustainable Community-Engaged Partnerships in Athletic Training and Using a Traveling Athletic Training Camp as an Implementation Strategy

Improving access to athletic trainers and increasing diversity in the profession have been major goals of the Strategic Alliance, with a particular interest in the secondary school setting. Within many marginalized communities, individuals are often faced with a lack of resources, high rates of poverty, and limited access to health care. This social and economic climate often extends to inequitable athletic training services and patterns of disparate health. Widely used and recognized strategies to cultivate diversity and address health inequities include community-engaged partnerships; however, these approaches are not well implemented across the athletic training discipline. Successful community-engaged partnerships link communities and universities, and they are rooted in intentionality to address intermediate and long-term health equity outcomes. Athletic training professionals and scholars frequently encounter gaps in resources and process-oriented methods to participate in community-engaged efforts that could include a roadmap or pathway to follow. To bridge this gap, our aims were 2-fold: (1) to disseminate a roadmap for building sustainable community-engaged partnerships in athletic training with the intent of promoting diversity, equity, inclusion, and social justice across athletic training education, research, and professional service and (2) to demonstrate how the roadmap can be implemented using a community-based athletic training education camp as an example. Implementation of the athletic training camp using the roadmap took place at secondary schools where community-engaged partnerships have been established throughout a geographic region known as the Alabama Black Belt, a region burdened with poor health outcomes, limited athletic trainer presence, and lower quality of life, exacerbated by racial and socioeconomic inequalities. Implementing this roadmap as a strategy to build sustainable community-engaged partnerships offers an innovative, interactive, and effective approach to addressing community needs by exposing secondary school students to the athletic training profession, advancing equitable athletic training research practices, and upholding and promoting the principles of diversity, equity, inclusion, and social justice in athletic training education.

Geographic Disparity in Distance to Trauma Care in Secondary Schools Across the United States

CONTEXT

Geographic disparities exist in trauma care (ie, "trauma center desert") within the United States. An athletic trainer (AT) on site at secondary schools (SSs) may help enhance collaboration with emergency medical systems and potentially lead to better outcomes after catastrophic injuries. However, access to AT services relative to the location of level I or II (ie, tertiary) trauma centers remains unknown.

OBJECTIVES

To visualize and describe the distance between SSs and trauma centers and compare access to AT services across the United States.

DESIGN

Cross-sectional study.

SETTING

Public and private SSs with interscholastic athletics programs in the United States.

PATIENTS OR OTHER PARTICIPANTS

Survey data obtained through the Athletic Training Locations and Services (ATLAS) project database between September 2019 and April 2023.

MAIN OUTCOME MEASURE(S)

The minimum distance from each SS to a tertiary trauma center was calculated on Tableau Desktop by geocoding with longitude and latitude. The status and level of AT employment were obtained from the ATLAS project database. The odds and percentages of access to AT services were examined by distance ranges.

RESULTS

A total of 18 244 SSs were included in the analyses. Of these, 75% (n = 13 613) were located within 50 miles (81 km) of a tertiary trauma center. The odds of access to AT services were 2.74 (95% CI = 2.56, 2.93) times greater in SSs situated within 50 miles of a tertiary trauma center (P < .001). Additionally, SSs located more than 60 miles (97 km) from a tertiary trauma center had decreased access to AT services (R2 = 0.9192).

CONCLUSION

This study highlighted the geographic disparities in distance to trauma care for SSs in the United States. Those SSs located more than 60 miles from trauma centers had reduced odds of access to AT services. Identification of geographic trends of AT services relative to the location of tertiary trauma centers is a critical first step in preventing fatal consequences of catastrophic injuries.

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.

Practices and Perceptions of Family-Centered Care: A Cross-Sectional Survey of Secondary School Athletic Trainers

Family-centered care (FCC) includes collaboration between families and healthcare providers, the creation of flexible policies, and the family taking an active role in the delivery of care. Secondary school athletic trainers provide care for underage patients in school-based health systems, making them responsible for maintaining communication with parents, guardians, and/or caregivers. This cross-sectional survey investigated the extent to which athletic trainers (n = 205) include aspects of FCC in their daily secondary school clinical practice (current practices = CP) and whether they believe that aspect of care is necessary for FCC to be provided in athletic training (perceived necessary = PN) in their everyday practice using the Family-Centered Care Questionnaire-Revised tool. The total mean score for the CP scale (mean = 26.83 ± 4.36) was significantly lower (p ≤ 0.01) than the PN scale (mean = 35.33 ± 4.17). All FCC subscales compared between CP and PN were significantly different (p ≤ 0.01), with each being of higher importance than CP in athletic training. Data analysis revealed four themes related to enhancing FCC in secondary schools: limited education and resources, staffing and space concerns, non-technical skills, and social determinants of health. Attention should be placed on developing resources and interventions for secondary school athletic trainers to collaboratively work with children and their support systems.

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.

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.

Medical Supervision of Illinois Public and Private High School Athletics

BACKGROUND

High-school sports participation in the United States has increased over the years with a corresponding increase in the number of injuries. Leading medical and sports organizations nationwide advocate for an increase in proper medical supervision of athletes.

OBJECTIVES

To analyze athletic medical coverage in Illinois high schools and compare differences between public and private Illinois high school.

METHODS

A survey addressing various components of sports medical coverage was distributed in 2018 to all 810 Illinois High School Association (IHSA) high schools to be completed electronically.

RESULTS

The response rate was 50% (407/810 schools). Of the responding schools, 14% were private high schools and 86% public high schools. An orthopedic surgeon, family doctor, pediatrician, or another type of physician were present on sidelines in 9.2% of private high schools and 8.5% of public high schools. Athletic trainers (ATs) were present on sidelines in 91% of private high schools and in 79% of public high schools. There was 68% of private high schools reporting coaches trained in CPR versus 85% in public high schools. Both private and public high schools had high rates of having written emergency action plans (89% vs 91%), AED on site (100% vs 99%), written concussion management protocols (96% vs 97%).

CONCLUSION

Our study found similar rates of high school medical coverage as compared to national studies, with some significant differences found between private and public high schools. Most Illinois high schools had high rates of having written EAPs, concussion management protocols and AEDs on site. Overall, an increase of medical supervision and emergency preparedness is needed, which should come in the form of increasing AT and physician presence alongside community and school engagement for improved implementation of coverage.

Perceived Management of Acute Sports Injuries and Medical Conditions by Athletic Trainers and Physical Therapists

BACKGROUND

While Athletic Trainers' (ATs) education emphasizes sport event coverage, Physical Therapists' (PTs) education may prepare them for event coverage responsibilities. The objectives of this study were to compare the perceived preparedness and decision-making related to acute injury/medical condition management among ATs and PTs and evaluate the relationship between perceived preparedness and decision-making.

HYPOTHESIS

ATs would report greater perceived preparedness and appropriate decision-making related to acute injury/medical conditions compared to PTs.

STUDY DESIGN

Cross-sectional, Online survey.

METHODS

An electronic survey was disseminated to licensed ATs (n=2,790) and PTs (n=10,207). Survey questions focused on perceived preparedness for management of acute injuries/medical conditions. Respondents also completed questions that assessed clinical decision-making related to acute injury case scenarios. Kruskal-Wallis H-Tests and Spearman's Rho Correlations were used for the analysis. Significance was set to p<0.003 after adjustment for family-wise error.

RESULTS

Six-hundred and fifty-five respondents (292 ATs, 317 PTs, 46 dual credentialed PT/ATs) completed the entire survey. ATs had the highest level of perceived preparedness of all the groups (p<0.0003). Greater than 75% of PTs responded either "appropriately" or "overly cautious" to 10 of the 17 case scenarios, as opposed to 11 of the 17 case scenarios by ATs. Greater than 75% of the PTs who were board specialty certified in sports responded either "appropriately" or "overly cautious" to 13 case scenarios.

CONCLUSION

More ATs than PTs perceived themselves to be prepared to manage acute injuries/ medical conditions. Further, results indicate that PTs may be an effective and safe provider of event coverage. Conditions/injuries with low perceived preparedness or poor performance may offer both ATs and PTs an opportunity to identify areas for future training and education to optimize care for athletes with acute injuries or medical conditions.

LEVEL OF EVIDENCE

Level 3b.

Secondary School Administrators' Knowledge and Perceptions of the Athletic Training Profession, Part I: Specific Considerations for Athletic Directors

CONTEXT

Athletic directors are charged with making impactful decisions for secondary school athletic programs that mitigate risks for stakeholders. This includes decision making regarding the provision of medical care for student-athletes. To date, few researchers have explored athletic directors' perceptions of the athletic training profession.

OBJECTIVE

To evaluate public school athletic directors' knowledge and perceptions of the athletic trainer (AT) role.

DESIGN

Concurrent mixed-methods study.

SETTING

Cross-sectional online questionnaire.

PATIENTS OR OTHER PARTICIPANTS

Athletic directors representing all 50 states and the District of Columbia (N = 954; 818 men, 133 women, 3 preferred not to answer; age = 47.8 ± 9.1 years; time in current role = 9.8 ± 8.3 years).

MAIN OUTCOME MEASURE(S)

The questionnaire was composed of demographics, quantitative measures that assessed athletic directors' knowledge and perceived value of ATs, and open-ended questions allowing for expansion on their perspectives. Descriptive statistics were reported, with key quantitative findings presented as count responses and overall percentages. Qualitative data were analyzed using the general inductive approach.

RESULTS

A majority of respondents recognized ATs' role in injury prevention (99.8%), first aid and wound care (98.8%), therapeutic interventions (93.8%), and emergency care (91.6%). Approximately 61% (n = 582) identified AT employment as a top sport safety measure, and 77% (n = 736) considered an AT to be extremely valuable to student-athlete health and safety. Athletic directors appeared to recognize the value of ATs as they provided "peace of mind" and relieved coaches and administration of the responsibility for making medical decisions.

CONCLUSIONS

Athletic directors seemed to recognize the value ATs brought to the secondary school setting and demonstrated adequate knowledge regarding ATs' roles and responsibilities. Educational efforts for this population should focus on ATs' tasks that add to their perceived value but are not frequently in the public eye, which may influence hiring decisions.

Athletic Trainers' Perceptions of Accessibility to Necessary Resources for Those Working Per Diem Services

CONTEXT

As the demand for athletic training services has grown, the per diem athletic training setting has expanded to fulfill this need. Per diem services are provided by athletic trainers (ATs) who are hired as independent contractors for short time periods. These service opportunities help to increase access to care for medically underserved populations; however, due to the transient nature of the work, the quality of care may be compromised.

OBJECTIVE

To examine current practices in per diem services and evaluate ATs' accessibility to resources.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 448 participants responded (access rate = 9.57%), of whom 210 were ineligible (46.9%). Of those who were eligible, 192 participants completed the entire tool (completion rate = 80.7%, age = 38 ± 12 years, years certified = 14 ± 11, years providing per diem services = 8 ± 8).

MAIN OUTCOME MEASURE(S)

The survey comprised 3 sections: (1) demographics, (2) accessibility to resources and influence on patient care, and (3) domains of athletic training while providing per diem services. Resources assessed included those that are relevant to ATs practicing in accordance with the Board of Certification "Standards of Professional Practice." The final instrument included approximately 30 questions (depending on display logic) and took an average of 12 minutes to complete.

RESULTS

Of the 11 primary resources assessed, participants had limited accessibility to 6. Critical resources related to informatics, legalities, and health care delivery were often not available, were seen as unimportant to providing medical services, or both.

CONCLUSIONS

Participants indicated varied perceptions about the need for and access to these resources. Yet such resources contribute to the creation of a safe infrastructure for providing medical services and should be part of the routine dialogue regarding independent contracting.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

BACKGROUND

Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years).

METHODS

A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant.

RESULTS

Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47).

CONCLUSION

Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Athletic training employment in secondary schools by geographic setting and school size within the United States

CONTEXT

The Athletic Training Locations and Services (ATLAS) Annual Report suggests there are differences in athletic trainer (AT) employment status on the basis of geographic locale. However, the influence of geographic locale and the school size on AT employment is undetermined.

OBJECTIVE

To describe if differences exist in the odds of having AT services by locale for public and private schools, and by student enrollment for public schools.

DESIGN

Cross-sectional study.

SETTING

Public and private secondary schools with athletics programs.

PATIENTS OR OTHER PARTICIPANTS

Data from 20,078 US public and private secondary schools were obtained.

MAIN OUTCOME MEASURES(S)

Data were collected by the ATLAS Project. AT employment status, locales (City, Suburban, Town, and Rural) for public and private schools, and school size category (large, moderate, medium, and small) only for public schools were obtained. AT employment status was examined for each category with odds ratios. A prediction model was produced by Logistic Regression Analysis.

RESULTS

Of the 19,918 public and private schools with AT employment status and locale, Suburban schools had the highest access to AT services (80.1%) with an increased odds compared with Rural schools (OR = 3.55 [3.28 to 3.850]). Of 15,850 public schools with AT employment status and student enrollment, large schools had the highest rate of having AT services (92.1%) with nearly 18.5 times greater odds (OR = 18.480 [16.197 to 21.083]) versus small schools. The logistic model determined that an odds of having access to AT increases by 2.883 times as the school size goes up by one category.

CONCLUSIONS

Nationally, Suburban schools and large public schools have the largest access to AT services compared to schools that are in more remote areas and with less student enrollment. These findings elucidate the geographic locales and student enrollment levels where AT services are most prevalent.

Practices of Athletic Trainers Using Weight Charts to Determine Hydration Status and Fluid-Intervention Strategies

CONTEXT

Determining an athlete's hydration status allows hydration-related concerns to be identified before significant medical or performance concerns arise. Weight charts are an accurate measure of hydration status changes, yet their clinical use by athletic trainers (ATs) is unknown.

OBJECTIVE

To investigate ATs' use of weight charts in athletic settings and describe their subsequent clinical decisions.

DESIGN

Cross-sectional survey.

SETTING

High schools and National Collegiate Athletic Association Divisions I, II, III and National Association Intercollegiate Athletics colleges.

PATIENTS OR OTHER PARTICIPANTS

A total of 354 ATs (men = 162, women = 175; 17 respondents did not answer the demographic questions) responded across athletic settings (Division I [45.7%]; Division II, Division III, National Association Intercollegiate Athletics combined [n = 19.9%]; and high school [34.4%]).

MAIN OUTCOME MEASURE(S)

The 26-question online survey was developed by content experts and pilot tested before data collection. Participants answered questions focused on weight-chart use (implementation, timing, and calculations) and clinical decision processes (policies, interventions, and referral). Frequency statistics were calculated.

RESULTS

The majority of ATs (57.2%) did not use weight charts. Of those who did, most (76.0%) used charts with football, soccer (28%), and wrestling (6%) athletes. They calculated changes as either an absolute (42.2%) or percentage (36.7%) change from prepractice to postpractice; only 11.7% used a baseline weight for calculations. Of those who used the percentage change in body mass, 66.0% selected a threshold of -3% to -4% for an intervention. Most ATs (97.0%) intervened with verbal education, whereas only one-third (37.0%) provided specific fluid amounts based on body mass changes.

CONCLUSIONS

Typically, ATs in athletic settings did not use weight charts. They considered a body mass change of -3% the indication for intervention but did not specify rehydration amounts for hypohydrated athletes. Educational workshops or technology applications could be developed to encourage ATs to use weight charts and calculate appropriate individual fluid interventions for their athletes.

Athletic trainer employment, physician access and care delivery in secondary schools

Objective: To evaluate the source of employment of athletic trainers (ATs), access to team physicians, and usage of up-to-date (implementation of the most current international sports medicine societies' position statements and evidence-based literature policy and procedure manuals in secondary schools. Methods: We conducted a cross-sectional study among National Athletic Trainers' Association (NATA) members. NATA 'Research Survey Request' was contacted to obtain 1,000 e-mail addresses of ATs who actively worked in the secondary school setting. We evaluated AT employment, access to team physicians, and usage of up-to-date policy and procedure manuals within different residential areas (urban, suburban, and rural) and school distinctions (public vs. private). Results: Two-hundred ninety-six responses were received (30% response rate). The majority (72%) of ATs reported having an assigned team physician for their school. Approximately one-third (36%) of ATs reported being employed by a hospital, clinic, or outreach facility. Fifty-one percent of ATs reported having a policy and procedure manual that was developed and reviewed with their team physician. There was a significantly greater amount of suburban ATs who reported having an up-to-date policy and procedure manual (urban 45% vs. suburban 60% vs. rural 39%; p = 0.007). Significantly more ATs who were employed in a public school setting reported conducting annual policy and procedure manual reviews than those employed in private school settings (public 63% vs. private 49%; p = 0.045). Conclusions: The majority of ATs have assigned team physicians and a third is employed by a medical group. A high number of ATs reported not having a policy and procedure manual that was developed and reviewed with their team physician. Sports medicine teams within secondary schools, particularly in private schools, should strive to develop and maintain an up-to-date policy and procedure manual that is frequently reviewed with their team physician.

Emergency Action Plans in Secondary Schools: Barriers, Facilitators, and Social Determinants Affecting Implementation

CONTEXT

Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics.

OBJECTIVE

To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States.

DESIGN

Cross-sectional study.

SETTING

Secondary schools.

PATIENTS OR OTHER PARTICIPANTS

A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey.

MAIN OUTCOME MEASURE(S)

The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant.

RESULTS

Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ² = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]).

CONCLUSIONS

Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

Access to Athletic Trainer Services in California Secondary Schools

CONTEXT

California is currently the only state that does not regulate who can and cannot call themselves athletic trainers (ATs). Therefore, previous national or state-specific investigations may not have provided an accurate representation of AT availability at the secondary school level in California. Similarly, it is unknown whether the factors that influence AT availability in California, such as socioeconomic status, are similar to or different from those identified in previous studies.

OBJECTIVE

To describe the availability of ATs certified by the Board of Certification in California secondary schools and to examine potential factors influencing access to AT services in California secondary schools.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Representatives of 1270 California high schools.

MAIN OUTCOME MEASURE(S)

Officials from member schools completed the 2017-2018 California Interscholastic Federation Participation Census. Respondents provided information regarding school type, student and student-athlete enrollment, whether the school had ATs on staff, and whether the ATs were certified by the Board of Certification. The socioeconomic status of public and charter schools was determined using the percentage of students eligible for free or reduced-price lunch.

RESULTS

More than half (54.6%) of schools reported that they either did not employ ATs (47.6%) or employed unqualified health personnel (UHP) in the role of AT (7.0%). Nearly 30% of student-athletes in California participated in athletics at a school that did not employ ATs (n = 191 626, 28.9%) and 8% of student-athletes participated at a school that employed UHP in the role of AT (n = 54 361, 8.2%). Schools that reported employing ATs had a lower proportion of students eligible for free or reduced-price lunch than schools that did not employ ATs and schools that employed UHP (both P values < .001).

CONCLUSIONS

With ongoing legislative efforts to obtain regulation of ATs in California, secondary school administrators are encouraged to hire ATs with the proper certification to enhance the patient care provided to student-athletes and improve health outcomes.

Athletic Trainer Services in the Secondary School Setting: The Athletic Training Locations and Services Project

CONTEXT

Previous research from a sample of US secondary schools (n = 10 553) indicated that 67% of schools had access to an athletic trainer (AT; 35% full time [FT], 30% part time [PT], and 2% per diem). However, the population-based statistic in all secondary schools with athletic programs (n = approximately 20 000) is yet to be determined.

OBJECTIVE

To determine the level of AT services and employment status in US secondary schools with athletics by National Athletic Trainers' Association district.

DESIGN

Cross-sectional study.

SETTING

Public and private secondary schools with athletics.

PATIENTS OR OTHER PARTICIPANTS

Data from all 20 272 US public and private secondary schools were obtained.

MAIN OUTCOME MEASURE(S)

Data were collected from September 2015 to April 2018 by phone or e-mail communication with school administrators or ATs and by online surveys of secondary school ATs. Employment categories were school district, school district with teaching, medical or university facility, and independent contractor. Data are presented as total number and percentage of ATs. Descriptive statistics were calculated for FT, PT, and no AT services data for public, private, public + private, and employment type by state and by National Athletic Trainers' Association district.

RESULTS

Of the 20 272 secondary schools, 66% (n = 13 473) had access to AT services, while 34% (n = 6799) had no access. Of those schools with AT services, 53% (n = 7119) received FT services, while 47% (n = 6354) received PT services. Public schools (n = 16 076) received 37%, 32%, and 31%, whereas private schools (n = 4196) received 27%, 28%, and 45%, for FT, PT, and no AT services, respectively. Most of the Athletic Training Locations and Services Survey participants (n = 6754, 57%) were employed by a medical or university facility, followed by a school district, school district with teaching, and independent contractor. Combined, 38% of AT employment was via the school district.

CONCLUSIONS

The percentages of US schools with AT access and FT and PT services were similar to those noted in previous research. One-third of secondary schools had no access to AT services. The majority of AT employment was via medical or university facilities. These data depict the largest and most updated representation of AT services in secondary schools.

Medical Supervision of High School Athletics in Chicago: A Follow-up Study

BACKGROUND

High school sports participation in the United States has increased dramatically over the past 25 years. A corresponding increase in the number of injuries has been noted, particularly in contact sports such as football. This has led medical and sports organizations nationwide to advocate for proper medical supervision of athletes at games and practices.

PURPOSE

To gather information from Chicago public high schools to gauge how medical supervision for high school sports has changed in 2017 compared with 2003.

STUDY DESIGN

Cross-sectional study.

METHODS

Survey questionnaires were sent to the athletic directors of all 99 Chicago public high schools to complete via email. The questionnaire survey contained the same questions as in a survey conducted in 2003 by Tonino and Bollier, with the addition of 4 novel questions relating to emergency action plans (EAPs), automated external defibrillators, concussion management policy, and tackling progression drills.

RESULTS

The response rate was 66.67% (66/99 schools). Of the 66 responding schools, all with football programs, no school had a physician on the sideline at home games (decrease from 10.6% in 2003), 37.9% had an athletic trainer present (increase from 8.5% in 2003), and 63.6% had a paramedic available (decrease from 89.4% in 2003). In 2017, 65.6% of responding schools had a coach certified in cardiopulmonary resuscitation (CPR) available at practice to handle medical problems, compared with 89.4% in 2003 (P < .001). Regarding the 4 novel questions, 93.9% of the responding schools had proper tackling progression drills in place, followed by 89.1% who had appropriate EAPs and 93.9% with concussion management protocols, including return-to-play and return-to-learn protocols.

CONCLUSION

Although significant improvement was found in athletic trainer coverage, especially at games, physician coverage was lacking and fewer coaches were certified in CPR in 2017 compared with 2003. EAPs and concussion management protocols were present in most Chicago public high schools. Overall, greater medical supervision is needed, which we believe should come in the form of increased athletic training and physician involvement and coverage, given that expert, expedited medical care saves lives.

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

Background

Increasing athletic trainer (AT) services in high schools has attracted widespread interest across the nation as an effective instrument to manage injuries and improve children’s health, but there is a lack of evidence on potential medical savings. Our study aimed to address this knowledge gap and provide evidence of AT impacts on medical payments and utilizations to inform public policy decision.

Methods

We obtained medical claims of patients aged 14 to 18 years from the 2011–2014 Oregon All Payer All Claims limited dataset. We calculated payer payments and utilizations for medical claims under AT’s scope of practice. We used zip codes to link patients with the enrollment boundaries of Oregon public high schools, which were classified as either “AT group” or “non-AT group”. We implemented an innovative microsimulation analysis to address the uncertainty of linkage between children and schools.

Results

Our analysis included 64,115 and 84,968 eligible children with Medicaid and commercial insurance, respectively. Associated with high school AT services, Medicaid saved an average of $64 per patient during the study period, while commercial insurance payment rarely changed. AT services may reduce emergency visits for both insurance types but increase total visits for commercially insured patients.

Conclusions

Our study provides evidence for the differential impacts of AT services on medical payments and utilizations. The legislators should consider to allocate funds for high schools to directly employ ATs. This will encourage ATs to work to their highest ability to improve children’s wellbeing while containing avoidable medical cost.

Filling the Gaps in Adolescent Care and School Health Policy-Tackling Health Disparities through Sports Medicine Integration

The School-Based Health Centre (SBHC) model of healthcare delivery in community health is designed to address the unique needs of adolescents. Through a collaborative interprofessional approach, they aim to provide comprehensive care with the goal of reducing health disparities in underserved, at-risk adolescents. Integration of sports medicine health professionals is a novel approach to increasing available services, as well as patient utilization, while addressing multiple public health issues, including lack of athletic training services for youth athletes.

School and Community Socioeconomic Status and Access to Athletic Trainer Services in Wisconsin Secondary Schools

CONTEXT

Secondary schools have made significant progress in providing athletic trainer (AT) coverage to their student-athletes, but the levels of access at schools with ATs may vary widely. Socioeconomic disparities in medical coverage and access have been noted in other health care fields, but such disparities in the level of access to AT services have not been thoroughly examined.

OBJECTIVE

To determine if (1) access to AT services or (2) the level of access (AT hours per week and athletes per AT hour) differed based on the socioeconomic characteristics of secondary schools.

DESIGN

Cross-sectional study.

SETTING

Mailed and e-mailed surveys.

PATIENTS OR OTHER PARTICIPANTS

High school athletic directors and ATs from 402 Wisconsin high schools.

MAIN OUTCOME MEASURE(S)

Respondents provided information as to whether their school used the services of an AT and the number of hours per week that their school had an AT on-site. The number of athletes per AT hour was calculated by dividing the total number of athletes at the school by the number of hours of AT coverage per week. The socioeconomic status of each school was determined using the percentage of students with free or reduced-cost lunch and the county median household income (MHI).

RESULTS

Schools without an AT on-site were in lower MHI counties ( P < .001) and had more students eligible for a free or reduced-cost lunch ( P < .001). Lower levels of AT access (fewer hours of AT access per week and more athletes per AT hour) were observed at schools in the lowest third of the county MHI and with the highest third of students eligible for a free or reduced-cost lunch ( P < .001).

CONCLUSIONS

Socioeconomic disparities were present in access to AT services. New models are needed to focus on providing a high level of AT access for all student-athletes, regardless of socioeconomic status.

Disparities in Athletic Trainer Staffing in Secondary School Sport: Implications for Concussion Identification

OBJECTIVE

First, to assess whether teams at schools with an athletic trainer (AT) on staff had a higher number of diagnosed concussions than teams without medical personnel present. Second, to assess whether the variability in employment of a certified AT by Washington state high schools is patterned by socioeconomic and demographic characteristics.

DESIGN

Cross-sectional survey.

SETTING

Washington state public high schools.

PARTICIPANTS

Stratified random sample of football and soccer coaches (n = 270 teams, 144 schools).

INDEPENDENT VARIABLES

Presence of an AT and school characteristics (percentage of students qualifying for free or reduced price lunch, rural location, enrollment).

RESULTS

Football and boys' soccer teams at schools with an AT had a significantly greater number of athletes with diagnosed concussions compared to teams at schools without an AT (P < 0.05). There was no difference in number of athletes with diagnosed concussions by AT staffing for girls' soccer. Schools with an AT on staff were significantly more likely than schools without an AT to be in an urban location (P < 0.001), to have an enrollment of 1000 students or more (P < 0.001), and to have a smaller proportion of students eligible for school lunch (P = 0.005).

CONCLUSIONS

The present study provides empirical support for the benefit of ATs in diagnosing concussions in high school sport and underscores the challenges to AT staffing in lower resource settings. These findings cause us to critically reflect on the threshold for medical oversight in contact and collision sport from the perspective of risk prevention, and the extent to which disparities in this medical oversight are acceptable in the public school setting.

CLINICAL RELEVANCE

Strategies for increasing AT staffing in high school sports settings should be explored given their demonstrated benefit in diagnosing concussions.

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.

Implementing Health and Safety Policy Changes at the High School Level From a Leadership Perspective

CONTEXT

Although consensus statements and recommendations from professional organizations aim to reduce the incidence of injury or sudden death in sport, nothing is mandated at the high school level. This allows states the freedom to create and implement individual policies. An example of a recommended policy is heat acclimatization. Despite its efficacy in reducing sudden death related to heat stroke, very few states follow the recommended guidelines.

OBJECTIVE

To retroactively examine why and how 3 states were able to facilitate the successful creation and adoption of heat-acclimatization guidelines.

DESIGN

Qualitative study.

SETTING

High school athletic associations in Arkansas, Georgia, and New Jersey.

PATIENTS OR OTHER PARTICIPANTS

Eight men and 3 women (n = 11; 6 athletic trainers; 2 members of high school athletic associations; 2 parents; 1 physician) participated. Participant recruitment ceased when data saturation was reached.

DATA COLLECTION AND ANALYSIS

All phone interviews were digitally recorded and transcribed verbatim. A grounded-theory approach guided analysis and multiple analysts and peer review were used to establish credibility.

RESULTS

Each state had a different catalyst to change (student-athlete death, empirical data, proactivity). Recommendations from national governing bodies guided the policy creation. Once the decision to implement change was made, the states displayed 2 similarities: shared leadership and open communication between medical professionals and members of the high school athletic association helped overcome barriers.

CONCLUSIONS

The initiating factor that spurred the change varied, yet shared leadership and communication fundamentally allowed for successful adoption of the policy. Our participants were influenced by the recommendations from national governing bodies, which align with the institutional change theory. As more states begin to examine and improve their health and safety policies, this information could serve as a valuable resource for athletic trainers in other states and for future health and safety initiatives.