Dissertation Title: "Risk and Sport: Individual, Institutional, and Ethical Considerations"This dissertation applies tools from health services research to the college sports medicine context. The first two papers analyze a sample survey of college football players, asking questions about individual-level risk perceptions and injury reporting. The third paper evaluates a novel combined data set and evaluates institutional-level modifiers of athlete injury outcomes. Together these papers provide important evidence about individual, institutional, and ethical considerations of risk in college sport.
Chapter one describes features of athletes’ concussion and injury reporting tendencies. Using original survey data from a cohort of college football players, we evaluate two assumptions of the current literature on concussion reporting. First, we assess whether athletes make reasoned deliberative decisions about whether to report their concussion or other injury. Second, we investigate whether the probability of reporting a concussion or injury is independent of where it occurs in the sequence of injuries experienced. Descriptively, we find that athletes are much less likely to report a concussion to a medical professional than they are to report another injury. We also find a much lower rate of concussion reporting in this study compared to the previous literature. There is no association between concussion or injury reporting behaviors and one measure of athletes’ ability to switch between fast reactive thinking to reasoned deliberative thinking. We do find significant variation in athletes’ injury and concussion reporting over the sequence of injuries. While the likelihood to report decreases for both injury and concussion, there is a notable decrease in the probability of reporting around four concussions, a cutoff that sports medicine clinicians may use as an occasion to discuss curtailing sports participation. Sports medicine clinicians may need to consider athlete injury history as a risk factor for concussion under-reporting.
Chapter two compares athletes’ perceptions of the risks of sports participation to an estimate of their actual risk. Using primary survey data of a cohort of football players from the most competitive sub-division of college football, we model athletes’ single-season risk of injury and of concussion and compare these to their perceptions of these risks. Across many measures, we find a significant proportion of athletes underestimate their risk of concussion specifically and injury overall. In the context of the modern debate around the risks of football, this has significant implications for advocates of an informed-consent approach to participation.
Chapter three describes the relationship between access to clinicians and injury outcomes in the context of college athletics. Using a novel combined dataset including injury and exposure data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP), sports medicine staffing data from NCAA Research, and athletic department characteristics from the United States Department of Education Equity in Athletics data, we evaluate whether the average number of clinicians per athlete at a college, is associated with rates of injury, reinjury, time loss to injury, and concussion. We also evaluate whether schools that voluntarily contribute data to the NCAA ISP differ from non-contributing schools in observable ways. We find a significant inverse relationship between number of clinicians per athlete and rates of injury, rates of reinjury, and rates of concussion, with schools one standard deviation above average in their number of clinicians per athlete having 9.5%, 2.7%, and 6.7%, fewer injuries respectively. We find a significant positive correlation between clinicians per athlete and time loss to injury, with schools one standard deviation above average in their number of clinicians per athlete having 16% greater time loss on average. Although these reductions in injury rates are relatively modest, the large number of college athletes means that the absolute reduction in injury that could be achieved is meaningful. For example, a 9.5% reduction in injury extrapolated to the NCAA context more broadly would equate to 3,165 fewer athlete injuries occurring annually. Schools that contribute data to the NCAA ISP tend to have more athletes, more clinicians per athlete, greater athletic department revenues and are more skewed toward Division I than non-contributing schools, reducing generalizability of these and other NCAA ISP findings. This study supports the idea that improving staffing in college sports medicine departments would improve athlete health and well-being by reducing rates of injury.