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Objectives: Evaluate professional rugby players' self-reported perceived understanding of the head injury assessment (HIA) and return to play (RTP) processes and determine factors related to understanding and trust pertaining to these processes., Methods: An electronic survey measured concepts of interest. A thematic analysis of player understanding was performed, and player statements were coded., Results: 207 U.S. Major League Rugby (MLR) players participated (26.7 ± 3.4 years). HIA and RTP protocol understanding was not correlated with concussion history ( p  = 0.41). International rugby experience and trust regarding MLR support of the following protocols and opposing team medical staff practices varied in their relationship to HIA understanding. Trust that all MLR teams follow the same protocols was positively correlated with all HIA questions (ps < 0.03). No HIA questions were correlated with trust in their own team's medical staff. All trust questions were significantly correlated with RTP process understanding. Qualitative analysis identified four HIA- and RTP-related themes: education needs, staffing needs, HIA criticisms, and importance of player safety., Conclusion: International playing experience and greater trust in the MLR and league stakeholders were associated with greater player understanding of the HIA and RTP protocols. These results provide insight into the importance of educating players on league-specific concussion protocols.

Importance: Sponsorship of promotional events for health professionals is a key facet of marketing campaigns for pharmaceuticals and medical devices; however, there appears to be limited transparency regarding the scope and scale of this spending., Objective: To develop a novel method for describing the scope and quantifying the spending by US pharmaceutical and medical companies on industry-sponsored promotional events for particular products., Design and Setting: This was a cross-sectional study using records from the Centers for Medicare & Medicaid's Open Payments database on payments made to prescribing clinicians from January 1 to December 21, 2022., Main Outcomes and Measures: An event-centric approach was used to define sponsored events as groupings of payment records with matching variables. Events were characterized by value (coffee, lunch, dinner, or banquet) and number of attendees (small vs large). To test the method, the number of and total spending for each type of event across professional groups were calculated and used to identify the top 10 products related to dinner events. To validate the method, we extracted all event details advertised on the websites of 4 state-level nurse practitioner associations that regularly hosted industry-sponsored dinner events during 2022 and compared these with events identified in the Open Payments database., Results: A total of 1 154 806 events sponsored by pharmaceutical and medical device companies were identified for 2022. Of these, 1 151 351 (99.7%) had fewer than 20 attendees, and 922 214 (80.0%) were considered to be a lunch ($10-$30 per person). Seven companies sponsored 16 031 dinners for the top 10 products. Of the 227 sponsored in-person dinner events hosted by the 4 state-level nurse practitioner associations, 168 (74.0%) matched events constructed from the Open Payments dataset., Conclusions and Relevance: These findings indicate that an event-centric analysis of Open Payments data is a valid method to understand the scope and quantify spending by pharmaceutical and medical device companies on industry-sponsored promotional events attended by prescribers. Expanding and enforcing the reporting requirements to cover all payments to all registered health professionals would improve the accuracy of estimates of the true extent of all sponsored events and their impact on clinical practice.

Background: The pharmaceutical industry promotes prescribing through the cultivation of key opinion leaders. Advanced practice nurses (APNs) are a growing and influential group of prescribers across generalist and specialty practice. Public reporting of industry payments to APNs allows for exploration of their influence within practice settings., Objective: To understand the characteristics of APNs with top industry payments including their positions of influence and other payment recipients at the same address., Design and Setting: Cross-sectional study of US national Open Payments reports of industry payments made between January 1, 2021, and December 31, 2021., Participants: APNs who received > $50,000 USD in industry payments for speaking, consulting, and honoraria ("personal fees")., Measures: Description of top APN recipients' practice setting type, clinical specialty, presence of other payment recipients, value of payments attributed to the same address, and top manufacturers and therapeutic categories associated with payments to top APN recipients. Structured content analysis of public-facing websites for evidence of APNs' clinical, research, and teaching leadership., Results: A total of 99 APNs received > $50,000 USD in aggregate personal fees and a median $74,080 USD (IQR $57,303-101,702) in aggregate payments. They shared a practice setting with a median of 1 (IQR 0-5) physician and 0 (IQR 0-3) other APN payment recipients and were often the only (39%, 42/109) or the dominant (45%, 30/67) payment recipient in their practice setting. In total, 36% held clinical leadership positions, 25% led scientific research, and 18% had university appointments. Forty-two percent (37/88) owned a clinical practice, including cosmetic clinics (51%, 19/37) and mental/behavioral health clinics (24%, 9/37)., Conclusions: Top APN payment recipients attracted high-value payments in practice settings and specialities associated with high-cost drug development; however, there may be little oversight of APNs' industry relationships. Policy development related to industry relationships must be inclusive of and responsive to the activities of interprofessional providers., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Importance: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease; understanding ALS risk factors is a critical public health issue., Objectives: To evaluate the incidence of and mortality from ALS in National Football League (NFL) athletes and to describe characteristics associated with ALS within this cohort., Design, Setting, and Participants: This population-based cohort study included all 19 423 NFL athletes who debuted between 1960 and 2019 and played 1 or more professional game. It was conducted between October 3, 2020, and July 19, 2021., Exposure: Participation in the NFL, including playing 1 or more professional games., Main Outcomes and Measures: Cases of ALS and death information were identified based on public records from NFL statistics aggregators, news reports, obituaries, and National Death Index results. The standardized incidence ratio and the standardized mortality ratio were calculated based on data acquired from surveillance studies of ALS accounting for age, sex, and race. Secondary analyses examined the association of body mass index, NFL career duration, race, birth location, and markers of fame, using a nested case-control design, matching athletes with ALS to athletes without ALS, by NFL debut year., Results: A total of 19 423 male former and current NFL players (age range, 23-78 years) were included in this cohort study and were followed up for a cumulative 493 168 years (mean [SD] follow-up, 30.6 [13.7] years). Thirty-eight players received a diagnosis of ALS, and 28 died during the study time frame, representing a significantly higher incidence of ALS diagnosis (standardized incidence ratio, 3.59; 95% CI, 2.58-4.93) and mortality (standardized mortality ratio, 3.94; 95% CI, 2.62-5.69) among NFL players compared with the US male population, adjusting for age and race. Among NFL athletes, nested-case-control analyses found that those who received a diagnosis of ALS had significantly longer careers (mean [SD] duration, 7.0 [3.9] years) than athletes without ALS (mean [SD] duration, 4.5 [3.6] years; odds ratio, 1.2; 95% CI, 1.1-1.3). There were no differences in ALS status based on proxies of NFL fame, body mass index, position played, birth location, or race., Conclusions and Relevance: The age-, sex-, and race-adjusted incidence of and mortality from ALS among all NFL players who debuted between 1960 and 2019 were nearly 4 times as high as those of the general population. Athletes with a diagnosis of ALS had longer NFL careers than those without ALS, suggesting an association between NFL duration of play and ALS. The identification of these risk factors for ALS helps to inform the study of pathophysiological mechanisms responsible for this fatal neurodegenerative disease.

Importance: Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury., Objective: To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk., Design, Setting, and Participants: In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association. Surveys were conducted between February and May 2017. Data were analyzed from June 2017 through July 2020., Main Outcomes and Measures: Multiple approaches were taken to compare athlete perceptions of their risks of concussion and nonconcussion injury with individual probabilities of these risks, which were modeled using logistic regression., Results: Of 296 male college-aged athletes from 4 football teams who participated in the survey, 265 (89%) answered all questions relevant for this study. Participating teams were similar to nonparticipating teams across nearly all measured characteristics. One hundred athletes (34%) had sustained 1 or more concussions, and 197 (68% of the 289 who responded to the question) had sustained 1 or more injuries in the previous football season. Logistic regression models of single-season injury and concussion had reasonably good fit (area under the curve, 0.75 and 0.73, respectively). Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001)., Conclusions and Relevance: The findings of this survey study suggest that college football players may underestimate their risk of injury and concussion. The implications for informed participation in sport are unclear given that people generally underestimate health risks. It is necessary to consider whether athletes are sufficiently informed and how much risk is acceptable for an athlete to participate in a sport.

Context: The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown., Objective: To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school., Design: Descriptive epidemiology study., Setting: National Collegiate Athletic Association (NCAA) men's ice hockey teams., Patients or Other Participants: Collegiate men's ice hockey athletes., Main Outcome Measure(s): The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers., Results: Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower., Conclusions: In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey., (© by the National Athletic Trainers' Association, Inc.)

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., (© by the National Athletic Trainers' Association, Inc.)

Background: Communication between coaches and athletes about concussion safety can reinforce or undermine a sport culture in which concussion under-reporting is often endemic., Method: This study tested a model in which self-reported coach communication about concussion safety was predicted by factors including concussion knowledge, attitudes and beliefs, sex of the coach, and sex of the team coached. Participants were 997 coaches of contact and collision sports teams competing in National Collegiate Athletic Association Division I, II, or III., Results: Concussion attitudes and beliefs were the strongest predictors of communication, and the small effect of knowledge on communication was transmitted nearly entirely through its effect on attitudes and beliefs. Much of the variability in communication was attributable to the sex of the coach and the sex of the team coached., Conclusions: These results serve as a starting point for the design of coach-targeted interventions that encourage communication about health and safety with athletes.

Concussions from sport present a substantial public health burden given the number of youth, adolescent and emerging adult athletes that participate in contact or collision sports. Athletes who fail to report symptoms of a suspected concussion and continue play are at risk of worsened symptomatology and potentially catastrophic neurologic consequences if another impact is sustained during this vulnerable period. Understanding why athletes do or do not report their symptoms is critical for developing efficacious strategies for risk reduction. Psychosocial theories and frameworks that explicitly incorporate context, as a source of expectations about the outcomes of reporting and as a source of behavioral reinforcement, are useful in framing this problem. The present study quantifies the pressure that athletes experience to continue playing after a head impact--from coaches, teammates, parents, and fans--and assesses how this pressure, both independently and as a system, is related to future concussion reporting intention. Participants in the study were 328 male and female athletes from 19 teams competing in one of seven sports (soccer, lacrosse, basketball, softball, baseball, volleyball, field hockey) at four colleges in the northeast region of the United States. Results found that more than one-quarter of the sample had experienced pressure from at least one source to continue playing after a head impact during the previous year. Results of a latent profile mixture model indicated that athletes who experienced pressure from all four of the measured sources were significantly more likely to intend to continue playing in the future than were athletes who had not experienced pressure from all sources, or only pressure from coaches and teammates. These findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting cognitions., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Many states and sports leagues are instituting concussion policies aimed at reducing risk of morbidity and mortality; many include mandates about the provision of concussion education to youth athletes. However, there is limited evidence if educational materials provided under these typically vague mandates are in fact effective in changing concussion risk-related behavior or any cognition predictive of risk-related behavior. The purpose of this pilot randomized controlled study was to conduct a theory-driven evaluation of three publically available concussion education materials: two videos and one informational handout. Participants were 256 late adolescent males from 12 teams in a single league of ice hockey competition in the United States. Randomization of educational condition occurred at the team level. Written surveys assessing postimpact symptom reporting behavior, concussion knowledge, and concussion reporting cognitions were completed by participants immediately before receiving their educational intervention, 1 day after, and 1 month after. Results indicated no change in any measure over any time interval, with the exception of perceived underreporting norms. In one of the video conditions, perceived underreporting norms increased significantly 1 day after viewing the video. Possible content and viewing environment-related reasons for this increase are discussed. Across all conditions, perceived underreporting norms increased 1 month after intervention receipt, raising the possibility that late in the competitive season underreporting may be perceived as normative. The need for the development of theory-driven concussion education materials, drawing on best practices from health behavior scholars, is discussed., (© 2014 Society for Public Health Education.)

Background: Recent injury data for collegiate-level swimming and diving are limited. This study describes the epidemiology of men's and women's swimming and diving injuries reported by the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) during the 2009/2010 to 2013/2014 academic years., Methods: Injuries and athlete-exposure (AE) data reported within 9 men's and 13 women's swimming and diving programmes were analysed. Injury rates, injury rate ratios (IRR), and injury proportions by body site, diagnosis and mechanism were reported with 95% CIs., Results: The ISP captured 149 and 208 injuries for men's and women's swimming and diving, respectively, leading to injury rates of 1.54/1000 and 1.71/1000 AEs. Among females, divers had a higher injury rate (2.49/1000 AEs) than swimmers (1.63/1000 AEs; IRR=1.53; 95% CI 1.07 to 2.19). Injury rates for male divers (1.94/1000 AEs) and swimmers (1.48/1000 AEs) did not differ (IRR=1.33; 95% CI 0.85 to 2.31). Most injuries occurred to the shoulder, resulted in strains and were classified as overuse or non-contact. Female swimmers had a higher overuse injury rate (1.04/1000 AEs) than male swimmers (0.66/1000 AEs; IRR=1.58; 95% CI 1.14 to 2.19). Overuse injury rates for female divers (0.54/1000 AEs) and male divers (0.46/1000 AEs) did not differ (IRR=1.16; 95% CI 0.40 to 3.34). Injury rates in 2012/2013-2013/2014 were lower than those in 2009/2010-2011/2012 for women's swimming (IRR=0.70; 95% CI 0.52 to 0.95) and diving (IRR=0.56; 95% CI 0.30 to 1.08), respectively. No time trends existed for men's swimmers or divers., Conclusions: Shoulder, strain and overuse injuries were common in collegiate men's and women's swimming and diving. Female swimmers were more likely to suffer an overuse injury than male swimmers. In addition, divers may have higher injury rates than swimmers, although small reported numbers warrant additional research., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)