More Than Skin Deep: Patient-Provider Racial and Ethnic Concordance and Discordance in Collegiate Athletics and Concussion Management

We used a retrospective, cross-sectional design by extracting clinical concussion documentation data from the medical records of NCAA collegiate athletes from 11 institutions (NCAA Division I, n = 8; NCAA Division II, n = 2; and NCAA Division III, n = 3) that are members of the Long-Term Impact of Military-Relevant Brain Injury Consortium Military and Tactical Athlete Research Study (LIMBIC MATARS) consortium. Although all 22 institutions in the LIMBIC MATARS consortium were recruited to participate, only 11 were able to secure institutional approval and complete data use agreements to contribute athlete medical record data to this chart review study. Data extraction occurred for all documented concussions sustained over a 5-year period from the 2015–2016 through 2019–2020 athletic seasons. The exact time range for data extraction was July 2015 through February 2020, as injuries sustained in March 2020 and beyond were excluded due to the onset of the COVID-19 pandemic. The master data file included 1044 total concussion cases.

The methods of the LIMBIC MATARS consortium’s data extraction project have been detailed elsewhere.³⁰  Briefly, the LIMBIC MATARS consortium investigators developed a priori common data elements based on the consortium purpose, goals, and research questions—predominantly encompassing postconcussion clinical outcomes in collegiate athletes. After institutional review board approvals at all partner sites, the establishment of data use agreements, and completion of confidentiality disclosure agreements, investigators reviewed medical records of concussion cases sustained by athletes who were diagnosed by ATs in accordance with protocols specific to each member institution’s athletic department. The definition of concussion was consistent, with the definition detailed in the fourth and fifth iterations of the international consensus statement that corresponded to the data extraction time frame.^21,31  Upon review, site investigators gleaned predetermined common data elements (eg, recovery milestone information, athlete demographic information) for each injury that occurred during the specified time frame and recorded them in a secure database. Once site investigators completed data extraction and ensured deidentification of the data, the consortium principal investigator combined all individual datasets from each member institution into an anonymized master dataset for distribution and analyses.

Patient-provider (ie, athlete-AT) racial and ethnic concordance or discordance was the independent variable for this study. Race and ethnicity categories were operationalized according to guidelines from the National Institutes of Health in 2015, which served as the beginning of the time period from which clinical data were extracted.³²  These categories are also consistent with the NCAA race and ethnicity demographics.¹⁸  The race and ethnicity of both the athlete who sustained a concussion and the responding AT were common data elements that were extracted for each concussion case when available. These variables were used to determine patient-provider racial and ethnic concordance/discordance, which we dichotomized as either yes (athlete and AT identified as the same race and/or ethnicity) or no (athlete and AT identified as different races and/or ethnicities). Self-reported race and ethnicity information was extracted from preexisting institutional documents (eg, preparticipation physical examination forms) at each site. Two of the 11 consortium institutions contributing data did not have documentation of these race and ethnicity variables; thus, our sample included concussion cases that occurred at only 9 institutions. The athletes’ biological sex (male or female) was also extracted from their medical files. The concussion diagnosis and recovery dependent variables were based on a number of time points that were extracted as common data elements for each concussion case. These included the date of injury, date of diagnosis, date of symptom resolution, and date of return to sport. Times between clinical milestones were calculated as the number of days from the date of injury to diagnosis, symptom resolution, and return to sport and from the date of diagnosis to symptom resolution and return to sport. Each institution also provided information indicating whether the concussion had occurred to an athlete from a sport that had a dedicated AT (yes, no), which was defined as having the same AT(s) who provided onsite medical care at all practices and competitions. Figure 2 provides a visual overview of the data preparation process.

First, we conducted descriptive statistics for demographic variables, specifically means and SDs for continuous variables and frequencies with percentages for categorical variables. Medians and interquartile ranges (IQRs) were calculated for each dependent variable stratified by racial concordance. With the count nature of the dependent variables (ie, days between milestones) and the overdispersion (ie, unequal mean to variance ratio), negative binomial regression models were used to assess for differences between the racially concordant and discordant groups for 4 of the time frames (days from injury to symptom free, injury to return to play, diagnosis to symptom free, and diagnosis to return to play). Due to the high degree of zero days (n = 350) for participants moving from injury to diagnosis, a zero-inflated regression model was used. Unadjusted and adjusted models, including variables of biological sex and dedicated AT with sport, were constructed along with 95% CIs for the incidence rate ratios from the negative binomial regression models and the odds ratios in the zero-inflated regression models.^33,34  The most parsimonious adjusted model with the lowest Akaike information criterion was maintained. Statistical significance was set a priori as P < .05 (pairwise comparisons) or exclusion of 1.0 within the 95% CI (regression models). All analyses were performed using SPSS (version 29; IBM Corp) and the PSCL package in R (version 4.3.2; R Foundation) specifically for the zero-inflated regression models.

We analyzed data from 694 concussion cases. Table 1 provides descriptive information for the included concussion cases. In total, 68.4% (n = 475 of 694) of cases were patient-provider racially and ethnically concordant, and 31.6% (n = 219 of 694) were discordant. Most concussion cases in our sample occurred to athletes who identified as White (n = 499, 71.9%) and male (n = 426, 61.4%). All concussion cases in the concordant group occurred to athletes who were White and paired with a White AT (n = 475 of 475, 100%; Figure 3), whereas most concussion cases in the discordant group occurred to athletes who identified as Black or African American (n = 170 of 219, 77.6%) and were most frequently paired with a White AT (n = 186 of 219, 84.9%). Furthermore, the sports most represented in the concordant group were football (n = 140 of 474, 29.5%) and wrestling (n = 39 of 474, 8.2%) and the most represented in the discordant group concussion cases were football (n = 142 of 219, 64.8%) and basketball (n = 26 of 219, 11.8%). See the Supplemental Table (available online at http://dx.doi.org/10.4085/1062-6050-0320.23.S1) for additional information regarding the frequency of ATs, athletes, and included concussion cases per year by LIMBIC MATARS site.

For the entire sample, the median (IQR) time from injury to diagnosis was 0 (0–2) days, from injury to symptom resolution was 7 (4–12) days, from injury to return to sport was 12 (8–20) days, from diagnosis to symptom resolution was 6 (3–10) days, and from diagnosis to return to sport was 11 (7–18) days. Clinical milestone outcomes stratified by racial concordance can be found in Table 2. Only the number of days from injury to diagnosis differed between the concordant and discordant groups (median [IQR] = 1 [0–2] versus 0 [0–1]) in the final model adjusted for the biological sex and dedicated AT with sport variables (odds ratio [95% CI] = 1.46 [1.07–1.85]). There were no other significant group differences between the concordant and discordant groups for the other clinical milestones (Table 3).

Our study was the first to investigate patient-provider racial and ethnic concordance and discordance within the realm of sports medicine. The primary aim of this research was to examine the presence of concordant and discordant cases among this sample, and our secondary aim was to discern potential disparities between these groups regarding diagnosis and recovery timelines after concussion. Importantly, all cases of patient-provider racial and ethnic concordance occurred exclusively between White athletes and White ATs, whereas athletes of underrepresented backgrounds experienced discordant health care provider matches. Further, a statistically significant, albeit modest, difference was observed between the racially and ethnically concordant and discordant groups concerning the time from date of injury to date of diagnosis, such that discordant pairings had a 1 day shorter (by median estimates) time to diagnosis compared with concordant pairings. However, no significant differences were found between the groups regarding times to symptom resolution and return to sport. Our findings provide an important first look into patient-provider racial and ethnic concordance and discordance within the field of sports medicine, and the lack of clinically meaningful group differences in concussion recovery timelines in our collegiate athlete sample is encouraging. These results also diverge from the patient-provider racial and ethnic concordance and discordance disparity trends observed in other patient populations and fields of health and wellness, which could suggest that the unique day-to-day patient-provider interactions that are intrinsic to the athletic training profession may serve as a protective factor against health disparities at the collegiate sport level.^3–8  Moving forward, further scientific exploration is needed to expand our understanding regarding the role of patient-provider racial and ethnic concordance and discordance in sports medicine health care to inform future approaches geared toward enhancing diversity within the athletic training profession, as well as establishing and advancing equitable care practices for all athletes.

The foundational findings from our study shed some light on the current state of patient-provider racial and ethnic concordance and discordance in athletic training, highlighting both complexities (eg, time to diagnosis differences by discordant and concordant groups) and favorable signs of equity (eg, similar recovery timelines by discordant and concordant groups) in concussion care. A substantial proportion of cases in our sample (68.4%) exhibited concordance between patients and health care providers, whereas a minority of cases (31.6%) displayed discordance. It is important to note that the concordant group was composed exclusively of White athletes paired with White ATs. Our observation may show the privilege allotted to White athletes regarding the ability to be cared for by a health care provider who looks like them and may share an understanding of their lived experience. However, this observation does not represent concordance with other racial and ethnic groups, limiting the generalizability of the overarching concordant findings within our study. Moreover, a marked proportion of concussion cases in our study (84.9%) were managed by White ATs, a proportion that aligns closely with the frequency of White ATs employed in NCAA settings (Figure 1). However, the number of individual ATs who provided care to the included concussion cases is unclear based upon the limitations of the dataset, and more research is needed to substantiate and extend these findings.

Overall, the lack of even a singular concordant concussion case of an athlete with an underrepresented racial and ethnic identity being cared for by an AT with an underrepresented racial and ethnic identity was surprising and may be concerning, especially to individuals coming from racial and ethnic communities that have historically been negatively affected by health disparities. This result adds support to the need to recruit more athletic training health care professionals from Black or African American, Asian, American Indian/Alaska Native, and Hispanic or Latino backgrounds to serve the diverse athlete populations found at all levels of sport and physical activity. This aligns with recent calls and initiatives geared toward increasing student diversity within medical education and training programs, including athletic training.^35–38  Proactive recruitment and retention initiatives should continue to be undertaken, involving multimodal, evidence-informed strategies aimed at supporting early interest in the athletic training profession, recruiting diverse students into professional programs, engaging in retention efforts within professional programs, and providing mentorship to early-career professionals as they transition to practice.^37–41  For example, these efforts could include the development of formal affiliation agreements between professional master of science in athletic training programs and minority-serving institutions, Hispanic-serving institutions, and historically Black colleges and universities to create direct pathways for students from these institutions into the profession. Additionally, the National Athletic Trainers’ Association’s Ethnic Diversity Advisory Committee provides resources for cultivating diversity within the athletic training profession, which include concordant mentoring opportunities, scholarships for members of underrepresented groups, and grants aimed at supporting scholarship and initiatives related to advancing ethnic diversity.⁴²  By creating a scaffolding of assistance to support the success of racially and ethnically diverse students, we can start to dismantle educational systems of oppression and associated financial barriers to make the athletic training profession more accessible and inclusive.

Our findings regarding concussion clinical milestones were relatively favorable. When considering the entire sample, the median number of days from injury to diagnosis was 0, to symptom resolution was 7, and to return to sport was 12. Both the concordant and discordant groups were within 1 day of the overall sample findings for these clinical milestones. The symptom resolution and return-to-sport recovery timelines are within the expected time frame for collegiate athletes and reflect those found in previous investigations.^43,44  The only significant patient-provider racial and ethnic concordant and discordant group difference we observed was for the diagnosis timepoint, with the discordant group being diagnosed most frequently on the day of injury, a median of 1 day earlier as compared with the concordant group, which was diagnosed the day after injury. The same-day diagnosis of concussion on the day the injury was sustained in the discordant group is an ideal finding given that prior research has noted the importance of immediate recognition of concussion and removal from activity to promote the most favorable injury outcomes.^23,43  However, although a significant group difference to time to diagnosis was identified, our observed 1-day difference should be interpreted with caution due to its small effect and lack of corroborating findings in the time-to-recovery outcomes. As stated previously, the concordant group in our sample was entirely composed of White athletes with White ATs. Therefore, generalized discussion of racial and ethnic concordance across athletes’ and ATs’ racial and ethnic identities is not possible at this time.

A 1-day delay in diagnosis timing could be due to a multitude of reasons, some of which may be benign and not impede concussion recovery. Collectively, the diagnosis timing for athletes from both the racial and ethnic concordant and discordant groups occurred in a reasonable amount of time from a clinical perspective, which is positive. Given the racial and ethnic homogeneity of the concordant group in this study, we could consider how general sport culture among different groups of people may affect our findings. We did include sport type as a covariate in our analyses, but perhaps categorizing sports into the 3 tiers of sport collision/impact expectation as defined within the NCAA Sports Medicine Handbook was not granular enough in this case.⁴⁵  The number of football concussion cases was nearly identical between the concordant and discordant groups; however, they accounted for 64.8% (n = 142 of 219) of the total discordant cases compared with only 29.5% (n = 140 of 475) of the concordant cases. The majority of football-related concussions within the discordant group occurred to athletes who identified as Black or African American (n = 125 of 142, 88.0%). The disproportionate incidence of football-related concussions among Black or African American athletes in the discordant group may warrant further investigation. Specifically, a refined approach in future research to comprehensively assess the complex interplay among sport culture, collision sport type, and AT and athlete sociodemographic variables may be indicated.

The delivery of person-centered health care is rooted in the development of a trusting relationship between the patient and their health care provider. Our null findings related to concussion recovery milestones may show that perhaps ATs are able to build strong relationships with athletes and provide them with quality care regardless of racial and ethnic similarities and differences. Redinger et al previously found that approximately 60% of collegiate athletes reported strongly agreeing that their ATs provided culturally competent care and were respectful of their preferences during health care delivery.⁴⁶  Additionally, authors of a qualitative study found that collegiate athletes perceived ATs to portray empathy through patient advocacy, communication, approachability, access, and competence.⁴⁷  One facilitator for relationship building in the collegiate sport setting may simply be the consistent presence of ATs, which creates the opportunity to have a high volume of interactions with their patient populations. These interactions come in all forms (eg, professional, personal) and occur within a variety of different environments (eg, on the field, in the clinic, during travel). Due to this, ATs are well positioned to form a trusting bond and an open line of communication with their patients before an injury or illness occurs that may serve to help overcome the racial and ethnic prejudices that are more readily found in other areas of health care. Indeed, prior research highlights the importance of training health care providers to engage in high-quality communication when navigating discordant patient-provider pairings by focusing on improving patient-centered care, partnership building, and shared contributions toward health-related goal settings.⁹  Perhaps cultural sensitivity and humility of the health care provider matter more for recovery rather than racial and ethnic concordance in this space. This sentiment is echoed by the inclusion of athletic training educational standards focused on cultivating professional skills related to cultural competency, humility, respect, compassion, and empathy, which are needed in order to provide high-quality care regardless of patient race and ethnicity, among other factors.⁴⁸ 

Data in this study were derived from medical records of athletes from geographically diverse NCAA institutions within the United States. Although the overarching goal of LIMBIC MATARS is to investigate brain health among collegiate athletes, this novel secondary analysis provides an important inquiry about racial and ethnic identities as social determinants of health. Due to the retrospective medical chart review study design of this investigation, we observed a lack of standardization of assessment tools as well as approaches to concussion diagnosis, management, and documentation approaches among participating institutions. The benefit of this study design was that the data captured are an authentic representation of concussion management clinical practices at the included institutions, but ultimately this resulted in lower methodologic internal validity among sites. Furthermore, the distribution of racial and ethnic identities for collegiate athletes included in this study was similar to that of the population of NCAA athletes between 2015 and 2019.¹⁸  However, we were limited in our ability to collect detailed information on the individual ATs providing care at these institutions. Each athlete included within the dataset had a unique participant code, but this approach was not used for each AT working at each site. Therefore, we were unable to determine how many individual ATs provided care to the 694 included concussion cases. Based upon the information available to us, the total number of ATs who may have managed these concussion cases ranged from 105 to 114 individuals annually (Supplemental Table). Additionally, the frequency of concussion cases was not equally distributed among the 9 LIMBIC MATARS sites, and the total number of included concussion cases per institution ranged from 11 to 241 (Supplemental Table). When considering these factors together, the findings within our sample regarding patient-provider racial and ethnic concordance and discordance should not be generalized to represent the larger NCAA athlete and collegiate AT populations at this time, nor do they reflect the reality of other sport populations (eg, youth, high school, professional).

Future research efforts should include stakeholders and partnerships among colleges and universities with large populations of diverse racial and ethnic identities, including those that were not substantially represented in the present study (ie, American Indian or Alaska Native, Asian, Hispanic or Latino, Native Hawaiian or other Pacific Islander). Additionally, these further inquiries should allow participants to select from a wider variety of racial and ethnic identities, including the selection of multiple identifiers. Further, qualitative and mixed-methods approaches are encouraged to better grasp the factors associated with racial and ethnic concordance and discordance that may contribute to more or less favorable clinical outcomes. Given that this study focused solely on race and ethnicity, future researchers should build upon this work by capturing a much larger sample of concussion cases from more institutions and investigate how multiple types of social identities (eg, gender, age, socioeconomic status) and environmental factors intersect to affect injury recognition and diagnosis, recovery timelines, and the patient-provider relationship. In addition, subsequent explorations of patient-provider racial and ethnic concordance and discordance in sports medicine should consider additional characteristics of the treating AT (eg, gender, age, level of experience) and interpersonal factors that may affect care and injury/illness outcomes.

Our study lays a foundation for future investigations regarding the role of patient-provider racial and ethnic concordance and discordance in sports medicine. There is a historical lack of diversity within the athletic training profession, which could relate to our findings that 95% of the included concussion cases were cared for by White ATs, and all of the concordant dyads were White athletes paired with White ATs. We did not observe meaningful differences in concussion clinical diagnosis and recovery milestones between the concordant and discordant groups. However, it should be noted that our study did not capture additional person-centered care elements (eg, satisfaction, comfortability, trust, communication) that may be affected by patient-provider racial and ethnic concordance and discordance and significantly influence a patient’s concussion experience and future care-seeking intentions. Progressing forward, we must learn and unpack the intricacies of race, ethnicity, and other social determinants of health both immediately within the athletic training profession and with regard to the delivery of patient care as we continue striving and advocating for health care equity within sports medicine.

Supplemental Table. Frequency of Athletic Trainers, Athletes, and Included Concussion Cases per Year by Site.

Found at DOI: http://dx.doi.org/10.4085/1062-6050-0320.23.S1