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122 School-level determinants of variability in observed concussion incidence: a care consortium study
  1. Bhavna Singichetti1,
  2. Stephen Marshall2,
  3. John Cantrell2,
  4. Katherine Breedlove3,
  5. Kenneth Cameron4,
  6. Paul Pasquina5,
  7. Michael McCrea6,
  8. Steven Broglio7,
  9. Thomas McAllister8
  1. 1University of North Carolina at Chapel Hill, Gillings School of Global Public Health
  2. 2University of North Carolina, Chapel Hill, Injury Prevention Research Center
  3. 3Harvard Medical School, Brigham and Women’s Hospital
  4. 4United States Military Academy, Keller Army Hospital
  5. 5Uniformed Services University, Walter Reed National Military Medical Center
  6. 6Medical College of Wisconsin, Brain Injury Research
  7. 7University of Michigan, Michigan Concussion Center
  8. 8Indiana University, School of Medicine


Statement of Purpose To investigate variability in observed concussion incidence between NCAA colleges participating in a multisite prospective study of concussion, and to quantify the effect of selected school-level factors on concussion risk.

Methods/Approach Data on sport-related concussion (SRC) were provided by the CARE Consortium, a multisite study of 30 collegiate institutions. School-level factors included NCAA Division (DI, DII, DIII) and school type (military or civilian) and a 3-level Sport Risk Index (Low, Medium, High). Random intercepts G-side log-binomial regression was used to model between- and within-school variability in concussion risk in NCAA athletes. Three concussion outcomes were modeled: all SRCs, competition SRCs only, and practice SRCs only.

Results School-Level Risk Factors: In fully adjusted models with all SRCs as the outcome, Sport Risk Index was the strongest predictor (risk ratio (RR) of 6.0; 95%CI: 4.4, 8.1, for the High vs. Low categories of the Index). Concussion risk was higher in Division I schools than in Division 2 (RR=1.6, 95%CI: 0.6, 4.2) and Division 3 schools (RR=1.8, 95%CI: 0.9, 3.6) schools. Military academies had an elevated risk of SRC (RR=1.5; 95%CI: 0.7, 3.3; analysis limited to NCAA athletes). School-Level Variability: Most of the variability in SRC risk was at the level of the athlete, not at the school. For all three outcomes, the within-school (athlete-level) variance was over five times the between-school variance. Adjusting for our three school-level risk factors (Division, Mil/Civ, and Sport Risk Index) removed 40% of the variation between schools for competition SRC, and 25% for overall SRCs and practice SRCs.

Conclusions Sport-level factors predict concussion risk, and a substantial portion of variability in concussion risk between schools is readily explainable.

Significance and Contributions to Injury and Violence Prevention Science Understanding school-level determinants and variability in concussion risk may identify opportunities for interventions to reduce SRC incidence.

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