State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics: Letter to the Editor

Michael C. Koester; Samuel T. Johnson; Marc F. Norcross

摘要

Dear Editor: We read with great interest the recent article “State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics” by Adams et al.~( 1 )The authors, and the Korey Stringer Institute with which they are affiliated, deserve tremendous credit for their work in advancing the health and safety of athletes. We also commend the authors for exploring sports safety policy development in this article—an area that garners scant attention in the sports medicine literature. However, we believe aspects of the methodology and approach used by the research team undermine the results and conclusions presented. In this study, the authors developed a rubric “utilizing current evidence-based best practices” to objectively assess “where individual states ranked in terms of health and safety policies aimed at preventing the leading causes of sudden death and catastrophic injuries in sport.”~( 1 )However, examination of the rubric and the supporting citations reveals several inconsistencies related to the evidence base and the weighting of the rubric’s components that call into question its validity. While a point-by-point discussion of the rubric is beyond the scope of this letter, we think it is important to highlight just a few examples that elucidate our concerns. With respect to the heat acclimatization best-practice components contained in the rubric, the authors provide as evidence for the effectiveness of these components an abstract whose results suggest that the adoption of mandated heat acclimatization guidelines by 14 states since 2011 resulted in a decreased number of deaths due to exertional heat stroke.~( 2 )However, in the current study, only 7 of these 14 states met all of the rubric’s components for heat acclimatization (according to data provided in the Appendix).~( 1 )While it is possible that this inconsistency is due to the use of a different set of criteria in the 2 analyses, it is difficult to reconcile how the abstract can be used as evidence for the effectiveness of the heat acclimatization policy components evaluated in the current investigation if half of the states included in the abstract are not in compliance with current best practices. Moreover, it is unclear how the relative weighting of each best-practice subsection in the overall exertional heat stroke section was determined. Specifically, the authors provide no rationale for why the treatment-related subsections (eg, availability and use of on-site cold water immersion) were given more weight than the activity-based modifications and roughly the same weight as the totality of the heat acclimatization subsection. Similarly, we were surprised by the weight given to the requirement for comprehensive training and education for coaches in the form of USA Football’s “Heads Up Football” educational program or equivalent. While we support and require the use of “Heads Up Football” for high school coaches in our state, there is no evidence that this program reduces injury risk when it is not coupled with contact restrictions.~( 7 )Nonetheless, this requirement is worth 10 points (10% of the total points for the entire rubric) and equal to the weight given to requiring an appropriate health care professional, such as a certified athletic trainer, at collision/contact practices. We agree that the rubric should have differential weighting for policy criteria that have greater evidence or greater impact, but (1) the rationale underlying the weighting system used is not adequately explained, and (2) greater weighting of policy criteria that have more evidence of effectiveness was not applied uniformly throughout the rubric. Regardless of our concerns about the validity of the rubric, it is also imperative to make clear that this investigation was an assessment of policy adoption—not implementation—as the authors did not evaluate to what extent, if any, high schools in each state actually complied with the mandated policies. Unfortunately, the inference that will likely be drawn from this article by most readers and the lay media~( 6 , 9 )is that if states do/do not have a mandated policy, then the best-practice safety recommendations are/are not being used by high schools in the state. This is a fundamental mistake given the challenges in implementing health policy~( 5 )and the need to not just create policy but to directly evaluate “the impact of policies on community- and individual-level behavior changes.”~( 3 )The most important factor in improving student-athlete safety is not the creation of a mandated policy but rather that the evidence-based best practices contained in any potential policy are used day in and day out in our high schools. State high school athletic associations, in collaboration with their sports medicine advisory committees, are tasked with protecting the health and safety of high school athletes to the extent possible. While mandated policies a

机译：尊敬的编辑：尊敬的读者，我们读到亚当斯（Adams）等人最近发表的文章“州一级在健康和安全政策方面的国家级实施，以防止中学运动中的猝死和灾难性伤害”（1）作者和Korey Stringer研究所作为他们的附属机构，他们在促进运动员的健康和安全方面所做的工作值得赞扬。在本文中，我们也赞扬作者探索运动安全政策的发展，这一领域在运动医学文献中很少引起关注。但是，我们认为研究团队所使用的方法论和方法会破坏所提出的结果和结论。在这项研究中，作者开发了一个标题“利用当前基于证据的最佳实践”来客观地评估“各个州在健康和安全政策方面的排名，旨在防止运动中突然死亡和灾难性伤害的主要原因。”〜（1）然而，对标题和辅助引用的检查揭示了与证据基础和标题成分的权重有关的一些不一致之处，这质疑了其有效性。尽管对原则的逐点讨论超出了本信函的讨论范围，但我们认为重要的是仅强调一些阐明我们关切的例子。关于该规范中的热适应最佳实践组成部分，作者提供了摘要作为这些组件的有效性的证据，其摘要表明，自2011年以来14个州采用了强制性热适应指南，导致数量减少。（2）然而，在当前的研究中，这14个州中只有7个满足热适应的所有规则要素（根据附录中提供的数据）。〜（1）这种不一致可能是由于在两次分析中使用了一组不同的标准所致，因此很难调和如何将摘要用作当前研究中评估的热适应政策组成部分有效性的证据，如果有一半摘要中包含的状态不符合当前的最佳实践。此外，还不清楚如何确定整个最佳运动性中风部分中每个最佳实践部分的相对权重。具体而言，作者没有提供理由说明与治疗相关的部分（例如，现场冷水的可利用性和使用情况）比基于活动的修改具有更多的权重，并且与热适应的总体大致相同的权重小节。同样，我们对以美国足球的“抬头足球”教育计划或同等形式的教练进行全面培训和教育的要求感到惊讶。尽管我们支持并要求在本州为高中教练使用“抬头足球”，但没有证据表明该程序在没有接触限制的情况下可以降低受伤风险。〜（7）尽管如此，此要求还是值得的10分（占整个分数的10％），等于在碰撞/接触练习中要求适当的医疗保健专业人员（例如，合格的体育教练）给予的重量。我们同意，对于具有更大证据或更大影响的政策标准，应对标准进行不同的加权，但是（1）所使用的加权系统的基本原理没有得到充分的解释，（2）对具有更多证据的政策标准进行更大的加权有效性未在整个专栏中统一应用。不管我们对规则的有效性是否感到担忧，也有必要明确说明本次调查是对政策采用（而非实施）的评估，因为作者没有评估每个州的中学实际在多大程度上（如果有）遵守强制性政策。不幸的是，大多数读者和非专业媒体可能会从本文中得出结论[6，9]，即如果国家没有/没有强制性的政策，那么就不会有最佳实践的安全建议。在该州的高中使用。考虑到实施卫生政策所面临的挑战，这是一个根本性错误〜（5），不仅需要制定政策，还需要直接评估“政策对社区和个人行为改变的影响。”〜（3）改善学生运动员安全的重要因素不是制定强制性政策，而是在我们的高中中每天都使用任何潜在政策中所包含的循证最佳实践。州高中体育协会与运动医学咨询委员会合作，负责尽可能保护高中运动员的健康和安全。强制性政策

State-Level Implementation of Health and Safety Policies to Prevent Sudden Death and Catastrophic Injuries Within Secondary School Athletics: Letter to the Editor

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