Time to Authorized Clearance From Sport-Related Concussion: The Influence of Health Care Provider and Medical Facility
Authors: Bretzin Abigail C. , Zynda Aaron J. , Wiebe Douglas J. , Covassin Tracey 
Published: December 2020

Context
Return to play after sport-related concussion (SRC) requires authorized clearance from a health care provider (HCP). The variability in HCPs and facilities where athletes seek care may influence return time.

Objective
To identify the initial examiner, HCPs who authorize clearance to return to play, and medical facilities that authorize clearance to return to play for high school student-athletes after SRC and compare authorized clearance time by HCPs and medical facilities.

Design
Prospective cohort study.

Setting
High school.

Patients or Other Participants
Student-athletes (n = 16 001) with SRC participating in athletics sponsored by the Michigan High School Athletic Association.

Main Outcome Measure(s)
Frequencies of initial examiner and authorized clearance for each HCP (doctor of osteopathic medicine, medical doctor, nurse practitioner, physician assistant) and medical facility (neurologist's office; team physician, primary care physician or pediatrician's office [PCP]; hospital; urgent/ready care) for each case of SRC. We calculated Kaplan-Meier curves and Peto tests to evaluate differences in the median time to authorized clearance between HCPs and facilities. Only cases with a date on which clearance to return to play was authorized (80.3%; n = 12 856) were included in the authorized clearance and time-to-return analyses.

Results
An athletic trainer was at least 1 of the initial examiners in 71.3% (n = 11 404) of SRC cases; 81.2% (n = 12 990) had only 1 initial examiner. We observed an association between the initial examiner and the medical facility providing clearance for athletic director (χ2 = 52.6, P &lt; .001, V = .06), athletic trainer (χ2 = 172.0, P &lt; .001, V = .12), coach (χ2 = 161.5, P &lt; .001, V = .11), doctor of osteopathic medicine (χ2 = 59.4, P &lt; .001, V = .07), and nurse practitioner (χ2 = 10.0, P = .04, V = .12). Clearance was authorized most frequently by a medical doctor (63.9%, n = 8218) and at a PCP (70.8%, n = 9099). Median (interquartile range) time to authorized clearance varied by facility (urgent/ready care = 7 days [4–11 days], hospital = 9 days [6–14 days], PCP = 10 days [6–14 days], team physician = 12 days [8–16 days], neurologist's office = 13 days [9–20 days]; P &lt; .001). An athletic trainer was the initial examiner more often for males (74.1%) than for females (65.8%). The medical facility where clearance to return to play was authorized also differed between males (PCP = 69.3%, team physician = 11.3%, neurologist's office = 8.4%) and females (PCP = 73.6%, team physician = 8.5%, neurologist's office = 8.3%).

Conclusions
Clearance to return to play after SRC was frequently provided by a medical doctor and at a PCP. The median time to return to unrestricted participation after SRC varied by HCP and medical facility. Future researchers should elucidate the reasons for these differences and determine why athletes seek care at different types of medical facilities.