Athletic Trainers' Knowledge Regarding Health Care Delivery Systems and Administration in the American Health Care System

Perceived Knowledge Questionnaire

The perceived knowledge questionnaire has been used in previous knowledge gap studies in athletic training^11–13 and was first established by Flynn and Goldsmith.¹⁴ The 5-item perceived knowledge assessment tool was evaluated through 5 empirical studies to estimate internal and external consistency and establish dimensionality, generalizability, and test-retest reliability.¹⁴ In addition, the authors confirmed content, convergent, criterion, nomological, and construct validity. Specifically, the tool was evaluated with several constructs, which made it generalizable, allowing us to insert the “administrative concepts in health care delivery systems.” To confirm within our population, we determined strong internal consistency among our participants (Cronbach α = 0.870).

Knowledge Assessment

We established content and face validity using a Delphi panel (n = 7). A Delphi panel uses multiple rounds of review to establish consensus. To begin the process of establishing consensus, we identified relevant literature and regulatory documents to guide our first round. We reviewed the 2020 Standards for Accreditation of Professional Athletic Training Programs and the associated Board of Certification Practice Analysis (seventh edition) tasks relative to health care delivery systems and administrative concepts (Standards 64 through 67, 88 through 94; Domain 5, Tasks 0501 through 0504).^8,9 In the first round of review, we sent the panelists a survey to detail their years of experience (18 ± 7 years) and contemporary qualifications to serve as a panelist (Table 2). We then asked the Delphi panel to read each standard closely and determine what concepts within that standard should be considered for inclusion in the knowledge assessment. From this round, we created a list of potential concepts for inclusion (Table 3) that explored health care delivery systems and administration with respect to knowledge retrieval and knowledge utilization style prompts. For Round 2, we sent the list to the Delphi panel in an e-mail and asked for feedback relative to significant concepts that panelists believed had been left out or whether a concept was insignificant and should be deleted. On the basis of the feedback in Round 2, we developed a 21-item knowledge assessment.

Table 2 Panelist Qualifications

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Table 3 Included Concepts in the Study

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At this point in the review process one of the panelists discontinued participating in instrument development. In Round 3, we presented the panelists with each item, a reference to provide evidence to support the correct response. We asked the panelists to indicate whether they believed the question and responses were adequate as written, the question was adequate as written, the responses were adequate as written, or the question should be removed from the knowledge assessment. If the panelists indicated that the responses or the question needed revision, we asked for suggested modifications. If the panelists believed that the question should be removed, we asked for a rationale. At the end of Round 3, we had achieved consensus on 11 items. In Round 4, we used the same platform as Round 3, presenting the question and reference and asking about necessary modifications and rationale. We highlighted changes to the remaining 10 items to draw attention to the modifications from Round 3 to Round 4. At the end of this survey, we asked the panelists to rate their level of agreement that the assessment reflects a wide range of health care delivery system concepts, enough so that it could be defined as a comprehensive knowledge assessment. We asked panelists to note that both clauses of the aforementioned statement must be true for them to agree. We also asked them to rate their level of agreement that the tool (all items and responses) was sufficient as written to measure actual knowledge of athletic trainers regarding health care delivery system concepts. At the conclusion of Round 4, we achieved consensus on all questions and responses, 83% (n = 5/6) agreement that the tool was wide-ranging and comprehensive, and 100% (n = 6/6) agreement that tool was sufficient as written.

Self-Efficacy Scale

The self-efficacy scale was developed to assess individuals' belief in their own abilities.¹⁵ Similar items have been used in athletic training research relative to the ability to assess for a concussion, apply specific tests and measures for concussion assessment, and return someone to play after a concussion.¹⁶ We used the scale similarly, interchanging the construct in the scale relative to the construct in a corresponding knowledge utilization question. For instance, relative to item 14, the participants ranked their confidence relative to “applying principles of patient privacy” and then were asked in the knowledge utilization question to appropriately apply laws relative to compliant communication for a patient case (Figure). We used an 11-point Likert scale prescribed by Bandura¹⁵ beginning with 0, which was equivalent to cannot do at all, and progressing at 10-point increments to 100, which meant highly certain can do. At the halfway mark 50, another descriptor indicated moderately can do. The self-efficacy scale demonstrated strong internal consistency (Cronbach α = 0.733).

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Six Domains of Health Care

The importance of providing high-quality patient-centered care is critical because all patients should be given all the necessary information regarding their health and additionally given the choice for their own plan of care.⁷ Participants within our study demonstrated a poor ability (21.9% responded correctly) to identify the constructs of the Institute of Medicine's Six Domains of Health Care Quality.⁹ This framework includes 6 aims for the current health care system: that it is safe, effective, patient-centered, timely, efficient, and equitable (Table 6). To ensure we, as health care providers, are delivering high-quality health care, we should be able to speak the language of health care providers. These tenets of quality health care are commonly discussed among providers and health care systems.

Table 6 Six Domains of Health Care Quality⁹

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Value-Based Care

Within our study, participants were asked to identify the best definition of value-based health care, but overall, they were unsuccessful at this task (23.5% responded correctly). Value-based health care is a model of health care that pays providers and hospitals on the basis of patient outcomes. There are 2 key challenges to athletic trainers in understanding value-based health care: (1) cost-containment health care facilities (common in athletic training) are not typically paid per service, and (2) athletic trainers are largely uncomfortable with measuring their outcomes.^36–38 These issues serve as barriers to understanding and applying value-based health care in athletic training. However, to align with the American health care system, we must measure and demonstrate value through positive patient outcomes.³⁹

Data-Driven Decisions

In athletic training, there is a breadth of epidemiological data that serve the traditional athletic training settings (college/university and secondary school) in best understanding injury trends.^40–49 As a result of this information, athletic trainers have the ability to use not just local data but to use data from larger groups to drive clinical practice. Within our study, participants were asked to consider epidemiological data indicating that both men's and boys' soccer participants have an increased risk for lower extremity injury.^43,48 A majority (72.2%) of the participants correctly identified that a functional movement screen should be conducted to further assess the risk and implement a prevention program for those who are at risk. Athletic trainers must continue to take both data that are driven from their own clinical practice as well as overall trends to begin and continue implementing prevention programs for at-risk patients.⁵⁰

Quality Improvement

Although the concepts of quality improvement have been engrained within health care since the 1980s,⁵¹ athletic training has been slow to engage.¹ The participants in this study were able to differentiate (69.3% responded correctly) the concepts of quality assurance (ie, a retrospective review of processes and outcomes)⁵¹ and quality improvement (ie, a proactive process to measure performance and implement change).⁵¹ However, much of the literature suggests that athletic trainers have not collected data on clinical outcomes,^36–38 cost (savings and expenditures),¹ and satisfaction,¹ making it impossible to effectively engage in quality-improvement practices. This is confirmed with the knowledge utilization item relative to quality improvement, where only 13.8% (n = 67) of participants were able to identify what action to take within a scenario. Given that the principles of quality improvement are embedded in education program expectations^8,52,53 as well as the standards that drive our clinical practice,⁵⁴ these skills are essential. Beyond the ability to demonstrate knowledge retrieval, athletic trainers need to be equipped to collect data to effectively engage in quality improvement,⁵⁵ which extends beyond simple self-reflection.

Measuring Patient Satisfaction

Patient satisfaction is measured through the value of health care services, attaining, improving and maintaining health, and personal experience at the point of care.⁵⁷ In our study, participants were unable to identify that frequent visits with a provider to resolve the condition may result in decreased patient satisfaction (42.3% responded correctly). Previous research has identified that physicians and patients are exceptionally satisfied with athletic trainers, especially compared with entry-level physician assistants and nurse practitioners in physician practice.⁵⁸ To combat the increasing number of patients seeking out health care without increasing providers, physician offices may employ athletic trainers; those that did noted improvement in physician practice productivity⁵⁹ and an increased number of patient encounters from 10% to 30%.^59,60 Employing athletic trainers in the physician-practice setting also had a significant impact on both the time before scheduling an appointment^21,61 as well as for the in-clinic wait time for patients.^21,62,63 Unfortunately, no similar data are available for traditional athletic-training settings. The lack of data on patient encounters, patient satisfaction, and the benefits of employing an athletic trainer in various settings serves as a challenge in athletic training and in our attempts to demonstrate our value to employers.

Standing Orders and Privileging Documents

Athletic trainers are required to work under the direction of another health care provider, which varies according to specific state practice acts. Written documents to guide the relationship between physician and athletic trainer are infrequent. Standing orders are guidance documents used by all providers within an organization with the same credentials, allowing an athletic trainer to practice under the full scope of practice as dictated by each state practice act.⁶⁴ Privileging documents are common in the American health care system and privilege-specific health care providers who demonstrate training and qualification to perform a skill. In athletic training, every provider should have written guidance for their role, but specific skills should be privileged by a directing physician. Participants in our study were unable to identify a clinical privileging document (16.1% responded correctly), even though these kinds of relationships are detailed in professional resource documents.⁶⁵ These findings raise concerns that athletic trainers may not be engaged in robust relationships with directing physicians and may not be practicing at the top of their license.

Centers for Medicare and Medicaid Services Billing

Third-party billing has long been an initiative of the NATA.⁶⁵ Limitations by organizations such as the Centers for Medicare and Medicaid Services since 2004 have created challenges to providing care to physically active patients insured through Medicaid and Medicare for athletic trainers working in the emerging settings. Within our study, only 56.9% of the participants were able to properly identify that athletic trainers are not able to bill for service under Medicaid and Medicare. There continues to be confusion and assumptions made that simply on the basis of the regulations from Medicaid and Medicare, athletic trainers are unable to bill in any state under other insurers. However, several states allow athletic trainers to bill for service, and in 2014 the NATA partnered with Ohio, Indiana, and Wisconsin state organizations to pilot recognition of athletic trainers from third-party payer systems.⁶⁶ Additional efforts, specifically the initiative to ensure all athletic trainers have a National Provider Identifier, have potential to increase the number of companies and insurance plans that reimburse for athletic training services and demonstrate the value that athletic trainers can have even outside of traditional patient populations.⁶⁶ The majority of our participants possessed their National Provider Identifier (n = 431, 88.9%), which perhaps demonstrates their basic understanding of the initiatives to bill for service.