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Available online at www.sciencedirect.com

Journal of Science and Medicine in Sport 13 (2010) 304–308

Original paper

Counting organised sport injury cases: Evidence of incomplete capturefrom routine hospital collections

Rebecca Mitchell a,∗, Caroline Finch b, Soufiane Boufous c

a NSW Injury Risk Management Research Centre, University of New South Wales, Australiab School of Human Movement and Sports Sciences, University of Ballarat, Australia

c The George Institute for International Health, University of Sydney, Australia

Received 18 December 2008; received in revised form 28 April 2009; accepted 30 April 2009

bstract

Organised sports are a popular form of physical activity, but unfortunately, participation can result in injury. Despite this, there have beenurprisingly few studies that have reported the population rate of sports injury. Data from the 2005 New South Wales (NSW, Australia)opulation Health Survey were analysed to describe self-reported injury experiences during participation in organised sports activities and theource of treatment for such injuries during a 12-month period in a population representative sample of adults aged 16+ years. At interview,414 respondents stated that they had participated in organised sport in the previous 12 months and just under one-third (30.9%) reportedhat they had been injured during this participation. Half of all injuries required formal treatment from a health or medical practitioner.hysiotherapists most commonly provided treatment for sports injury (26.6% of cases) followed by general practitioners (15.6%). Only 2.8%f all injured sports participants were admitted to hospital for their injury and a further 6.1% received treatment in an emergency department.

his corresponds to at most only 8.9% of all treated sports injuries receiving treatment in a hospital setting. Population-based estimates of

he rate and burden of sports injuries that rely solely on routine hospital data collections are likely to grossly underestimate the size of theroblem, as very few cases are treated in a hospital setting.

2009 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

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eywords: Organised sport; Sports injury; Population survey; Surveillance

. Introduction

Injuries are a well recognised possible adverse conse-uence of participation in sport and other physical activities,1

et little is known about the population rate of such injuriesn Australia,2 and indeed in most other countries. This isroblematic because descriptive epidemiological informa-ion about the occurrence of sports injuries is needed forolicy development, setting prevention priorities and tar-ets, and for identifying suitable prevention and controleasures.Routine health sector data collections have been used to

escribe the rate and patterns of sports injuries, with mostata relating to emergency department presentations or injuryospitalisations.3–6 In New South Wales (NSW) Australia,

∗ Corresponding author.E-mail address: r.mitchell@unsw.edu.au (R. Mitchell).

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440-2440/$ – see front matter © 2009 Sports Medicine Australia. Published by Eloi:10.1016/j.jsams.2009.04.003

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or example, sports injuries have been estimated to accountor between 13.9% and 38.3% of all hospitalised injury.7

hilst these routine hospital-based data collections do pro-ide a wealth of information about the nature of acute severenjuries, they are limited because only a proportion of sportsnjuries are treated in these settings.8,9 For instance, in aeographically defined region in Australia, Finch et al.9 esti-ated that for every hospital admission for a sport-related

njury, there were 10.6 emergency department visits and 11.7eneral practitioner consultations. As routine hospital dataollections do not identify all sports injuries, a number ofecent studies have employed population-based surveys toetermine the frequency of sport-related injuries.9–12 Thesetudies have all found sports injuries to be more common in

ales, younger people and in people who frequently partici-

ate in sport.9–12

Whilst there is accumulating information about the fre-uency of sports injuries in relation to participation, there

sevier Ltd. All rights reserved.

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R. Mitchell et al. / Journal of Science

as been very few examinations of the proportion of individ-als reporting a sports injury in a population-based sampleo quantify the level of case-capture of these injuries throughoutine hospital-based data collections.6,8,9 This is largelyecause health surveys have not obtained information abouthe sources of treatment for reported injuries. This paper takesdvantage of recent data from the NSW Population Healthurvey to describe the frequency of self-reported injury and

he source of injury treatment of individuals aged 16+ yearsarticipating in organised sport.

. Methods

The NSW Population Health Survey is a continuousnnual survey, undertaken by the NSW Department of Health.n 2005 it surveyed a representative sample of 13,701 adultsaged 16+ years) across NSW Australia about their health sta-us. A two-stage sampling process was used, with the sample

tratified by NSW Area Health Service (AHS). Within eachHS, households were randomly selected using a computer-enerated list of telephone numbers and postal addressesn the electronic phone book. Selected households were

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ig. 1. Proportion of respondents who participated in organised sport in the last 12 mstimates based on 11,273 respondents and injury estimates based on 2374 injuretated and 40 respondents whose injury status was not stated.

edicine in Sport 13 (2010) 304–308 305

ent a letter describing the aims of the survey 2 weeksefore telephone contact. A single respondent was then ran-omly selected from each household to participate in aomputer-assisted telephone interview (CATI). Interviewsere conducted continuously from February to December005 by trained Health Survey Program CATI interviewers.p to seven callbacks were made to establish contact withhousehold and up to five callbacks were made to contactselected respondent. Almost all respondents (98.1%) were

nterviewed in English. Full details about the survey devel-pment and methods are described elsewhere.13 The surveyesponse rate was 57.7%.13

Information was obtained through approximately 150uestions about respondents’ age, gender, health behaviours,ealth status and health service use. Respondents reportingarticipating “in organised sport or an activity as part of alub or association or high school whether for training, fit-ess or competition in the past 12 months” were also askedow much sport they played on average and whether they had

ustained an injury associated with this participation. Injuredespondents were then asked about the number of times theyad been injured during organised sport (including training)n the previous 12 months and the type of medical treatment

onths by injured status, age group and gender,1 NSW 2005. 1Participationd respondents. Excludes 7 respondents whose sport participation was not

306 R. Mitchell et al. / Journal of Science and Medicine in Sport 13 (2010) 304–308

Table 1Self-reported treatment for organised sport injury in previous 12 months by treatment type and gendera, NSW 2005.

Source of treatment Males % (95% CI) Females % (95% CI) Persons % (95% CI)

Treated self 33.9 (27.5, 40.4) 33.8 (25.8, 41.7) 33.9 (28.8, 39.0)Physiotherapist 24.7 (18.7, 30.7) 30.5 (22.5, 38.4) 26.6 (21.8, 31.4)No treatment 18.0 (12.4, 23.5) 13.3 (8.1, 18.5) 16.4 (12.3, 20.6)General practitioner 16.1 (11.3, 21.0) 14.6 (8.7, 20.4) 15.6 (11.9, 19.4)Chiropractor, osteopath or acupuncturist 5.1 (1.7, 8.4) 10.3 (5.2, 15.5) 6.8 (4.0, 9.6)Emergency department 7.0 (3.5, 10.6) 4.2 (1.3, 7.2) 6.1 (3.5, 8.7)Masseur 4.0 (0.9, 7.2) 3.5 (0.8, 6.2) 3.9 (1.5, 6.2)Admitted to hospital 3.5 (1.2, 5.8) 1.4 (0.1, 2.7) 2.8 (1.2, 4.4)Sports trainer 2.0 (0.0, 4.2) 0.4 (0.0, 1.1) 1.5 (0.0, 3.00Dentist or orthodontist 0.4 (0.0, 0.9) 0.0 (0.0, 0.0) 0.3 (0.0, 0.6)Naturopath or alternative health practitioner 0.2 (0.0, 0.5) 0.8 (0.0, 2.0) 0.4 (0.0, 0.8)O

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ther 0.2 (0.0, 0.5)a Estimates based on 534 respondents who reported playing an organised s

ould be given, so percentages add to >100%.

hat they received for their most recent injury. All organisedport questions were pilot tested prior to use. The injury statusf 40 (1.7%) respondents was not available. Unfortunately,o information was collected about the nature of the organ-sed sport being undertaken at the time of the injury or theype and severity of the injuries sustained.

Survey data were obtained for all respondents whoeported participating in organised sport in the previous 12onths. Analysis of the survey data was undertaken usingAS, version 8.02.14 The surveymeans procedure was used

o estimate proportions (and 95% confidence intervals, 95%I) of reported organised sports injury and treatment by agend gender. The surveyfreq procedure was used to calculateao–Scott design-adjusted chi-square statistics. Data were

tratified by AHS and a sampling weight was applied todjust for differences in the probabilities of selection amongespondents associated with the sample survey design. Theseifferences were due to the varying number of people livingn each household, the number of residential telephone con-ections for the household, and the varying sampling fractionn each AHS.

. Results

A total of 2414 respondents (25.4% of the total; 95%I: 24.2–26.6) stated that they had participated in organised

port in the previous 12 months. Males were significantlyore likely to report participation than females (30.2% versus

0.7%, p < 0.001) (Fig. 1). Participation decreased with age,specially between the 16–24 and 25–34 years age groups.n average, females played sport for fewer hours per week

4.0, 95% CI: 3.5–4.5) than males (5.3, 95% CI: 4.7–6.0).Just under one-third of all organised sport participants

30.9%; 95% CI: 28.2–33.6) stated that they had been injuredhilst playing sport. Whilst the majority of respondents

males: 64.2%, 95% CI: 60.4–68.0; females: 75.9%, 95%I: 72.5–79.3) reported that they had not sustained an injuryuring organised sport in the last 12 months, overall 22.5%95% CI: 20.1–24.8) had sustained 1–2 injuries, 5.9% (95%

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sustained an injury and reported the type of treatment received. >1 response

I: 4.8–9.2) had sustained 3–5 injuries and 2.5% (95% CI:.5–3.6) more than 5 injuries. Fig. 1 shows the relation-hip between the reporting of sports participation and relatednjuries according to age and gender.

Around half of the injured sports participants did notequire formal treatment, with around one-third reportinghat they self-treated their injury and just fewer than 20%eceiving no treatment (Table 1). There were no significantifferences in treatment sources for injured male and femaleports participants. Physiotherapists and general practitionersere the most common health practitioners providing treat-ent for sports injury. Fewer than 3% of all injured sports

articipants were admitted to hospital for their injury andewer than 10% received treatment in an emergency depart-ent. Overall, hospital-treated cases accounted for at most

.9% of self-reported sports injuries.

. Discussion

Developing and evaluating sports safety policies andnjury prevention initiatives needs to be informed by high-uality, relevant data that contain compelling argumentsbout the public health burden of health conditions15 andetailed information about causal factors.16 Most countriesnd regions do not currently conduct routine reporting ofopulation-level sport-related injury rate trends over time,hether for organised sport or for all sport and recreational

ctivities.This analysis of a large population-based survey of adult

esidents from the most populous state of Australia, has foundhat almost one in three adults who reported participatingn organised sport in the previous 12 months were injureduring this participation. In Australia, up to 9.5 million Aus-ralians aged 18+ years participate in any form of sport oreneral physical recreation each year,17 with 3.5 million

ustralians aged 15+ years participating in organised sport

i.e. participation for a club, association or school).18 Acrossustralia, males have slightly higher participation rates inrganised sport than females (26% versus 20%, respectively)

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R. Mitchell et al. / Journal of Science

nd younger adults (15–24 years) had higher participationates (39%) than older Australians (65+ years) (19%). Theact that our sample participation rates showed similar trendso those reported from other population surveys across thehole of Australia adds weight to the likely generaliabilityf our results outside of NSW.

Obtaining population level information to generate sport-elated injury rates is a challenge. In many countries, onlyeath and hospitalisation data have the potential to rou-inely identify and monitor sports injuries over time and torovide population estimates of their incidence.3–5,19 Hospi-alisations and hospital-treated sports injuries only represent

fraction of the overall burden of all injuries.6 For exam-le, an earlier British study concluded that only about 25%f all reported sports injuries were treated at an emergencyepartment or admitted to hospital.20 On the basis of ourndings, population-based sports injury surveillance systemselying solely on routine hospital data collections are likely torossly underestimate the size of the problem, as only one in0 organised sport-related injuries were treated in a hospitaletting. Moreover, the population prevalence of sports injuresequiring treatment from a health or medical practitioner isikely to be five times that obtained relating to hospital-basedreatment only.

In other contexts, rates of serious hospitalised injury (i.e.dentified by International Classification of Diseases (ICD)-ased Injury Severity Scores (ICISS) severity threshold scoref ≤0.941) have been proffered as an indicator suitable toonitor injury trends over time and to inform policy devel-

pment as this type of indicator is unlikely to be influencedy changes in hospital admission practices or other hospitalolicies21 and are therefore likely to be more stable and torovide a valid measure of injury over time. However, in aounter argument, more minor injuries (i.e. injuries not result-ng in hospitalisation) are estimated to make up the majorityf the burden of injury, have the greatest impact on the popu-ation in terms of morbidity, and thus are argued should be theocus for injury policy intervention and prevention efforts.22

oreover, limitations in the application of ICD activity andlace codes to select sports injury cases mean that hospitalata systems are unlikely to identify all cases of sports injuryospitalisations.7,23 To this end, to more correctly estimatehe burden of sports injuries in a given community, the feasi-ility of collecting information about sports injuries treatedn other settings, such as by physiotherapists and generalractitioners, in particular should be examined.6,8

In accordance with other researchers who have used simi-ar health survey data,9–12 the NSW Population Health Surveyas the potential to be a useful source of sports injuryrevalence data. For example, in a comparison of emer-ency department records and health survey data collections,ulder24 concluded that both health sector data and surveys

re important contributors to describing the burden of homend leisure accidents. In addition, surveys undertaken usingpopulation-based sample can provide additional informa-

ion regarding injury than what is collected in routine health

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edicine in Sport 13 (2010) 304–308 307

ata collections and can also provide evidence of the pro-ortion of injured individuals not captured in these routineollections.25

Unfortunately, direct comparisons between the informa-ion reported in the NSW Population health survey with otherelf-report surveys of sport-related injuries are not possible ashese have used different age groups, definitions of sport andhysical activities, and recall periods.8–12 Nonetheless, theimilarity in our findings and those of other studies in termsf the predominance of injuries in males and younger people,s well as those who participate in the organised sports, addsonfidence to our results.

There are several limitations of the health survey data wesed, including those biases normally associated with self-eport surveys, such as response, selection and recall biasver a 12-month period. A previous Australian study foundhat athletes had almost complete correct recall of whetherr not they were injured over a 12-month period, and 80%orrect recall of the number of injuries they sustained.26 It isnlikely therefore, that this data has led to an overestimatef the prevalence of sports injury during organised sport.lthough survey respondents in the current study reported

he total number of injuries they had sustained over the pre-ious 12 months, the information about the treatment sourceas associated with only their most recent injury. As such, it

s less likely to be subject to recall bias, but it is possible thathe most recent injury was either the most (or least) severe ofll injuries and so the distribution of treatment sources mayeflect this. Unfortunately, it is not possible for us to assesshe extent or direction of any bias that might have resultedrom this.

A further limitation of the 2005 NSW Population Healthurvey was that it did not ask about the type of sport played at

he time of the most recent injury and so specific sport injuryriorities in terms of treatment source needs could not beetermined from this data. Information from this, and otherimilar surveys, would be improved by the inclusion of addi-ional questions such as the type of sport played at the timef injury, the type of injury sustained, and the time takenff work, school or daily activities due to the injury, as aroxy measure of the impact of the injury on the individual’saily life. These sorts of questions have been successfullypplied in other population surveys.9 In addition, obtain-ng information about the proportion of injuries resultingrom all sport and recreation activities, not just more formalrganised sporting events, would be of benefit to estimatehe full impact of these types of activities on the population.his would broaden the sports injury prevention policy scope

rom sporting clubs, associations and schools to agencies andndividuals that promote and support all forms of sport andecreation.

In conclusion, solely using data from routine health sector

ata collections to estimate the burden of sports injury sig-ificantly underestimates the size of the public health burdenssociated with sports injury. Information on sport-relatednjuries would be available from all health professionals

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08 R. Mitchell et al. / Journal of Science

hat commonly treat sport-related injuries, such as generalractitioners and physiotherapists. The ability to report onport-related injuries treated by health professionals outsidehe hospital system would allow for a better estimation ofhe incidence of these injuries to be calculated. Considera-ion should therefore be given to assessing the feasibility ofnhancing or establishing new routinely collected data col-ections to describe the burden of sport injuries on healthervice delivery and individuals.

ractical implications

Just under one-third of organised sport participants reportsustaining an injury related to that participation over a 12-month period.Many injuries resulting from organised sport do not requiretreatment from a health professional, with fewer than 9% ofall cases requiring treatment at an emergency departmentor admission to hospital.Population-based sports injury surveillance systems rely-ing solely on hospital-based data collections will grosslyunderestimate the incidence of sports injuries because fewsuch injuries require acute medical care in a hospital set-ting.

cknowledgements

This study was funded by the NSW Sport Injuries Com-ittee (NSWSIC) under its Research and Injury Preventioncheme. Dr R. Mitchell was supported by the NSW Injuryisk Management Research Centre (IRMRC) core funding,hich is provided by the NSW Department of Health, theSW Roads and Traffic Authority, and the NSW Motor Acci-ents Authority. Prof C. Finch was supported by an NHMRCrincipal Research Fellowship. Dr S. Boufous was supportedy the IRMRC core funding and an NHMRC Postdoctoralellowship during the paper writing phase.

The authors wish to thank the Centre for Epidemiologynd Research at the NSW Health Department for providingccess to the Health Outcomes and Information Statisticaloolkit (HOIST) and the NSW Population Health Survey for

his study.

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