Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry.

OBJECTIVE: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. DESIGN: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. SETTING: Dallas, TX, USA. PARTICIPANTS: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. OUTCOME MEASURES: Data included demographic and clinical characteristics, charges, and healthcare utilization. RESULTS: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. CONCLUSION: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Community-based InterVentions to prevent serIous Complications (CIVIC) following spinal cord injury in Bangladesh: protocol of a randomised controlled trial.

INTRODUCTION: In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh. METHODS AND ANALYSIS: A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBERS: ACTRN12615000630516, U1111-1171-1876.

Effects of paraplegia on quality of life and family economy among patients with spinal cord injuries in selected hospitals of Sri Lanka.

OBJECTIVES: The study was conducted with the aim of assessing the effects of paraplegia caused by spinal cord injuries on the quality of life of patients and their family economy. STUDY DESIGN: A descriptive cross-sectional study. SETTING: The study was carried out in Accident Service, Orthopedic and Neurosurgery Units of the National Hospital of Sri Lanka and the Spinal Injury Unit of Rehabilitation Hospital Ragama. METHODS: One hundred traumatic paraplegic patients were included as the study sample. Modified Ferrans and Powers quality of life index: spinal cord injury version was used to measure the quality of life. Pre- and post-family economic data were collected using an interviewer-administered questionnaire. RESULTS: Quality of Life was calculated under four major components. Paraplegics' family component (mean=3.50) and social, economic aspects (mean=3.24) are considerably good when compared with health and functioning (mean=2.83) and psychological (mean=2.78) components. Also the study revealed that expenditures are significantly high (P=0.001) and income is significantly less (P=0.001) after injury than before. CONCLUSION: Quality of life is relatively good on family and social aspects, whereas the physical and psychological aspects are somewhat poor. Regarding family economy, expenses are significantly high and earnings are significantly less after the injury. Contribution to the income from self-employment shows the most significant decline. Findings suggest that the family economy of such patients should be supported.

Initial and long-term costs of patients hospitalized with West Nile virus disease.

There are no published data on the economic burden for specific West Nile virus (WNV) clinical syndromes (i.e., fever, meningitis, encephalitis, and acute flaccid paralysis [AFP]). We estimated initial hospital and lost-productivity costs from 80 patients hospitalized with WNV disease in Colorado during 2003; 38 of these patients were followed for 5 years to determine long-term medical and lost-productivity costs. Initial costs were highest for patients with AFP (median $25,117; range $5,385-$283,381) and encephalitis (median $20,105; range $3,965-$324,167). Long-term costs were highest for patients with AFP (median $22,628; range $624-$439,945) and meningitis (median $10,556; range $0-$260,748). Extrapolating from this small cohort to national surveillance data, we estimated the total cumulative costs of reported WNV hospitalized cases from 1999 through 2012 to be $778 million (95% confidence interval $673 million-$1.01 billion). These estimates can be used in assessing the cost-effectiveness of interventions to prevent WNV disease.

Long-term gendered consequences of permanent disabilities caused by the 2005 Pakistan earthquake.

This study documents the long-term gendered impact of the 2005 Pakistan earthquake on women and men who were rendered paraplegic as a result of spinal cord injuries sustained during the disaster. Coping mechanisms are also mapped. The findings show that three years after the disaster, paraplegic women are socially, emotionally, and financially isolated. The small stipend they receive is a significant source of income, but it has also led to marital distrust, violence, and abuse. In contrast, men receive full social and emotional support. Their key concern is that the government is not providing them with opportunities to be economically productive. Contemporary discourse and post-disaster policies, while acknowledging the importance of incorporating a gender perspective in the immediate post-disaster period, have failed to acknowledge and address the longer-term gendered impact of disasters, in terms of the different types of impact and strategies adopted by women and men.

A cost analysis of conservative management of spinal cord-injured patients in Nigeria.

STUDY DESIGN: A prospective study. OBJECTIVES: To determine the cost of acute phase of injury (ASCI) among spinal cord-injured patients managed conservatively in Nigeria. SETTINGS: Gwagwalada, Abuja. METHODS: Over a 1-year period (1 January 2009 to 31 December 2009), the cost of ASCI of consecutive spinal cord-injured patients, gainfully employed preinjury, who paid the hospital bill directly from their purses and could estimate their daily income, and who were managed conservatively for 6 weeks before discharge to rehabilitation, was prospectively examined. RESULTS: A total of 34 cases of spinal cord-injured patients with a mean age of 35.4 ± 12.8 years were included in this study. The mean cost of ASCI over 6 weeks was $1598.29, an average of 6.4-232.8% of patients' annual income where >50% of the people live on less than a dollar a day. The mean cost of hospitalization was 14.9% of the total cost of ASCI in this study. It was significantly more expensive to treat tetraplegics compared with paraplegics. CONCLUSION: This study identified the cost of acute phase of spinal cord injury in Nigeria to assist clinicians in planning treatment that could reduce financial burden on the patients but optimize patients' care.

Employment after paraplegia in India: a postal survey.

STUDY DESIGN: This study was carried out as a postal survey. OBJECTIVES: The aim of this study was to ascertain employment after paraplegia in India. SETTING: This study was conducted in India. METHODS: The study was conducted by means of a questionnaire. This questionnaire was mailed to the identified individuals (n=600) on the addresses obtained from the medical records section of hospitals and from various organisations. Data analysis was carried out by using descriptives. RESULTS: The return rate was 46% (276/600) and the employment rate was 41% (114/276). Among 114 subjects who were employed, 68 (59.6%) were living in centres run by armed force and 46 (40.4%) were living in specialised centres or under the region of non-governmental organisations. CONCLUSIONS: Individuals who were employed were living either in centres run by armed force or in specialised centres. None of the individuals living in community was employed.

Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries.

OBJECTIVES: During the last decade, endovascular repair (EV) has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. This has resulted in reductions in mortality, length of stay, and major complications, including paraplegia, with the added expense of the initial endograft, subsequent surveillance, and reinterventions. The purpose of this study was to conduct an economic evaluation comparing these two methods of repair. METHODS: We performed an economic comparison of EV and OSR for the treatment of BTAI using a decision tree analysis with transition points derived from our institution's experience and through a review of the literature. Over a 15-year period (1991-2006), 28 patients with BTAI were treated at our center (15 EV, 13 OSR). Costs were obtained from our hospital's case costing center, the Ontario Case Costing Initiative, Ontario's Drug Benefit Formulary, and Ontario's Schedule of Benefits for physician costs. Our center's results were then combined with those from the literature to arrive at an economic model. RESULTS: These combined results revealed that EV, when compared to OSR, resulted in decreased early mortality (7.2% vs 22.5%), decreased composite outcome of mortality and paraplegia (7.7% vs 27.6%) and decreased composite outcome of mortality and major complication (42.5% vs 69.8%). Patients undergoing EV also had shorter intensive care unit stays (12.2 vs 15.3 days), total hospital length of stays (22.5 vs 28.6 days), and ventilator days (8.0 vs 9.2 days). Additionally, patients undergoing EV had decreased total 1-year costs compared with OSR ($70,442 vs $72,833). CONCLUSIONS: EV repair of BTAIs offers a survival advantage as well as a reduction in major morbidity, including paraplegia, compared with OSR, and results in a reduction in costs at 1 year. As a result, from the cost-effectiveness point of view, EV is the DOMINANT therapy over OSR for these injuries.

Health care costs for patients with chronic spinal cord injury in the Veterans Health Administration.

BACKGROUND/OBJECTIVE: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, > 2 years after injury). METHODS: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted. RESULTS: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample. CONCLUSIONS: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization.

Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs.

In Ile-Ife, Nigeria, traumatic brain injuries are largely due to traffic accidents caused mainly by the bad maintenance of the roads and unsafe driving. Young men in the productive stage of their lives are those most affected. The resultant disabilities include quadriplegia (in more than half the patients) and paraplegia. The cost of treating and providing adequate facilities for these patients imposes a heavy economic burden upon developing countries.

The DALY, context and the determinants of the severity of disease: an exploratory comparison of paraplegia in Australia and Cameroon.

This paper summarises the findings of an empirical investigation of some of the technical and social assumptions on which the disability adjusted life year (DALY) is based. The objectives of the study were to examine the notion that the burden of disease is broadly similar without regard to country, environment, gender or socio-economic status and to develop detailed descriptions of the experiences of the burden of disease as they related to these contextual factors. The study was a multi-factorial exploratory study employing qualitative and quantitative techniques to obtain data on the effects of country (development), environment (urban versus rural), gender and socio-economic status on people with paraplegia. The data provided an extensive and detailed compilation of context rich descriptions of living with paraplegia. Striking features of the data were the differences between countries with respect to the impact of the health conditions on functioning and highlight a context in which paraplegia of like clinical severity can be fatal in one environment and not in another. While there has been some focus on the control of social determinants of disease, there has been little work on the social determinants of the severity of disease. The underlying assumptions of the DALY, which ignore context in the assessment of the burden of disease, risk exacerbating inequalities by undervaluing the burden of disease in less-developed countries. There is a need to continue to subject the development of indicators to rigorous debate to determine a balance between the assumption of a global "average social milieu" and the treatment of each individual as belonging to their own context in the assessment of population health in order for indicators to be meaningful cross-culturally.

Exploring the role of order effects in person trade-off elicitations.

BACKGROUND: The person trade-off (PTO) has been advocated by some as an alternative measure for the purposes of cost-effectiveness analyses. However, the measurement properties of PTO elicitations are still being defined. METHODS: We presented subjects with two PTO scenarios. In the pre-existing paraplegia scenario, they were asked how many paraplegics' lives would have to be saved to be just as important as saving 100 'normal' people's lives. In the paraplegia onset scenario, they were asked how many patients who would experience the onset of paraplegia need to be saved to equal the benefit of saving 100 'normal' lives. We varied the order of the two scenarios across subjects to test whether PTO elicitations are susceptible to order effects. In addition, we varied whether subjects were required to provide a numerical response to the first elicitation. RESULTS: Subjects' PTO indifference points for the two scenarios varied dramatically depending on the order with which they received the scenarios, and according to whether the first elicitation required a numerical response. For those subjects providing numerical responses to both elicitations, median PTO responses varied by a factor of close to two in the pre-existing paraplegia scenario and by a factor of eight in the paraplegia onset scenario. However, the magnitude of the order effect was significantly reduced when subjects were not asked to provide a numerical response to the first PTO elicitation. CONCLUSION: PTO elicitations are susceptible to order effects. These order effects are partly due to numerical anchoring. However, other cognitive factors contribute to the order effect. Further research should clarify whether these order effects can be reduced.

Socio-economic outcome of paraplegia compared to lower limb amputation.

STUDY DESIGN: The socio-economic outcome was retrospectively compared between patients with traumatic lower limb amputation and those with paraplegia due to a spinal cord injury (SCI). OBJECTIVE: To evaluate the effect of specific rehabilitative procedures on the socio-economic outcome. SETTING: Paraplegic Centre at the University Hospital in Zurich, Switzerland. METHODS: Accidents occurring in a collective of 1.9 million persons in Switzerland over 3 years were included in the study. Fifty-six persons with unilateral amputation of lower limbs were compared with 54 persons with paraplegia. The follow-up was assessed over 5 years. RESULTS: The following data was obtained in patients with amputations compared to those with SCI (median values): (1) hospital stay: 150 versus 164 days; (2) the work was taken up after 689 versus 616 days; (3) the global average case costs amounted to SFr. 491.000 versus SFr. 606.000 during the first 5 years after injury; (4) the permanent degree of disability was determined to 40% versus 42%. Except for the global costs, all differences were not significant. CONCLUSIONS: There are only a few differences between the socio-economic outcomes between patients with lower limb amputations and those with paraplegia. It remains unclear if the highly specialised rehabilitation services provided for patients with SCI accounts for the similarity since individuals with SCI have additional neurogenic dysfunction of the bladder and bowel. Alternatively, the data may suggest a need for greater rehabilitation services for amputees or may reflect a threshold effect in rehabilitation outcomes.

Age-related differences in length of stays, hospitalization costs, and outcomes for an injury-matched sample of adults with paraplegia.

OBJECTIVE: To investigate the effects of age at injury on neurological and functional outcomes and hospitalization length of stays and charges following spinal cord injuries resulting in paraplegia. METHODS: Subjects were 180 adults with paraplegia who were assessed in acute care and inpatient rehabilitation as part of the National Institute on Disability and Rehabilitation Research Model Spinal Cord Injury Systems. Age differences were examined by separating the sample into 3 age groups (18-39, 40-59, and 60+ years). A matched block design was used to control for injury characteristics. Cramer's statistic was used to identify age-related differences in qualitative variables; 3 x 5 one-way analysis of variance identified the main effects of age on quantitative variables. Tukey post hoc tests were performed to identify differences between age and age x injury characteristic variable levels. OUTCOME AND TREATMENT MEASURES: American Spinal Injury Association motor index scores, Functional Independence Measure (FIM) motor scores, discharge to private residence ratios, and hospitalization length of stays and charges were outcome and treatment measures. RESULTS: Age-related differences were found for etiology and health care plan, as well as for preinjury marital status, education level, and employment status. The main effects of age at injury were found for the following treatment and outcome measures: rehabilitation length of stays, FIM motor scores at rehabilitation discharge, FIM motor improvement (change), and FIM motor daily improvement (efficiency). Tukey post hoc tests revealed that older patients had longer rehabilitation stays, lower rehabilitation discharge FIM motor scores, and showed less improvement compared with younger and middle-aged injury-matched patients. No age-related differences were found in rates of discharge disposition. CONCLUSIONS: Using a matched block design procedure, older patients are discharged with lower levels of functional independence and show lower levels of improvement despite longer rehabilitation stays when compared with younger patients. Older patients' neurological recovery appears equivocal to younger patients' recovery. In contrast to findings with a matched tetraplegia sample, older and younger patients with paraplegia are discharged to private residences at similar rates.

Age, outcome, and rehabilitation costs after paraplegia caused by traumatic injury of the thoracic spinal cord, conus medullaris, and cauda equina.

The object of this study was to investigate the relationships of age on neurologic and functional outcome, hospitalization length of stay (LOS), and hospital charges after spinal cord injury (SCI). At 20 medical centers, 2,169 consecutive adult patients with paraplegia SCI were assessed in acute care and inpatient rehabilitation. Outcome and treatment measures included the ASIA motor index score, functional independence measure, discharge to community ratio, LOS, and hospital charges. Age differences were examined by separating the sample into 11 age categories and conducting one-way analyses of variance on treatment, medical expense, and outcome measures that included the Functional Independence Measure (FIM) and ASIA motor index scores. Cramer's statistic was used to derive a chi-square value that indicated whether variables differed significantly in terms of age. Post-hoc Tukey tests were also performed. Age-related differences were found with multiple demographic variables. Significant differences between age categories were found with regard to the following treatment measures: ASIA motor index scores at acute-care admission and at discharge, rehabilitation LOS, inpatient rehabilitation hospitalization charges, total LOS, total hospitalization charges, FIM scores at inpatient rehabilitation admission and discharge, FIM change, and FIM efficiency. In conclusion, in patients with paraplegia, age appears to adversely affect functional outcome, rehabilitation LOS, and hospital costs. However, neurologic recovery as defined by the ASIA motor scores does not appear to be related to age.

Relation of disability costs to function: spinal cord injury.

OBJECTIVE: This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community. DESIGN: A cross-sectional study. SUBJECTS: One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation. RESULTS: A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance. CONCLUSION: The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.

Donal Munro Lecture: Functional and neurologic recovery following acute SCI.

Patient management in the current health care environment requires the provider to make reliable and valid clinical decisions regarding patient care, decisions that are cost effective and will lead to optimal functional improvement. Neurologic examination, according to the Standards for Neurological and Functional Classification of Spinal Injury developed by the American Spinal Injury Association, provides every clinician with simple clinical tools that are highly predictive of functional recovery following a spinal cord injury. The ability to predict motor recovery provides a rational basis to help support the provider's recommendation for the patient's goals and care planning, as well as differentiates care that is essential for improving functional outcomes from care that is not.

Investigation of the social status of paraplegic individuals after medical rehabilitation.

The social services of the German centres for spinal cord injuries compiled social data on 2000 recently injured paraplegics. The aim of the study was to determine whether and to what extent patients had been reintegrated to jobs after completion of physical rehabilitation treatment. A 31-point questionnaire surveyed all relevant data pertaining to the projected professional vita. The results for the medically rehabilitated population (n = 651) indicate that 45% returned to their previous job, school or college. Intensified use of computers and advanced academic backgrounds of afflicted individuals contribute to a higher chance for reintegration at a previous job. Our social statistics also include data on living conditions and social support. Household caretaking support is offered by family members in 73% of cases, while 5% permanently live in nursing homes.

[Costs and long-term results of plastic surgery treatment of decubitus ulcers in paraplegic patients]. / Aufwand und Langzeitergebnisse der plastisch-chirurgischen Behandlung von Dekubitalulzera bei Paraplegikern.

Costs and long-term results of plastic surgical procedures were evaluated in 17 paraplegics with a mean age of 39 years and Campbell-Grade 5 pressure sores. Seven sacral, nine ischial and one trochanteric ulcers were treated by myocutaneous or fasciocutaneous flaps. The mean hospitalization period was 82 days: up to 44 days in the plastic surgical department, 29 days in referring hospitals. During the follow-up period, averaging 18 (6 to 33) months, four patients suffered recurrences, all of them ischial sores. Evaluated regarding occupational resumption or duration of wheelchair mobility, eleven patients achieved full and two patients partial rehabilitation. The success rate justifies the operative procedures. Cost reduction by shortened hospitalization could be achieved through earlier transfer of patients to specialized units since preoperative preparation requires rarely more than one week and surgical relief can usually be achieved within a confined period of time. Orthopaedic deformities contributed to the majority of sores and to all recurrences.