Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study

Meaning of self-management from the perspective of individuals with traumatic spinal cord injury, their caregivers, and acute care and rehabilitation managers: an opportunity for improved care delivery

BACKGROUND

The trend of decreasing length of stay in rehabilitation facilities has led to individuals with spinal cord injury (SCI) entering the community with unmet needs and fewer self-care skills to prevent secondary complications. The implementation of a self-management program for individuals with SCI for the management of these complex needs, including secondary complications, may be one option to fill these care gaps. A greater understanding of the meaning of self-management may facilitate the development of a tailored self-management program in this population. Thus, the current research aims to understand the meaning of self-management in traumatic SCI from the perspectives of individuals with traumatic SCI and their caregivers as well as acute care/trauma and rehabilitation managers.

METHODS

A descriptive qualitative approach was used. Semi-structured telephone interviews were conducted with 26 individuals with traumatic SCI, their family members/caregivers, and managers from acute care/trauma and rehabilitation centres. Inductive thematic analysis was applied.

RESULTS

The meaning of self-management in SCI related to two overarching themes of internal and external responsibility attribution and revealed differences between the meaning of self-management in SCI among individuals with traumatic SCI and their caregivers versus managers. Overall, the meaning of self-management among the SCI and caregiver participants related principally to internal responsibility attribution. For the manager participants, the meaning of self-management was much narrower and the overarching theme of internal responsibility attribution that was observed among the SCI-caregiver dyads was not as widely expressed by this group.

CONCLUSIONS

Interventions that are co-created by users and health care professionals are associated with positive physical and mental health outcomes. Thus, the understanding of self-management from these varying perspectives could be applied to the development of a tailored self-management program that is relevant to individuals with traumatic SCI and their caregivers. This may involve the development of a program that uses some of the structure of traditional chronic disease self-management programs, in accordance with the beliefs held by the managers, but also incorporates elements of wellness/health promotion interventions, in accordance with the beliefs held by the SCI and caregiver participants.

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

OBJECTIVE

To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).

DESIGN

A retrospective cohort design was employed, using data retrieved from administrative databases.

SETTING

Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.

PARTICIPANTS

Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.

OUTCOME MEASURES

Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics.

RESULTS

There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).

CONCLUSION

Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.

Examining health-care utilization in the first year following spinal cord injury

OBJECTIVE

To identify factors associated with health-care utilization during the first year after inpatient rehabilitation (IR) in individuals with traumatic spinal cord injury (SCI).

DESIGN

Prospective cohort.

METHODS

One hundred and sixty-eight patients were prospectively enrolled and followed over 1 year after discharge from an SCI Model System IR program. Telephone follow-up occurred at 3, 6, 9, and 12 months. Participants were grouped into four impairment levels (C1-4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-C, C5-C8 AIS A-C, paraplegia AIS A-C, and all AIS D). Three domains of health-care utilization were examined: hospital care, outpatient provider visits, and home services.

RESULTS

Health-care utilization in the first year following IR was high with 45% of subjects reporting re-hospitalization. Twenty percent of patients were initially discharged to a skilled nursing facility (SNF), and an additional 10% required SNF care during this first year. Overall, those with C1-4 AIS A-C used the most services. Participants discharged home used less health care compared to those discharged elsewhere. SCI due to falls (vs. vehicular crashes) was associated with fewer in-home service visits. Age, sex, race, and education were unrelated to higher use.

CONCLUSION

Those with greater neurological impairment or not discharged home after IR had higher health-care utilization, while age was not associated with utilization. Targeted efforts to reduce genitourinary and respiratory complications may reduce the need for hospital care in the first year after IR.

Developing quality of care indicators for patients with traumatic and non-traumatic spinal cord injury (SCI): A feasibility study using administrative health data

OBJECTIVES

(1) to inform the development of health system quality indicators for traumatic and non-traumatic spinal cord injury from acute care admission to community care discharge using administrative data, and (2) to examine characteristics and differences in care among type of care facility, and type of pathology using administrative data.

DESIGN

Retrospective cohort study using administrative health data.

SETTING

Ontario, Canada.

PARTICIPANTS

Using administrative health data, we used International Classification codes 10(th) version Canadian Edition to identify incident cases of SCI from April 1, 2006 to March 31, 2012.

RESULTS

We identified 7,693 cases in our cohort, of whom 1,537 (20.0%) were categorized as traumatic spinal cord (TSCI) and 6,156 (80.0%) as non-traumatic (NTSCI). Of those identified with NTSCI, more than half (54.0%) were diagnosed with either Guillain Barré syndrome and Multiple Sclerosis (n = 3,326). More individuals admitted to a trauma/spine center were seen by an orthopedic surgeon or a neurosurgeon (20.3% compared to 5.6% for NTSCI; 77.7% compared to 24.9% for TSCI). Only 25.7% (n = 724) of the NTSCI cohort were admitted to a rehabilitation facility from a trauma/spine center, compared to 58.9% (n = 754) of those with TSCI.

CONCLUSIONS

Important challenges in data completeness and utility were identified. Province wide processes to flag incomplete data and provision of incentives for comprehensive data are urgently needed to develop quality indicators across the care continuum. Consensus on the coding for NTSCI for the purposes of developing health system indicators is required.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury

Study design:

Cross-sectional survey.

Objective:

To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI).

Setting:

Community-dwelling individuals with traumatic SCI living across Canada.

Methods:

Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS).

Results:

Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively).

Conclusion:

Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

Health care utilization in persons with traumatic spinal cord injury: the importance of multimorbidity and the impact on patient outcomes

BACKGROUND

Persons with spinal cord injury (SCI) living in the community have high health care utilization (HCU). To date, the interrelationships among multiple secondary health conditions (multimorbidity due to comorbidities and complications) that drive HCU and their impact on patient outcomes are unknown.

OBJECTIVE

To determine the association among multimorbidity, HCU, health status, and quality of life.

METHODS

Community-dwelling persons with traumatic SCI participated in an online/phone SCI Community Survey. Participants were grouped using the 7-item HCU questionnaire (group 1 did not receive needed care and/or rehospitalized; group 2 received needed care but rehospitalized; group 3 received needed care and not rehospitalized). Personal, injury, and environmental factors; multimorbidity (presence/absence of 30 comorbidities/ complications); health status (Short Form-12); and quality of life measures (Life Satisfaction-11 first question and single-item quality of life measure) were collected. Associations among these variables were assessed using multivariate analysis.

RESULTS

The 1,137 survey participants were divided into 3 groups: group 1 (n = 292), group 2 (n = 194), and group 3 (n = 650). Group 1 had the greatest number of secondary health conditions (15.14 ± 3.86) followed by group 2 (13.60 ± 4.00) and group 3 (12.00 ± 4.16) (P < .05). Multimorbidity and HCU were significant risk factors for having a lower SF-12 Mental (P < .001) and Physical Component Score (P < .001). They in turn were associated with participants reporting a lower quality of life (P < .001, for both questions).

CONCLUSIONS

Multimorbidity and HCU are interrelated and associated with lower health status, which in turn is associated with lower quality of life. Future work will include the development of a screening tool to identify persons with SCI at risk of inappropriate HCU (eg, rehospitalization, not able to access care), which should lead to better patient outcomes and cost savings.

Views of people with traumatic spinal cord injury about the components of self-management programs and program delivery: a Canadian pilot study

Background

Given the increasing emphasis on the community management of spinal cord injury (SCI), strategies that could be developed and implemented in order to empower and engage individuals with SCI in promoting their health and minimizing the risk of health conditions are required. A self-management program could be one approach to address these complex needs, including secondary complications. Thus, the objective of this study was to determine the importance attributed to the components of a self-management program by individuals with traumatic SCI and explore their views/opinions about the delivery of such a program.

Methods

Individuals with SCI were recruited by email via the Rick Hansen Institute (Vancouver, British Columbia, Canada) as well as an outpatient hospital spinal clinic. Data were collected by self-report using an on-line survey.

Results

The final sample size was 99 individuals with traumatic SCI. The components of a self-management program that were rated as “very important” by the greatest proportion of participants included: exercise (n= 53; 53.5%), nutrition (n= 51; 51.5%), pain management (n= 44; 44.4%), information/education on aging with a SCI (n= 42; 42.4%), communicating with health care professionals (n= 40; 40.4%), problem solving (n= 40; 40.4%), transitioning from rehabilitation to the community (n= 40; 40.4%), and confidence (n= 40; 40.4%). Overall, 74.7% (n= 74) of the sample rated the overall importance of the development of a self-management program for individuals with traumatic SCI as “very important” or “important”. Almost 40% (n= 39) of the sample indicated that an internet-based self-management program would be the best delivery format. The highest proportion of participants indicated that the program should have individuals of a similar level of injury (n= 74; 74.7%); having individuals of a similar age (n= 40; 40.4%) was also noted. Over one-quarter of the sample (n= 24) had a depression score consistent with significant symptoms of depression.

Conclusions

Future research is needed to further evaluate how the views of people with traumatic SCI change over time. Our findings could be used to develop and pilot test a self-management program for individuals with traumatic SCI.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-014-0209-9) contains supplementary material, which is available to authorized users.

Impact of pressure ulcers on individuals living with a spinal cord injury

OBJECTIVE

To describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Nationwide survey.

PARTICIPANTS

Participants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%-36.3%) had a pressure ulcer over the last 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0.

RESULTS

Of the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05).

CONCLUSIONS

Pressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.

Perceived facilitators and barriers to self-management in individuals with traumatic spinal cord injury: a qualitative descriptive study

Background

Current evidence has suggested the need for increased self-management support efforts in spinal cord injury (SCI) to reduce secondary complications. However, current self-management programs may not be suitable for the unique needs of individuals with SCI, including reduced mobility and the importance of attendant care. There is a need for greater understanding of the self-management strategies adopted by individuals with SCI and the potential need for a tailored self-management program. Thus, the purpose of the current study was to understand the perceived facilitators and barriers to self-management to prevent secondary complications.

Methods

A descriptive qualitative approach was used and involved telephone interviews. Semi-structured interviews were conducted with individuals with traumatic SCI, their family members/caregivers, and managers from acute care/trauma and rehabilitation centres. Participants were recruited between September 2011 and May 2012. Analysis was conducted using inductive thematic analysis to understand the perceived facilitators and barriers to self-management to prevent secondary complications.

Results

A total of 26 interviews were conducted and they included 7 individuals with traumatic SCI, 7 family/caregivers (i.e., 7 SCI-caregiver dyads), and 12 acute care/rehabilitation managers from across the province of Ontario. The following five facilitators to self-management were identified: physical support from the caregiver, emotional support from the caregiver, peer support and feedback, importance of positive outlook and acceptance, and maintaining independence/control over care. The following five barriers to self-management were identified: caregiver burnout, funding and funding policies, lack of accessibility, physical limitations and secondary complications, and difficulties achieving positive outlook or mood.

Conclusions

This study demonstrated that the caregiver and the individual’s own mood/outlook, among other facilitators and barriers, make significant contributions to the self-management of individuals with traumatic SCI. The issues of timing/readiness and comorbidities and aging were observed across many of these themes. As such, the development of a tailored self-management program for individuals with traumatic SCI and their caregivers should incorporate these considerations.

Residential movement patterns of families of young children with chronic conditions in Ontario, Canada: a population-based cohort study

INTRODUCTION

Care giving for children with chronic diseases can lead to financial strain and compromised family well being. Little is known about whether these stresses lead to changes in residential movement patterns as they relate to income adequacy and proximity to care.

METHODS

We compared the residential movement patterns and associated changes in neighbourhood income of children with mild to severe chronic diseases compared with those that are healthy. A cohort of infants born from 2002-2007 in Ontario, Canada was followed for 5 years and divided into those with single- or multiple- body system complex chronic conditions (CCCs); low birth weight (LBW); asthma/recurrent wheeze (A/RW) and the control group of otherwise healthy children.

RESULTS

Of 598,716 children studied, 15,207 had a single CCC, 3,600 multiple CCCs, 33,206 LBW, 57,137 A/RW and 489,566 were healthy. Lowest income quintile children were most likely to move residence. Compared with healthy controls, chronic disease cohorts, apart from those with asthma, were more likely to be born in the lowest income quintile neighbourhood and to move. Among children who moved, all chronic disease cohorts were significantly more likely to move to a low income quintile neighborhood (adjusted odds ratios for all chronic disease cohorts of 1.1-1.2). There were no differences across cohorts in residential movement close to a children's hospital.

CONCLUSIONS

Young children with chronic conditions, particularly those born in low income neighbourhoods, are more likely to move residence than other healthy young children. However, it does not seem that proximity to specialized care is driving this movement. Further research is required to determine if these movement patterns impact the ability of children with chronic conditions to secure health services.

Enhanced susceptibility to urinary tract infection in the spinal cord-injured host with neurogenic bladder

Neurogenic bladder predisposes to recurrent urinary tract infections (UTI) and renal failure, and susceptibility is commonly ascribed to urinary stasis from elevated residual urine volumes. Escherichia coli UTI was modeled in the spinal cord-injured (SCI) rat with the hypothesis that SCI animals would require fewer bacteria to establish infection, have an exaggerated inflammatory response, and have delayed clearance of infection compared to normal-voiding controls. T10 SCI rats and controls had median infectious doses (ID50) of 10(2) and 10(5) CFU, respectively. Mean residual volumes in the SCI animals did not correlate with susceptibility to initiation of UTI or outcome. In the acute infection, control and SCI rats developed acute cystitis and pyelitis without acute differences in histopathological scores of inflammation. However, in vivo imaging of infected animals revealed persistently higher levels of bacteria in the SCI urine and bladders than were seen for controls over 2 weeks. Likewise, at 2 weeks, acute and chronic inflammatory infiltrates persisted in the bladders and kidneys of SCI rats, whereas inflammation largely resolved within the controls. Together these data demonstrate that SCI rats exhibit delayed clearance of infection and exaggerated inflammatory responses in bladders and kidneys; however, the severity of residual volumes does not predict increased susceptibility to UTI. These studies suggest that host-dependent mechanisms that are discrete from alterations in bladder physiology influence UTI susceptibility with the SCI-neurogenic bladder. This model will allow elucidation of SCI-neurogenic bladder-mediated changes in host response that yield UTI susceptibility and may lead to new preventative and therapeutic options.

The application of operations research methodologies to the delivery of care model for traumatic spinal cord injury: the access to care and timing project

The long-term impact of spinal cord injury (SCI) on the health care system imposes a need for greater efficiency in the use of resources and the management of care. The Access to Care and Timing (ACT) project was developed to model the health care delivery system in Canada for patients with traumatic SCI. Techniques from Operations Research, such as simulation modeling, were used to predict the impact of best practices and policy initiatives on outcomes related to both the system and patients. These methods have been used to solve similar problems in business and engineering and may offer a unique solution to the complexities encountered in SCI care delivery. Findings from various simulated scenarios, from the patients' point of injury to community re-integration, can be used to inform decisions on optimizing practice across the care continuum. This article describes specifically the methodology and implications of producing such simulations for the care of traumatic SCI in Canada. Future publications will report on specific practices pertaining to the access to specialized services and the timing of interventions evaluated using the ACT model. Results from this type of research will provide the evidence required to support clinical decision making, inform standards of care, and provide an opportunity to engage policymakers.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation

OBJECTIVE

To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization.

DESIGN

Prospective observational cohort study.

SETTING

Six geographically dispersed rehabilitation centers in the U.S.

PARTICIPANTS

Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations.

RESULTS

More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered.

CONCLUSIONS

Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Association of various comorbidity measures with spinal cord injury rehabilitation outcomes

OBJECTIVE

To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status.

DESIGN

Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury.

SETTING

Inpatient rehabilitation and community follow-up at 6 SCI treatment centers.

PARTICIPANTS

Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI).

RESULTS

Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school.

CONCLUSIONS

Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account.

Impact of quality improvement strategies on the quality of life and well-being of individuals with spinal cord injury: a systematic review protocol

BACKGROUND

After a spinal cord injury, quality of life, as well as the determinants of quality of life, has been widely assessed. However, to date, there have been no systematic reviews on the impact of quality improvement strategies, including self-management strategies, on the quality of life and well-being of individuals with a spinal cord injury. The current protocol outlines a strategy for a systematic review that aims to identify, assess, and synthesize evidence on the impact of quality improvement strategies on the quality of life and physical and psychological well-being of individuals with spinal cord injury.

METHODS/DESIGN

All study designs, except qualitative studies will be included. Studies reporting on quality improvement including audit and feedback, case management, team changes, electronic patient registries, clinician education, clinical reminders, facilitated relay of clinical information to clinicians, patient education, (promotion of) self-management, patient reminder systems, and continuous quality improvement among individuals with spinal cord injury will be included. The primary outcome is quality of life. The secondary outcomes are physical and psychological well-being. Studies will be included regardless of publication status, year of dissemination, or language of dissemination. Potentially relevant articles not written in English will be translated. We will search Medline, CINAHL, EMBASE, and PsycINFO. The use of these databases will be supplemented by other data sources, including unpublished data. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Results will be grouped according to the target group of the varying quality improvement strategies (that is, health system, health-care professionals, or patients) and/or by any other noteworthy grouping variable, such as etiology of spinal cord condition or by sex. If deemed appropriate, a meta-analysis will be conducted.

DISCUSSION

This systematic review will identify those quality improvement strategies aimed at the health system, health-care professionals, and patients that impact the quality of life and well-being of individuals with spinal cord injury. Knowledge and application of such quality improvement strategies may reduce inappropriate health-care utilization costs, such as acute care inpatient readmission in the years post injury. Prospero registry number: CRD42012003058.

Use of the Spine Adverse Events Severity System (SAVES) in patients with traumatic spinal cord injury. A comparison with institutional ICD-10 coding for the identification of acute care adverse events

STUDY DESIGN

Observational cohort comparison.

OBJECTIVES

To compare the previously validated Spine Adverse Events Severity system (SAVES) with International Classification of Diseases, Tenth Revision codes (ICD-10) codes for identifying adverse events (AEs) in patients with traumatic spinal cord injury (TSCI).

SETTING

Quaternary Care Spine Program.

METHODS

Patients discharged between 2006 and 2010 were identified from our prospective registry. Two consecutive cohorts were created based on the system used to record acute care AEs; one used ICD-10 coding by hospital coders and the other used SAVES data prospectively collected by a multidisciplinary clinical team. The ICD-10 codes were appropriately mapped to the SAVES. There were 212 patients in the ICD-10 cohort and 173 patients in the SAVES cohort. Analyses were adjusted to account for the different sample sizes, and the two cohorts were comparable based on age, gender and motor score.

RESULTS

The SAVES system identified twice as many AEs per person as ICD-10 coding. Fifteen unique AEs were more reliably identified using SAVES, including neuropathic pain (32 × more; P<0.001), urinary tract infections (1.4 × ; P<0.05), pressure sores (2.9 × ; P<0.001) and intra-operative AEs (2.3 × ; P<0.05). Eight of these 15 AEs more frequently identified by SAVES significantly impacted length of stay (P<0.05). Risk factors such as patient age and severity of paralysis were more reliably correlated to AEs collected through SAVES than ICD-10.

CONCLUSION

Implementation of the SAVES system for patients with TSCI captured more individuals experiencing AEs and more AEs per person compared with ICD-10 codes. This study demonstrates the utility of prospectively collecting AE data using validated tools.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project

BACKGROUND/OBJECTIVE

Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.

METHODS

Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.

RESULTS

PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries.

CONCLUSION

Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care

PURPOSE

To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI).

METHOD

This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified.

RESULTS

Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies.

CONCLUSIONS

Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

IMPLICATIONS FOR REHABILITATION

• Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

Social networks and secondary health conditions: the critical secondary team for individuals with spinal cord injury

OBJECTIVES

To describe the structure of informal networks for individuals with spinal cord injury (SCI) living in the community, to understand the quality of relationship of informal networks, and to understand the role of informal networks in the prevention and management of secondary health conditions (SHCs).

DESIGN

Mixed-method descriptive study.

SETTING

Ontario, Canada Participants: Community-dwelling adults with an SCI living in Ontario Interventions/methods: The Arizona Social Support Interview Survey was used to measure social networks. Participants were asked the following open-ended questions: (1) What have been your experiences with your health care in the community? (2) What have been your experiences with care related to prevention and/or management of SHCs?, (3)What has been the role of your informal social networks (friends/family) related to SHCs?

RESULTS

Fourteen key informant interviews were conducted (6 men, 8 women). The overall median for available informal networks was 11.0 persons (range 3-19). The informal network engaged in the following roles: (1) advice/validating concerns; (2) knowledge brokers; (3) advocacy; (4) preventing SHCs; (5) assisting with finances; and (6) managing SHCs. Participants described their informal networks as a "secondary team"; a critical and essential force in dealing with SHCs.

CONCLUSIONS

While networks are smaller for persons with SCI compared with the general population, these ties seems to be strong, which is essential when the roles involve a level of trust, certainty, tacit knowledge, and flexibility. These informal networks serve as essential key players in filling the gaps that exist within the formal health care system.

Upper gastrointestinal dysmotility after spinal cord injury: is diminished vagal sensory processing one culprit?

Despite the widely recognized prevalence of gastric, colonic, and anorectal dysfunction after spinal cord injury (SCI), significant knowledge gaps persist regarding the mechanisms leading to post-SCI gastrointestinal (GI) impairments. Briefly, the regulation of GI function is governed by a mix of parasympathetic, sympathetic, and enteric neurocircuitry. Unlike the intestines, the stomach is dominated by parasympathetic (vagal) control whereby gastric sensory information is transmitted via the afferent vagus nerve to neurons of the nucleus tractus solitarius (NTS). The NTS integrates this sensory information with signals from throughout the central nervous system. Glutamatergic and GABAergic NTS neurons project to other nuclei, including the preganglionic parasympathetic neurons of the dorsal motor nucleus of the vagus (DMV). Finally, axons from the DMV project to gastric myenteric neurons, again, through the efferent vagus nerve. SCI interrupts descending input to the lumbosacral spinal cord neurons that modulate colonic motility and evacuation reflexes. In contrast, vagal neurocircuitry remains anatomically intact after injury. This review presents evidence that unlike the post-SCI loss of supraspinal control which leads to colonic and anorectal dysfunction, gastric dysmotility occurs as an indirect or secondary pathology following SCI. Specifically, emerging data points toward diminished sensitivity of vagal afferents to GI neuroactive peptides, neurotransmitters and, possibly, macronutrients. The neurophysiological properties of rat vagal afferent neurons are highly plastic and can be altered by injury or energy balance. A reduction of vagal afferent signaling to NTS neurons may ultimately bias NTS output toward unregulated GABAergic transmission onto gastric-projecting DMV neurons. The resulting gastroinhibitory signal may be one mechanism leading to upper GI dysmotility following SCI.

Direct costs of adult traumatic spinal cord injury in Ontario

STUDY DESIGN

Retrospective economic analysis.

OBJECTIVES

To determine the total direct costs of publicly funded health care utilization for the three fiscal years 2003/04 to 2005/06 (1 April 2003 to 31 March 2004 to 1 April 2005 to 31 March 2006), from the time of initial hospitalization to 1 year after initial acute discharge among individuals with traumatic spinal cord injury (SCI).

SETTING

Ontario, Canada.

METHODS

Health system costs were calculated for 559 individuals with traumatic SCI (C1-T12 AIS A-D) for acute inpatient, emergency department, inpatient rehabilitation (that is, short-stay inpatient rehabilitation), complex continuing care (CCC) (i.e., long-stay inpatient rehabilitation), home care services, and physician visits in the year after index hospitalization. All care costs were calculated from the government payer's perspective, the Ontario Ministry of Health and Long-Term Care.

RESULTS

Total direct costs of health care utilization in this traumatic SCI population (including the acute care costs of the index event and inpatient readmission in the following year after the index discharge) were substantial: $102 900 per person in 2003/04, $100 476 in 2004/05 and $123 674 in 2005/06 Canadian Dollars (2005 CDN $). The largest cost driver to the health care system was inpatient rehabilitation care. From 2003/04 to 2005/06, the average per person cost of rehabilitation was approximately three times the average per person costs of inpatient acute care.

CONCLUSION

The high costs and long length of stay in inpatient rehabilitation are important system cost drivers, emphasizing the need to evaluate treatment efficacy and subsequent health outcomes in the inpatient rehabilitation setting.

Application of the Andersen's health care utilization framework to secondary complications of spinal cord injury: a scoping review

PURPOSE

The purpose of this scoping review was to identify research priority areas related to secondary complications and associated health care use for individuals with spinal cord injury (SCI).

METHOD

DATA SOURCES

Peer-reviewed journals were identified using CINAHL, MEDLINE, PubMed, Embase, Social Sciences Abstracts, Social Works Abstract and PsycInfo search engines. Key references were hand searched.

STUDY SELECTION

A total of 289 abstracts were identified from the initial search strategy. We removed studies that did not measure health care and those that did not involve analytical investigation.

DATA EXTRACTION

The selected 31 studies were reviewed in detail using a coding template based on the domains and sub-components of the Andersen model (i.e. environmental, population characteristics, health behavior and outcome).

RESULTS

Most studies measured predisposing characteristics (e.g., age, gender) and need characteristics (e.g., level of injury). There was a notable absence of environmental characteristics (e.g., health system, neighborhood variables), enabling characteristics and health behaviors (beyond diet and nutrition).

CONCLUSIONS

We identified a gap in the SCI literature. Future research should focus on longitudinal study designs with more representation of non-traumatic spinal cord injury, as well as utilizing more advanced statistical analyses (i.e., multivariate level) to adjust for confounding variables.

Defining neurotrauma in administrative data using the International Classification of Diseases Tenth Revision

Background

It is essential to use a definition that is precise and accurate for the surveillance of traumatic brain injuries (TBI) and spinal cord injuries (SCI). This paper reviews the International Classification of Diseases 10^th revision (ICD-10) definitions used internationally to inform the definition for neurotrauma surveillance using administrative data in Ontario, Canada.

Methods

PubMed, Web of Science, Medline and the grey literature were searched for keywords "spinal cord injuries" or "brain injuries" and "international classification of diseases". All papers and reports that used an ICD-10 definition were included. To determine the ICD-10 codes for inclusion consensus across papers and additional evidence were sought to look at the correlation between the condition and brain or spinal injuries.

Results

Twenty-four articles and reports were identified; 15 unique definitions for TBI and 7 for SCI were found. The definitions recommended for use in Ontario by this paper are F07.2, S02.0, S02.1, S02.3, S02.7, S02.8, S02.9, S06, S07.1, T90.2, and T90.5 for traumatic brain injuries and S14.0, S14.1, S24.0, S24.1, S34.1, S34.0, S34.3, T06.0, T06.1 and T91.3 for spinal cord injuries.

Conclusions

Internationally, inconsistent definitions are used to define brain and spinal cord injuries. An abstraction study of data would be an asset in understanding the effects of inclusion and exclusion of codes in the definition. This paper offers a definition of neurotrauma for surveillance in Ontario, but the definition could be applied to other countries that have mandated administrative data collection.