The effects of insurance benefits coverage on functional and psychosocial outcomes after spinal cord injury

Adding insult to injury: discontinuous insurance following spine trauma

BACKGROUND

Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.

METHODS

We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.

RESULTS

The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.

CONCLUSIONS

Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury

OBJECTIVE

To assess the associations of race and socioeconomic status (SES) with pressure ulcers (PUs) after accounting for health care access among persons with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Large specialty hospital in the southeastern United States.

PARTICIPANTS

Persons with traumatic SCI who (1) had residual effects from their injury, (2) were 18 years or older at the time of the survey, and (3) were a year or more postinjury at the time of survey (N=2549).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Outcomes were measured by a mail-in survey: having a current PU (yes vs no), having a PU in the past year with or without reduced sitting time (no PU, no reduced sitting time, month or less, ≥5wk), and having at least 1 PU surgery since SCI onset (yes vs no).

RESULTS

Of participants, 39.3% reported a PU in the past year, 19.9% had a current PU, and 21.9% reported having had surgery for a PU since their SCI onset. While race was preliminarily associated with each PU outcome, it became nonsignificant after controlling for SES and health care access. In each analysis, household income was significantly associated with PU outcomes after controlling for demographic and injury factors and remained significant after accounting for the health care access factors. Persons with lower income had higher odds of each PU outcome. Health care access was not consistently related to PU outcomes.

CONCLUSIONS

Even after accounting for health care access, household income, a measure of SES, remained significantly associated with PU outcomes after SCI; however, race became nonsignificant.

Coverage policy for neurorehabilitation: an international perspective

BACKGROUND

Coverage policy ultimately determines the delivery of services. This article summarizes the authors' effort to ascertain the extent of publically available information on coverage for neurorehabilitation services internationally.

OBJECTIVE

Present available data on neurorehabilitation coverage and examine the needs for further research in this area.

METHODS

Review of published literature, review of government Web sites, survey of World Federation of NeuroRehabilitation (WFNR) program chairs, and attendees of the 2010 World Congress of NeuroRehabilitation.

RESULTS

A wide variation in coverage was found internationally. Data are not routinely accessible.

CONCLUSIONS

Informed policy requires current data. There is an opportunity for the WFNR to provide leadership in policy for neurorehabilitation services by assembling and maintaining current data on coverage policy internationally.

Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment

PURPOSE

To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

METHOD

Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

RESULTS

There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

CONCLUSIONS

A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.

Agricultural workers' return to work following spinal cord injury: a comparison with other industry workers

PURPOSE

To investigate the impact of spinal cord injury on employment outcomes as experienced by agricultural workers in comparison with persons employed in other industries. Because of the challenges associated with working in many of the agricultural industries, it was anticipated that agricultural workers would achieve inferior return-to-work outcomes.

METHOD

Survey of all employed persons who experienced a traumatic spinal cord injury in southeastern Australia between 1990 and 1996 (inclusive).

RESULTS

Contrary to expectation, agricultural workers had a significantly higher rate of return to work (61.7% vs. 41.1%). However, an investigation into the hours spent working and agricultural workers' satisfaction with their employment activities, indicated that most were underemployed and had the potential to achieve even better outcomes.

CONCLUSION

Results indicate that more can be done to help injured agricultural workers achieve their employment potential.

Home aids and personal assistance 10-45 years after spinal cord injury

OBJECTIVE

Assessment of home aids, adaptations and personal assistance received after traumatic spinal cord injury (SCI).

SETTING

Clinic for Spinal Cord Injuries, Denmark. Uptake area, 2.5 million inhabitants.

STUDY DESIGN AND METHODS

Cross-sectional follow-up with retrospective data from medical files.

MATERIALS

Individuals with traumatic SCI before 1 January 1991, still in regular follow-up and with sufficient medical record. In all, 279 were included, and 236 answered the questionnaire (193 men and 43 women), with a response rate of 84.6%. Mean age at follow-up was 50.5 years, and mean follow-up time, 24.1 years. One hundred and twenty-six were paraplegic and 110, tetraplegic. Responders and non-responders were comparable.

RESULTS

Most common aids or adaptations reported were commode/shower chair on wheels or a seat (69%), grab bar by the toilet (41%), electrical bed (44%), special mattress (28%), lift/hoist (20%), computers (39%) and kitchen tools or cutlery with special handles (14%). In all, 7.6% of the participants reported no aids. Eighty-two percent answered 'Yes' to the question 'Have the aids, you currently or previously needed, been available to you?' The majority reported that their source of information about aid had been various journals and magazines. Twenty-one percent had personal helpers, with 60 h per week in median (range 2-168). Thirty-three percent received domestic help with 2.5 h per week in median (range 0.5-37). Eight percent had a home nurse. A total of 98.7% were living in their own homes.

CONCLUSIONS

This is the first study of a representative SCI population giving information on home aids. Individuals with SCI in Denmark seem to be sufficiently supplied with aids and personal assistance.

The Real Predictors of Disposition in Patients with Spinal Cord Injuries

OBJECTIVES

A primary goal of health care providers for managing patients with spinal cord injury (SCI) is to discharge them to a rehabilitation facility (RF) to allow for maximal functional recovery. This study was undertaken to analyze hospital mortality and disposition of patients with SCI with a specific focus on evaluating the effect of payor source on discharge to a RF. Our hypothesis was that commercial insurance (CI) would be the greatest influence of hospital disposition.

METHODS

All patients under 60 years of age with SCI over a 7-year period were identified from the trauma registry; and grouped according to payor source: No insurance (NI), Government insurance (GI), No Commercial insurance (NCI) (NCI = NI + GI), and CI.

RESULTS

A total of 492 patients with SCI were identified with a mean age of 33, an ISS of 29, and a hospital mortality of 7.7%. Independent predictors of mortality were cervical SCI and blood transfusions. Patients who were discharged to a RF had higher ISS and %CI with lower functional independent measurement scores compared with patients who were not discharged to a RF. Logistic regression analysis demonstrated that the predictors of disposition to a RF were CI (p < 0.001) and ISS (p = 0.002).

CONCLUSION

The presence of CI was an independent predictor of disposition to a RF for patients with SCI. Lack of commercial insurance clearly compromises recovery and rehabilitation of patients with SCI and predicts outcome more clearly than any other parameter. Additional funding for patients without CI is necessary to afford all with an equal opportunity for maximal functional recovery.

Services provided following compensable work-related tetraplegia

DESIGN

Descriptive study.

OBJECTIVE

To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI).

SETTING

Workers' compensation claims database.

METHODS

The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories.

RESULTS

Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications/supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher.

CONCLUSIONS

Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE

To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center.

PARTICIPANTS

A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily hours of paid, unpaid, and occasional PCA services.

RESULTS

Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance.

CONCLUSION

Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.

Incidence and patterns of spinal cord injury in Australia

The objective of this paper is to report on the epidemiology of spinal cord injury (SCI) based on the Australian SCI register and to discuss the implications for prevention. All adult cases of SCI are reported to the registry. The case reports for 1998/1999 were aggregated and described. The age adjusted rate of persisting SCI was 14.5 per million of population. Rates were highest in young adults and in males. The vast majority of cases (93%) were due to unintentional injury. Forty-three percent were due to motor vehicle crashes, principally from motor vehicle rollover. Cases of SCI from falls, aquatic activities, and working for income are also described. Incomplete cervical cord injuries were most common (38%), particularly as a result of motor vehicle crashes and low falls. The study indicates that the surveillance of SCI needs to be improved internationally so that comparative studies can be undertaken. It is recommended that the Centers for Disease Control case definition be adopted. Australia is one of the few countries that have a register based on that case definition, and the only one that has a register covering a full national adult population. The results presented on the basis of this data source provide some hitherto unavailable information on the incidence rates and patterns of SCI. National population based surveillance is fundamental to an understanding of the epidemiology, and hence the prevention, of this severe and costly health and welfare problem.

Predictors of life satisfaction: a spinal cord injury cohort study

OBJECTIVE

To determine unique demographic, medical, perceived health, and handicap predictors of life satisfaction 2 years after spinal cord injury (SCI), as well as the predictors of change in life satisfaction from year 1 to year 2.

DESIGN

Prospective predictive study performed by using longitudinal data from 18 Spinal Cord Injury Model Systems.

SETTING

University physical medicine and rehabilitation department.

PARTICIPANTS

Adults with traumatic onset SCI (N = 940) evaluated at 1 and 2 years' postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction with Life Scale (SWLS) 2 years post-SCI.

PREDICTOR VARIABLES

demographic characteristics, impairment and disability classifications, and 1 year post-SCI measures of life satisfaction (SWLS), medical complications, self-perceived health (Medical Outcomes Study 12-Item Short-Form Health Survey), and extent of handicap (Craig Handicap Assessment and Reporting Technique).

RESULTS

The factors uniquely associated with an increased risk of lower self-reported life satisfaction at year 2 post-SCI included being male and unemployed, with poor perceived health, decreased mobility, and decreased social integration. After controlling for year 1 estimates of life satisfaction (ie, examining change in life satisfaction), only mobility and perceived health were uniquely related to life satisfaction 2 years post-SCI.

CONCLUSION

Mobility and perceived health appear to be the consistent predictors of life satisfaction at year 2 post-SCI, as well as change in satisfaction from year 1 to year 2. Because both factors are amenable to change, they are reasonable targets of intervention programs. Identifying specific mechanisms of perceived health and mobility associated with life satisfaction should be an important area of continued research.

Spinal cord injury medicine. 3. Rehabilitation outcomes

This self-directed learning module highlights rehabilitation outcomes in spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on the multiple concerns for functional recovery after SCI, chiefly, the potential for ambulation, upper-extremity recovery, options for functional neuromuscular stimulation (FNS), sexual activity, and optimal outcome after a metastatic lesion. Motor incomplete patients have a better prognosis for ambulation than persons with sensory incomplete injury. Positive predictors for ambulation, including pinprick and lower-extremity motor scores greater than 20, are discussed. Meaningful recovery can occur in the upper extremities for at least 1 year. FNS options have been developed to promote functional control of the upper extremities for persons with tetraplegia, phrenic pacing, and bladder continence. A critical component of an individual's expression of self is his/her sexuality; sexual function after SCI is described in detail, including options for treatment of erectile dysfunction and various birth control methods for women. Expectations for an appropriate rehabilitation stay for a person with metastatic SCI differ for an individual with traumatic SCI. Differences may include changing routine pathways and timelines to focus on patient-centered quality of life for transition to home.

OVERALL ARTICLE OBJECTIVE

To identify potential outcomes in ambulation, upper-extremity function, FNS, and sexual function after SCI and after metastatic cancer.

Work related spinal cord injury, Australia 1986-97

OBJECTIVES

Little has been published before on the epidemiology and prevention of work related spinal cord injury (SCI). This study is the first national population based epidemiological analysis of this type of injury. It presents that largest case series ever reported.

SETTING

The study utilises information from the Australian Spinal Cord Injury Register, which has full coverage of the population.

METHODS

All newly incident cases of SCI from 1986 to 1997 were considered.

RESULTS

Work related SCI accounted for about 13% of all traumatic cases of SCI over the period 1986-97. The labour force based incidence rate in Australia averaged four cases per million of population per annum over the period. The rate was highest among those aged 25-34 years (4.9/million) and among farmers (17.0/ million). Nearly half of the cases studied received their injury due to a fall. Motor vehicle crashes were also common and vehicle rollover was the predominant crash type. A high proportion of cases did not receive any compensation for their SCI.

CONCLUSIONS

Although rare, SCI is one of the most severe and debilitating injuries that can be suffered in the workplace. As there is no cure for SCI, and the level of impairment does not improve substantially for the vast majority of cases even after rehabilitation, it is arguable that primary prevention should receive substantially greater emphasis.

Access to the environment and life satisfaction after spinal cord injury

OBJECTIVE

To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART).

DESIGN

Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care.

SUBJECTS

Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury.

OUTCOME MEASURE

Satisfaction With Life Scale (SWLS).

PREDICTOR VARIABLES

Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale.

RESULTS

Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for.

CONCLUSION

Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.

Trauma-rehabilitation connections: discharge and admission decisions for children

Paediatric discharge coordinators and rehabilitation admission coordinators were surveyed about how children are selected for rehabilitation. The following areas are covered: (1) the decision process, and how children are selected for rehabilitation; (2) who is involved in making acute-care discharge and rehabilitation admission decisions; (3) factors that guide selection of children for rehabilitation; and (4) satisfaction with referral practices. Surveys were completed by 30 trauma discharge and rehabilitation admission coordinators, recruited from paediatric trauma units and paediatric/general rehabilitation units nationwide. Most respondents were satisfied with transfers, although some voiced concerns about constraints placed on referrals by insurance. Even when inpatient rehabilitation was clearly needed, 40% said insurance status still affected whether children were admitted. There was little evidence that any uniform criteria are used to make decisions. Half had no training in discharge/admission planning and half did not base decisions on functional assessments. Although guidelines are increasingly used in clinical decision-making, few are available concerning critical decisions about which children receive inpatient rehabilitation following trauma.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

The impact of managed care on the practice of occupational therapy by hand therapists

Current Occupational Therapy (OT) literature on managed care is limited to opinion or anecdotal experience. Questionnaires were mailed to 214 OTs practicing as hand therapists nationwide to test the null hypothesis that there was no difference in reimbursement or barriers to practice for OT services between patients enrolled in managed care organizations and those enrolled in fee-for-service insurance plans. Statistically significant results were obtained indicating greater barriers to reimbursement for OT under managed care. The primary effect has been the increased administrative demands it places on both therapists and patients. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworth.com].