The "Boston model" of managed care and spinal cord injury: a cross-sectional study of the outcomes of risk-based, prepaid, managed care

High-Level Spinal Cord Injury and the Failure of US Acute Rehabilitation: An Analysis and Commentary

ABSTRACT

Acute and long-term morbidity and mortality rates have not changed in the United States for people with high-level spinal cord injury in 40 yrs, neither has the conventional invasive respiratory management for these patients. This is despite a 2006 challenge to institutions for a paradigm shift to avoid or decannulate patients of tracheostomy tubes. Centers in Portugal, Japan, Mexico, and South Korea decannulate high-level patients to up to continuous noninvasive ventilatory support and use mechanical insufflation exsufflation, as we have done and reported since 1990, but there has been no such paradigm shift in US rehabilitation institutions. The quality of life and financial consequences of this are discussed. An example of decannulation of a relatively easy case, after failure to do so during 3 mos of acute rehabilitation, is presented to encourage institutions to begin to learn and apply noninvasive management before decannulating more severe patients with little to no ventilator free breathing ability.

Noninvasive Respiratory Management of Spinal Cord Injury

Intubated ventilator-dependent patients with high-level spinal cord injury can be managed without tracheostomy tubes provided that they have sufficient cognition to cooperate and that any required surgical procedures are completed and they are medically stable. Intubation for a month or more than extubation to continuous noninvasive ventilatory support (NVS) can be safer long term than resort to tracheotomy. Noninvasive ventilation (NIV) is not conventionally being used for ventilatory support. Noninvasive interfaces include mouthpieces, nasal and oronasal interfaces, and intermittent abdominal pressure ventilators. NIV/NVS should never been used without consideration of mechanical insufflation-exsufflation for airway secretion clearance.

Spinal Cord Injury and Migraine Headache: A Population-Based Study

Migraine headaches are a common neurological condition, negatively impacting health and quality of life. The association between migraines and spinal cord injury (SCI) is intriguing to consider from the perspective that migraine headaches may be acquired in response to damage in the spinal cord [corrected].The primary objective of this study was to further examine the association between SCI and migraine headache, controlling for potential confounding variables. A secondary objective was to determine the impact of migraine headaches on self-perceived health. Data from a sample of 61,047 participants were obtained from the cross-sectional Canadian Community Health Survey. Multivariable logistic regression was used to explore the association between SCI and migraine headache using probability weights and adjusting for confounders. The multivariable age- and sex-adjusted model revealed a strong association between SCI and migraine headache, with an adjusted odds ratio for migraine of 4.82 (95% confidence interval [3.02, 7.67]) among those with SCI compared to those without SCI. Further, individuals who experienced both SCI and migraine tended to report poorer perceived general health compared with the other groups (i.e., SCI and no migraine). In conclusion, this study established a strong association between SCI and migraine headache. Further research is needed to explore the possible mechanisms underlying this relationship. Improvements in clinical practice to minimize this issue could result in significant improvements in quality of life.

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.

Out-patient rehabilitation programme for spinal cord injured patients: Evaluation of the results on motor FIM score

PURPOSE

The aim of this study was to evaluate an out-patient attention programme based on a short in-patient phase followed by an out-patient interdisciplinary rehabilitation programme.

METHODS

A prospective quasi-experimental before-and-after study was carried out; a phase 2 trial. The study population consisted of 42 patients who met the inclusion criteria. The Functional Independence Measurement (FIM) was the main outcome, and the American Spinal Injury Association (ASIA) motor scores and morbidity the secondary ones. The intervention was a two-phase goal-based interdisciplinary programme which consisted of a hospital and an ambulatory phase. After an evaluation upon admission to hospital, follow-up was carried out 1, 3, 6, 12 and 18 months later.

RESULTS

Initially, 208 patients were evaluated and only 42 completed the study. The in-patient phase was short (average: 13.5 days) and the out-patient phase lasted 18 months. Motor FIM scores progressively increased from 25/91 up to 69/91 (p < 0.01). Some 25% of the patients had pressure sores at 1 month, and 11.9% still had them after 18 months. Pain was the most frequent complication, in 80% of patients by the third month. Urinary and fecal continence improved during follow-up (74% at 18 months and 81.1% at 12 months, respectively).

CONCLUSIONS

Good functional evolution of SCI patients and low morbidity can be obtained with a low-cost out-patient rehabilitation programme. Such a programme must emphasize patient and family education concerning self-care and possible SCI complications.

Improving the health and health behaviors of women aging with physical disabilities: A peer-led health promotion program

OBJECTIVE

To examine the efficacy of a health promotion program for women aging with physical disabilities.

METHOD

A sample of 137 middle-aged and older women with physical disabilities was randomly assigned to either an 8-week health promotion program or to a wait-list control group. Both groups completed questionnaires before, immediately after, and 3 months after the intervention.

RESULTS

Relative to women in the control group, women in the health-promotion program demonstrated improvements in health behaviors, most of which were maintained at follow-up. The intervention group showed some improvements on measures of physical health, but there was little evidence of improvement in psychological health outcomes. Testing our theoretical model, self-efficacy was supported as a mediator of the effect of the intervention on health behaviors, and health behaviors combined with self-efficacy were supported as mediators of the effect of the intervention on physical health outcomes. Contrary to our hypotheses, our measures of social support and social connectedness were not affected by the intervention.

CONCLUSIONS

A brief, peer-led, group health promotion program resulted in improved scores on measures of self-efficacy, increased health behavior, and physical health. Self-efficacy, which was supported as a mediator in the effect of the intervention on behaviors and health outcomes, should remain an important focus of future interventions with this population.

Secondary Conditions in a Community-Based Sample of Women With Physical Disabilities Over a 1-Year Period

OBJECTIVE

To examine prevalence and predictors of secondary conditions in women with physical disabilities.

DESIGN

Cross-sectional.

SETTING

Women were recruited through private and public health clinics and various community organizations.

PARTICIPANTS

A sample of 443 predominantly ethnic minority women with physical disabilities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Health Conditions Checklist interference score.

RESULTS

Aggregated data over a 1-year period showed that nearly the entire sample reported interference from pain (94.5%) and fatigue (93.7%) and that at least three quarters of the sample reported problems with spasticity (85.4%), weakness (81.8%), sleep problems (80.2%), vision impairment (77.9%), and circulatory problems (77.9%). Obesity was substantially more prevalent in this sample (47.6%) than in the general population of women (34.0%). The mean number of secondary conditions per woman +/- standard deviation was 14.6+/-6.2 (range, 1-42), with 75% of the sample endorsing 10 or more conditions. On average, women reported experiencing 5.7+/-4.03 (range, 0-20) conditions that they rated as significant or chronic. A third (33.4%) of the variance in interference scores was accounted for in the regression analysis, with significant variance accounted for by race, disability type (women with joint and connective tissue disorders and women with postpolio reported the highest overall interference scores), greater functional limitations, and lower levels of general mental health.

CONCLUSIONS

Secondary conditions in women with physical disabilities are substantially more problematic than reported previously in the literature. Further research is needed to determine health disparities of women with and without disabilities. Measurement issues and the clinical relevance of these findings are discussed.

Health problems of persons with spinal cord injury living in the Netherlands

PURPOSE

To investigate the prevalence of health problems among persons with spinal cord injury (SCI) living in the Netherlands, to identify the problems experienced as most important, and to analyse the experienced impact of these most important problems on daily activities and social life.

METHOD

Postal survey among all members of the Dutch Association of Patients with SCI. The questionnaire focused on 26 health problems: 13 secondary impairments, 8 problems of daily living and 5 psychosocial problems.

RESULTS

The respondents (response rate 45.5%, 454 persons) experienced an average of 8 health problems. The most frequently occurring problems regarded bladder and bowel regulation, spasms, pain, oedema and sexuality. Except for oedema, these problems were also most often cited as the most important. The most disabling condition for both daily and social activities was pain. Few significant relationships were found between the prevalence of health problems and the level, completeness and duration of the injury or gender.

CONCLUSION

Persons with SCI living in the community experience many health problems and limitations in daily activities and social life due to these problems. The occurrence of these problems does not diminish with increasing time after injury. This strongly emphasises the need for follow-up care.

Vieillissement chez les blessés médullaires

OBJECTIVE

Literature review of the data on aging with spinal cord injury.

METHOD

Interrogation on Medline using the following keywords: aging, spinal cord injuries, paraplegia, quadriplegia, mortality, morbidity, quality of life, survival, health status.

RESULTS

The expectation of life of the spinal cord injury patients improved even though it remains even lower than that of the general population. The effects of aging add to the specific complications which are numerous and alter almost every function. Respiratory complications became the first cause of death especially for tetraplegics. Urinary and cutaneous complications remain important as well as osteo-articular pathologies (particular upper limbs) whose consequences can be serious on the functional capacities. Studies on the quality of life show that adaptation to the handicap is done in a continuous way and a long time after the initial phase of rehabilitation. They underline the importance of professional resources, psychological reactions and previous experiences of the spinal cord injury patients in appreciating the quality of life after the traumatism.

CONCLUSION

The specificities of the aging of the spinal cord injury patients require to be well known and underline the importance and the necessity of an adequate and specific follow-up. On a more general plan, they imply a reflection on the strategies of initial rehabilitation, not to compromise the future of these spinal cord injury patients.

The SIP68: an abbreviated sickness impact profile for disability outcomes research

The Sickness Impact Profile (SIP) is one of the most widely recognized generic health status instruments, but its length has often left it out of consideration for outcomes research. We assess a short alternative, the Sickness Impact Profile 68 (SIP68), for retest and proxy reliability, validity, and scaling properties, in a population of adults with disability (PWD). For convergent validity, the SIP68 was compared to the instrumental activities of daily living (IADLs), activities of daily living (ADLs) and the short-form 36 (SF-36). We completed 398 interviews with PWD, 131 index-proxy sets, and 40 retests. Retest intraclass correlations were above 0.75 for all scales and dimensions except the physical dimension (0.61). Proxy reliability ranged from 0.26 (psychological autonomy and communication) to 0.85 (somatic autonomy). Correlation between the SIP68 and SIP was 0.94 overall; between the SIP68 and similar scales of the SF-36 correlations was moderate, and highest for physical health scales. We repeated the SIP68 development factor analysis and reproduced a structure of the full SIP that included 65 of SIP68 items. However, 36 additional items were retained that are not part of the SIP68. Overall, the SIP68 shows promise for use as a disability outcomes tool.

International differences in ageing and spinal cord injury

DESIGN

The present study is part of a programme of longitudinal research on ageing and spinal cord injury involving three populations - American, British and Canadian. The design was multivariate.

OBJECTIVE

To identify international differences in outcomes associated with ageing and spinal cord injury.

SETTING

A sample of 352 participants was assembled from five large, well-established databases. The Canadian sample was derived from the member database of the Canadian Paraplegic Association (Ontario and Manitoba divisions). The British sample was recruited from Southport Hospital's Northwest Regional Spinal Injuries Centre and Stoke-Mandeville Hospital's National Spinal Injuries Centre. The American sample has been recruited through Craig Hospital in Denver, Colorado.

METHODS

The sample included individuals who had incurred a spinal cord injury at least 20 years previously; were admitted to rehabilitation within 1 year of injury; were between age 15 and 55 at the time of injury. Data were collected using a combination of self-completed questionnaires and interviews. Data included medical information, general health, hospitalisations, and changes in bladder and bowel management, equipment, pain, spasticity, the need for assistance, and other health issues.

RESULTS

Clear international differences existed between the three samples in the three different countries. After controlling for sampling differences (ie, differences in age, level of lesion, duration of disability, etc.), the following differences were seen: (1) American participants had a better psychological profile and fewer health and disability-related problems; (2) British participants had less joint pain and less likelihood of perceiving they were ageing more quickly; (3) Canadians had more health and disability-related complications (particularly bowel, pain and fatigue problems).

CONCLUSION

These differences are discussed in terms of socio-political, health care system and cultural factors that might be used to explain them, and to generate hypotheses for future research.

Proxy reliability: health-related quality of life (HRQoL) measures for people with disability

OBJECTIVES

Research and surveillance activities sometimes require that proxy respondents provide key exposure or outcome information, especially for studies of people with disability (PWD). In this study, we compared the health-related quality of life (HRQoL) responses of index PWD to proxies.

METHODS

Subjects were selected from nursing home, other assisted living residences, and from several clinic samples of PWD. Each index identified one or more proxy respondents. Computer-assisted interviews used a random order of measures. Proxy reliability was measured by intraclass correlation (ICC) and kappa statistics. HRQoL measures tested included the surveillance questions of the Behavioral Risk Factor Surveillance System (BRFSS), basic and instrumental activities of daily living (ADLs and IADLs), medical outcomes study short-form 36 and 12 (SF-36 and SF-12).

RESULTS

A total of 131 index-proxy sets were completed. In general, agreement and reliability of proxy responses to the PWD tended to be best for relatives, with friends lower, and health care proxies lowest. For example, the ICC for the physical functioning scale of the SF-36 was 0.68 for relatives, 0.51 for friends, and 0.40 for healthcare proxies. There was a tendency for proxies to overestimate impairment and underestimate HRQoL. This pattern was reversed for measures of pain, which proxies consistently underestimated. The pattern among instruments, proxy types, and HRQoL domains was complex, and individual measures vary from these general results.

CONCLUSIONS

We suggest caution when using proxy respondents for HRQoL, especially those measuring more subjective domains.

The organization and financing of health services for persons with disabilities

Americans with disabilities are rarely considered a distinct group of health care users in the same way as are older Americans, children, racial and ethnic minorities, and others who are perceived to have different needs and access issues. Indeed, to some extent individuals with disabilities overlap with all these groups. But they also have distinct needs with material implications for the organization, delivery, and financing of health care services. Despite the disproportionate health care needs and expenditures of many--though not all--individuals with disabilities, the mainstream health services research community has largely neglected them. This article outlines the most pressing health service research issues in addressing the health care needs of individuals with disabilities.

Enabling our instruments: accommodation, universal design, and access to participation in research

The objective of this article is to discuss problems related to full participation of people with disabilities in health services and health outcomes research. To show the problems and to suggest solutions, we offer examples from personal research experiences (ours and colleagues'), as well as from published literature, requirements of research agencies, web and news sources, and research participants' feedback. A combination of formal and informal processes can be used to enable future instruments and methods. There are ethical, legal, and methodologic imperatives for research participation enablement.

A model of outcomes research: spinal cord injury

OBJECTIVE

To use spinal cord injury (SCI) care and research as a paradigm to illustrate how the principles and practices of outcomes research have been and can be applied to the sequelae of a specific disability.

DATA SOURCES

Review of data sources and literature pertaining to outcomes of SCI.

STUDY SELECTION

English language literature, health status and health services research agencies, academic and governmental research, and surveillance settings.

DATA EXTRACTION

A critical review of measures that have been and may be used to measure the outcomes of SCI. Special attention was paid to data sources; the need for methodologic accommodations: the research balance between generic and condition-specific methods; and the measurement outcomes that are highly relevant to people with SCIs.

DATA SYNTHESIS

There is a substantial research record related to the natural history, rehabilitation, survival, and long-term social reintegration of people with SCI, but relatively less addressing widely used generic health outcomes.

CONCLUSION

Contemporary outcomes research is relevant to people with SCI and those who provide treatment. One area of special attention is the occurrence of secondary conditions. To a large extent, SCI outcomes research can use conventional methods and generic instruments. There also is a need to modify research methods and to refine and apply some measures specific to people with SCI.