A structural analysis of health outcomes after spinal cord injury

The association between secondary health conditions and indirect costs after spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVE

Identify the association between secondary health conditions (SHC) and the indirect costs of traumatic spinal cord injury (SCI) based on the pre-injury and post-injury changes in employment and earnings.

SETTING

Medical university in the southeastern United States (US).

METHODS

A population-based cohort of 304 participants met the following eligibility criteria: received treatment for acute SCI within the state, residual effects resulting from traumatic SCI, at least 1-year post injury, age between 23 and 64 years at the time of injury onset, and younger than 65 years at the time of study measurement. The indirect costs estimate was measured by the annual forgone earnings and fringe benefits calculated as the difference in the sum of earnings and benefits between before injury and after injury adjusting for inflation in 2019 US dollars. We considered seven SHC in this study: bowel accidents, urine accidents, urinary tract infections, pressure sores, unintentional injury, severe pain, and depressive disorder. We used multivariate ordinary least squares regression models to examine their relationship controlling for age, sex, race/ethnicity, marital status, years of education, injury level, and ambulatory status.

RESULTS

The indirect costs were significantly associated with the total number of SHC and with the individual conditions of bowel accidents, urine accidents, pressure sores, and depressive disorder after controlling for age, sex, race/ethnicity, marital status, years of education, injury level, and ambulatory status.

CONCLUSIONS

Preventing SHC relates to better economic consequences for individuals, their families, and society, even after accounting for differences in severity of SCI.

Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Identify the risk and protective factors of all-cause and cause-specific mortality among persons with traumatic spinal cord injury (SCI).

SETTING

Rehabilitation specialty hospital in the Southeastern United States.

METHODS

A prospective cohort study was conducted with 3070 adults with traumatic SCI who were a minimum of 1 year post-injury at assessment. Prospective data were collected in 1997-1998 and 2007-2010, with mortality determined as of 31 December, 2016. The deceased were classified into six categories based on underlying cause of death: septicemia, pneumonia and influenza, cancer, heart and blood vessel diseases, unintentional injuries, and all other causes. The competing risk analysis strategy applied to each of the specific causes.

RESULTS

There were a total of 803 observed deaths among the 2979 final study sample. After controlling for demographic and injury characteristics, general health, pressure ulcer history, and symptoms of infections were significantly associated with all-cause mortality. Except for cancer, they were also related with at least one of the specific causes of death, whereas orthopedic complications and subsequent injuries were unrelated to any cause.

CONCLUSIONS

Three health domains, global health, pressure ulcers, and symptoms of illness or infection, were significantly associated with mortality after SCI, and the patterns of association varied as a function of specific cause of death.

Latent Structural Analysis of Health Outcomes in People Living With Spinal Cord Injury

OBJECTIVE

To develop a latent structural model of health outcomes in people with spinal cord injury (SCI) that accounts for the measurement of underlying factors and their association with demographic and injury-related exogenous variables.

DESIGN

Cross-sectional study.

SETTING

Specialty hospital and medical university.

PARTICIPANTS

Participants with traumatic SCI (N=1871) of at least 1-year duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Exploratory factor analysis was used to identify latent health outcome structures. Several key exogenous variables were also linked with the latent health outcome factors.

RESULTS

Six latent health outcome factors were identified by the exploratory factor analysis with excellent model fit (root mean square error of approximation=.040). These latent factors included (1) global health problems; (2) chronic disease; (3) acute treatments; (4) symptoms of SCI complications, (5) pressure ulcers; and (6) subsequent injuries. Sex, race/ethnicity, age, years since injury, and injury severity were all significantly associated with at least 1 latent health outcome factor, which indicates that these latent health outcomes varied as a function of the exogenous variables.

CONCLUSIONS

This study improved our understanding of the structure of health outcomes, and utilization of latent health outcome factors provides more stable and comprehensive composite scores than does utilization of a single observed health outcome indicator.

Training a Spinal Cord Injury Rehabilitation Team in Motivational Interviewing

Background. An acute spinal cord injury (ASCI) is a severe condition that requires extensive and very specialized management of both physical and psychological dimensions of injured patients. Objective. The aim of the part of the study reported here was twofold: (1) to describe burnout, empathy, and satisfaction at work of these professionals and (2) to explore whether a tailored program based on motivational interviewing (MI) techniques modifies and improves such features. Methods. This paper presents findings from an intervention study into a tailored training for professionals (N = 45) working in a spinal cord injury (SCI) unit from a general hospital. Rehabilitation professionals' empathy skills were measured with the Jefferson Scale of Physician Empathy (JSPE), burnout was measured with the Maslach Burnout Inventory (MBI), and additional numeric scales were used to assess the perceived job-related stress and perceived satisfaction with job. Results. Findings suggest that professionals are performing quite well and they refer to satisfactory empathy, satisfaction at work, and no signs of burnout or significant stress both before and after the training. Conclusions. No training effect was observed in the variables considered in the study. Some possible explanations for these results and future research directions are discussed in depth in this paper. The full protocol of this study is registered in ClinicalTrials.gov (identifier: NCT01889940).

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.

Prevalence of pressure ulcers in Thai wheelchair users with chronic spinal cord injuries

Study design:

A cross-sectional study.

Objectives:

To study prevalence of pressure ulcers (PrUs), quality of life (QoL) and effect of wheelchair cushions used by Thai wheelchair users with chronic spinal cord injury (SCI).

Setting:

Maharaj Hospital, Chiang Mai, Thailand.

Methods:

Thai chronic SCI wheelchair users, aged over 18 years and non-ambulatory with ASIA impairment scale A, B or C were recruited. They completed the PrUs questionnaire and rated the EuroQoL-5D and their health status with a visual analog scale (VAS). Demographic data of each participant were extracted from medical records. The EQ-5D health states were transformed to utility scores by using the Thai algorithm and the prevalence of PrUs was reported. The EQ-5D, the utility scores and the health status VAS were compared between those with and without current PrUs and between those participants using foam and air-filled cushions.

Results:

Of 129 participants, 26.4% had current PrUs at the time of the study, 27.9% had healed PrUs and 45.7% never had PrUs. The median VAS score for health status was 70 (Q1=50, Q3=80). Based on the EQ-5D, only one dimension (anxiety/depression) was significantly different between those with and those without current PrUs (P=0.015). Those using an air-filled cushions had a mean utility score four times higher than of those using a foam cushion (0.131 vs 0.032, P=0.089) but not statistically significant.

Conclusions:

PrUs are still prevalent among Thai wheelchair users with chronic SCI. Anxiety/depression is associated with current ulcers.

Factor structure of the Spanish version of the Patient Health Questionnaire-9 in Mexican women

Structure of the Spanish version of the nine-item Patient Health Questionnaire (PHQ-9) has been inconclusive. We report the factor structure of the PHQ-9 in 55,555 women from the Mexican Teachers' Cohort (MTC). Factor structure of the PHQ-9 was assessed by exploratory and confirmatory factor analyses in two sub-samples (n = 27,778 and 27,777 respectively). A one-factor model of the PHQ-9 was the solution with the best fit to the data, exhibiting strong factor loadings (0.71 to 0.90) and high internal consistency (Cronbach's alpha = 0.89). A prevalence rate of moderate to high severity of depressive symptoms of 12.6% was identified. Results suggest that a global score is an appropriate measure of depressive symptoms and commend the use of the Spanish PHQ-9 as a measure of depression for research and clinical purposes.

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.

Feasibility of sensory tongue stimulation combined with task-specific therapy in people with spinal cord injury: a case study

Background

Previous evidence suggests the effects of task-specific therapy can be further enhanced when sensory stimulation is combined with motor practice. Sensory tongue stimulation is thought to facilitate activation of regions in the brain that are important for balance and gait. Improvements in balance and gait have significant implications for functional mobility for people with incomplete spinal cord injury (iSCI). The aim of this case study was to evaluate the feasibility of a lab- and home-based program combining sensory tongue stimulation with balance and gait training on functional outcomes in people with iSCI.

Methods

Two male participants (S1 and S2) with chronic motor iSCI completed 12 weeks of balance and gait training (3 lab and 2 home based sessions per week) combined with sensory tongue stimulation using the Portable Neuromodulation Stimulator (PoNS). Laboratory based training involved 20 minutes of standing balance with eyes closed and 30 minutes of body-weight support treadmill walking. Home based sessions consisted of balancing with eyes open and walking with parallel bars or a walker for up to 20 minutes each. Subjects continued daily at-home training for an additional 12 weeks as follow-up.

Results

Both subjects were able to complete a minimum of 83% of the training sessions. Standing balance with eyes closed increased from 0.2 to 4.0 minutes and 0.0 to 0.2 minutes for S1 and S2, respectively. Balance confidence also improved at follow-up after the home-based program. Over ground walking speed improved by 0.14 m/s for S1 and 0.07 m/s for S2, and skilled walking function improved by 60% and 21% for S1 and S2, respectively.

Conclusions

Sensory tongue stimulation combined with task-specific training may be a feasible method for improving balance and gait in people with iSCI. Our findings warrant further controlled studies to determine the added benefits of sensory tongue stimulation to rehabilitation training.

Training professionals’ communication and motivation skills to improve spinal cord injury patients’ satisfaction and clinical outcomes: Study protocol of the ESPELMA trial

Acute spinal cord injury leaves patients severely impaired and generates high levels of psychological distress among them and their families, which can cause a less active role in rehabilitation, worse functional recovery, and less perceived satisfaction with the results. Additionally, rehabilitation professionals who deal with this psychological distress could ultimately experience higher stress and more risk of burnout. This article presents the study protocol of the ESPELMA project, aimed to train rehabilitation professionals in the clinical management of acute spinal cord injury–associated psychological distress, and to measure the impact of this training on the patients’ perceived satisfaction with treatment.

Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research

BACKGROUND

To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies.

OBJECTIVE

Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention.

METHODS

We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research.

CONCLUSIONS

The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.

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.

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.

Personality and Behavioral Predictors of Pressure Ulcer History

PURPOSE: To assess the relationship of psychological, environmental, and behavioral factors with pressure ulcers (PUs) in persons with spinal cord injury (SCI). METHODS: A total of 1,549 participants from a large rehabilitation hospital in the southeast United States answered questions regarding outcomes after SCI. Variables from each set of factors were entered sequentially into the model: (1) psychological and environmental, and (2) behavioral. RESULTS: Forty-eight percent of participants reported having a PU in the past year. After entering behavioral variables into the model, all environmental and psychological variables became nonsignificant. Odds of having a PU increased 28% with each psychotropic medication taken weekly. Persons who smoked one or more packs of cigarettes daily had 2.82 times the odds of having a PU than persons who did not smoke. Increased hours out of bed were protective against PUs. CONCLUSION: This study demonstrated the importance of health behaviors in the occurrence of PUs after SCI. These health behaviors provide important targets for intervention for health care providers.

The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury

OBJECTIVE

To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators.

DESIGN

Cohort study.

SETTING

A large rehabilitation hospital in the southeastern US.

PARTICIPANTS

1466 white and African American adults at least 1-year post-traumatic SCI.

OUTCOME MEASURES

(a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury.

RESULTS

In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU.

CONCLUSION

These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.