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

Health care needs and health services utilization of people with spinal cord injury living in Jiangsu and Sichuan provinces of China: a cross-sectional community survey

PURPOSE

We aimed to investigate health care needs, health service utilization, and their socio-economic and health-related determinants in people with spinal cord injury (SCI) living in Jiangsu and Sichuan Provinces of China.

MATERIALS AND METHODS

A total of 1355 participants with SCI living in the community were recruited using a multi-stage stratified random sample and surveyed by telephone or online. Outcomes evaluated included the presence of health care needs, mode of health service utilization, and specific provider types seen within 12 months preceding the survey.

RESULTS

The prevalence of healthcare needs was 92%. Needs were higher in Sichuan (98%) as compared to Jiangsu (80%). Of those in need of health care, 38% reported not having utilized care, more in Sichuan (39%) than in Jiangsu (37%). In Jiangsu, inpatient care was more often used than in Sichuan (46% vs. 27%), while in Sichuan outpatient services were utilized more often (33% vs. 17%). On average, 1.6 provider types were seen, with Sichuan reporting fewer different provider types.

CONCLUSIONS

Considerable differences in the prevalence of health care needs and service utilization patterns were found between provinces, mostly in favour of the economically more developed Jiangsu Province.Implications for RehabilitationPeople with low income, particularly those below the World Bank poverty line for middle-income countries, had increased health care needs but utilized health care less often.Moreover, environmental barriers contributed significantly to unmet health care needs.This implies the necessity to provide better accessible and more affordable rehabilitation services for people with spinal cord injury (SCI) in China such as community-based rehabilitation programming.Policies for alleviation of poverty in the case of SCI including insurance for catastrophic health expenditure should also be reviewed and adapted where applicable.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury

Introduction

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.

Purpose

We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.

Methods

This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.

Results

There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.

Conclusion

This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

How Can Policymakers be Encouraged to Support People With Spinal Cord Injury-Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVE

Regarding that inappropriate medical care approaches, absence of rehabilitation services, and existing barriers in physical, social, and policy environments lead to poor outcomes in individuals with spinal cord injury (SCI) and provision for appropriate interventions and care must be created by health policymakers, we conducted this scoping review to investigate how policymakers can be persuaded to set new plans for individuals with SCI.

METHODS

This review was performed according to Arksey and O'Malley's framework. PubMed was searched in February2019 without language limitation. We looked for other potential gray literature sources and some professional websites. References sections of selected articles were also scanned for other relevant literature.

RESULTS

We included literature that met inclusion criteria to answer our research question. The literature was divided into 3 categories. The first category included economic impact of SCI. The second category included the role of research and developing research strategy. The third category included effective interaction and communication with policymakers.

CONCLUSION

It is essential to consider multiple factors for influencing policymakers' decisions. These factors include knowing how to communicate with policymakers and presenting constructive ideas, providing a source of valid, reliable, and consistent data, considering the role of patients' advocacy groups and Non-Governmental Organizations (NGOs), and presentation of the importance of early intervention in reducing healthcare system costs. Ultimately, the goal is to have a comprehensive and flexible plan for influencing policymakers.

Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature

OBJECTIVES

To (1) provide an overview of the use of the Knowledge-to-Action Cycle (KTA) to guide a clinical implementation project; (2) identify activities performed in each phase of the KTA; and (3) provide suggestions to improve KTA activities in physical medicine and rehabilitation.

DATA SOURCES

Google Scholar and PubMed were searched through December 31, 2019.

STUDY SELECTION

Two reviewers screened titles, abstracts, and full-text articles to identify published studies that used the KTA to implement a project.

DATA EXTRACTION

Two reviewers examined full-text articles. Data extraction included activities performed in each phase of the KTA, including measurements used to evaluate the project's effectiveness.

DATA SYNTHESIS

Commonly performed KTA activities were identified and country of study, area of rehabilitation, and other factors related to the use of the KTA in rehabilitation were described. A total of 46 articles that met the study's inclusion criteria provided an overview of the use of the KTA in rehabilitation. Strengths and weaknesses of the articles are discussed and recommendations for improved KTA use are provided.

CONCLUSIONS

Implementation of evidence-based practice requires focused engineering and efforts. This review provides an overview of the knowledge translation activities occurring in physical medicine and rehabilitation and considerations to improve knowledge translation research and practice.

Models of Care Delivery from Rehabilitation to Community for Spinal Cord Injury: A Scoping Review

Spinal cord injury (SCI) is a chronic condition that results in high healthcare utilization and lifetime cost across the care continuum. In the absence of a standardized model of care delivery for SCI in western countries such as Canada, a scoping review of the literature was performed to identify and summarize existing international SCI models of care delivery. Four databases were searched using key words and subject headings for concepts such as: "spinal cord injury," "delivery of healthcare," "model of care," "patient care planning," and "care pathway." Title, abstract, and full text review were competed by two independent reviewers. A combined total of 46 peer-reviewed and gray literature articles were included. No single SCI model of care has been adopted across different countries internationally. However, optimal attributes of models of care were identified, including the importance of having multidisciplinary SCI specialty care providers along the continuum, provision of rural SCI services and outreach, integration of primary care, peer mentoring, and using a hub and spokes model of care. These findings inform the future development of an SCI model of care, which ideally would serve all geographical locations and span the continuum of care, improving the health status and quality of life of persons with SCI.

Trends, Challenges, and Opportunities Regarding Research in Non-traumatic Spinal Cord Dysfunction

Background: Spinal cord dysfunction (SCDys) is caused by heterogeneous health conditions, and the incidence is increasing. Despite the growing interest in rehabilitation research for SCDys, research into SCDys faces many challenges. Objective: The objective of this project was to perform a clinical review of changes in SCDys research over the last 4 decades; identify challenges to conducting research in SCDys; and propose opportunities for improving research in SCDys. Methods: A triangulation approach was used for obtaining evidence: literature search (January 2017) using MEDLINE and Embase databases for publications in English (1974-2016) regarding SCDys; workshop discussions at the International Spinal Cord Society annual meeting, September 16, 2016, Vienna, Austria; and our collective expertise in SCDys clinical rehabilitation research. Results: There has been a substantial increase in publications on SCDys over the 4 decades, from 1,825 in 1974-1983 to 11,887 in the decade 2004-2013, along with an improvement in research methodology. Numerous challenges to research in SCDys rehabilitation were grouped into the following themes: (a) identification of cases; (b) study design and data collection; and (c) funding, preclinical, and international research. Opportunities for addressing these were identified. Conclusions: The increase in scientific publications on SCDys highlights the importance of this heterogeneous group among the research community. The overall lack of good quality epidemiological studies regarding incidence, prevalence, and survival in these patients serves as a benchmark for guiding improvements to inform evidence-based care and policy.

Optimizing Clinical Decision Making in Acute Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a devastating event causing lifelong disability that results in a significant decrease in quality of life and immense cost to the health care system, individuals and their families. Providing specialized and timely care can improve recovery and reduce costs, but to make this a reality requires understanding of the current care delivery processes and the care journey. The objective of this focus issue is to examine the current state of health care delivery and discover opportunities to improve access and timing to specialized care for individuals with tSCI. This issue provides an overview of care throughout the SCI continuum and its impact on individuals with tSCI using pan-Canadian data. The issue also presents findings from the RHI Access to Care and Timing (ACT) Project, a multi-center research study involving a multi-disciplinary team of Canadian researchers and clinicians. The initial articles describe the current state of the tSCI care journey including a comparison of environmental barriers, health status, and quality-of-life outcomes between patients living in rural and urban settings. The issue concludes with an article describing the national knowledge translation efforts of using the evidence from the articles published here to inform practice and policy change. Overall, this focus issue will be an excellent reference to guide and optimize evidence informed decision-making in the care of those with tSCI. The evidence can be transferred to care in non-traumatic SCI and other conditions that benefit from timely access to specialized care such as stroke and traumatic brain injury.

Surgical management of patients following traumatic spinal cord injury: Identifying barriers to early surgery in a specialized spinal cord injury center

CONTEXT/OBJECTIVE

Early surgery in individuals with traumatic spinal cord injury (T-SCI) can improve neurological recovery and reduce complications, costs and hospitalization. Patient-related and healthcare-related factors could influence surgical delay. This study aimed at determining factors contributing to surgical delay in individuals with T-SCI.

DESIGN

Prospective cohort study.

SETTING

Single Level I trauma center in Québec, Canada.

PARTICIPANTS

One hundred and forty-four patients who sustained a T-SCI.

INTERVENTIONS

None.

OUTCOME MEASURES

Socio-demographic and clinical administrative data were collected during the pre-operative period. The cohort was stratified in early surgery, or ES (<24 hours post-trauma) and late surgery, or LS (≥ 24 hours post-trauma) groups. A multivariate logistic regression analysis using patient- and healthcare-related factors was carried out to identify the main predictors of LS.

RESULTS

93 patients had ES (15.6 ± 4.7 hours post-trauma), which is 31 hours earlier than the 51 patients in the LS group (46.9 ± 30.9 hours; P < 10^-3). The transfer delay from trauma site to the SCI center was 8 hours shorter (5.0 ± 3.0 hours vs 13.6 ± 17.0; P < 10^-3) for the ES group, and the surgical plan was completed 17 hours faster (6.0 ± 4.0 hours vs 23.3 ± 23.6 hours; P < 10^-3) than for the LS group. The occurrence of LS was predicted by modifiable factors, such as the transfer delay to the SCI center, the delay before surgical plan completion, and the waiting time for the operating room.

CONCLUSIONS

A dedicated team for surgical treatment of individuals with T-SCI, involving direct transfer to the SCI center, faster surgery planning and access to the operating room in hospitals dealing with emergencies from all subspecialties could improve surgical delay and increase the rate of patients undergoing ES.

Using Evidence To Inform Practice and Policy To Enhance the Quality of Care for Persons with Traumatic Spinal Cord Injury

In today's economic climate, there is a need to demonstrate a return on investment for healthcare spending and for clinical practice and policy to be informed by evidence. Navigating this process is difficult for decision-makers, clinicians, and researchers alike. This article will describe how a knowledge translation framework and an evidence-based policy-making process were integrated to clarify the problem, frame options, and plan implementation, to impact clinical practice and policy in the area of traumatic spinal cord injury (tSCI). The Access to Care and Timing (ACT) project is focused on optimizing the access and timing of specialized healthcare delivery for persons sustaining a tSCI in Canada. A simulation model was developed that uses current patient data to address complex problems faced by the healthcare system. At a workshop, participants stressed the importance of linking interventions to short- and long-term outcomes to drive change. Presently, there are no national, system level indicators to monitor performance after tSCI. Although the ideal system of care after tSCI is unknown, indicator collection will establish a baseline to measure improvement. The workshop participants prioritized two indicators important from the clinician and patient perspective-timely admission to rehabilitation and meaningful community participation. The ACT simulation model for tSCI care will be used to promote the uptake of identified indicators and provide a predictive link between interventions on potential outcomes. The standardized collection of outcome-oriented indicators will help to evaluate the access and timing of care and to define the ideal system of care after SCI.

Traumatic Spinal Cord Injury Care in Canada: A Survey of Canadian Centers

Specialized centers of care for persons sustaining a traumatic spinal cord injury (tSCI) have been established in many countries, but the ideal system of care has not been defined. The objective of this study was to describe care delivery, with a focus on structures and services, for persons with tSCI in Canada. A survey was sent to 26 facilities (12 acute, 11 rehabilitation, and three integrated) from eight provinces participating in the Access to Care and Timing project. The survey included questions about: 1) care provision; 2) structural attributes and; 3) service availability. Survey completion rate was 100%. Data sources used to complete the survey were the Rick Hansen Spinal Cord Injury Registry, other hospital databases, clinical protocols, and subject matter experts. Acute and rehabilitation care provided by integrated facilities were described separately, resulting in data from 15 acute and 14 rehabilitation facilities. The number of admissions for tSCI over a 12-month period between 2009-2011 ranged from 17 to 104 (median 39), and 11 to 96 (median 32), for acute and rehabilitation facilities, respectively. Grouping of patients was reported by 8/15 acute and 10/14 rehabilitation facilities. Criteria for admission to the inpatient rehabilitation facilities varied among facilities (25 different criteria reported). Results from the survey revealed similarities in the basic structure and the provision of general services, but also some differences in the degree of specialization of care for persons with tSCI. Continued work on the impact of specialized care for both the patient and healthcare system is needed.

Rural and Urban Living in Persons with Spinal Cord Injury and Comparing Environmental Barriers, Their Health, and Quality-of-Life Outcomes

There is worldwide geographic variation in the epidemiology of traumatic spinal cord injury (tSCI). The aim of this study was to determine whether environmental barriers, health status, and quality-of-life outcomes differ between patients with tSCI living in rural or urban settings, and whether patients move from rural to urban settings after tSCI. A cohort review of the Rick Hansen SCI Registry (RHSCIR) was undertaken from 2004 to 2012 for one province in Canada. Rural/urban setting was determined using postal codes. Outcomes data at 1 year in the community included the Short Form-36 Version 2 (SF36v2™), Life Satisfaction Questionnaire, Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF), Functional Independent Measure® Instrument, and SCI Health Questionnaire. Statistical methodologies used were t test, Mann-Whitney U test, and Fisher's exact or χ2 test. In the analysis, 338 RHSCIR participants were included; 65 lived in a rural setting and 273 in an urban setting. Of the original patients residing in a rural area at discharge,10 moved to an urban area by 1 year. Those who moved from a rural to urban area reported a lower SF-36v2™ Mental Component Score (MCS; p = 0.04) and a higher incidence of depression at 1 year (p = 0.04). Urban patients also reported a higher incidence of depression (p = 0.02) and a lower CHIEF-SF total score (p = 0.01) indicating fewer environmental barriers. No significant differences were found in other outcomes. Results suggest that although the patient outcomes are similar, some patients move from rural to urban settings after tSCI. Future efforts should target screening mental health problems early, especially in urban settings.

Forecasting Financial Resources for Future Traumatic Spinal Cord Injury Care Using Simulation Modeling

Survivors of traumatic spinal cord injury (tSCI) have intense healthcare needs during acute and rehabilitation care and often through the rest of life. To prepare for a growing and aging population, simulation modeling was used to forecast the change in healthcare financial resources and long-term patient outcomes between 2012 and 2032. The model was developed with data from acute and rehabilitation care facilities across Canada participating in the Access to Care and Timing project. Future population and tSCI incidence for 2012 and 2032 were predicted with data from Statistics Canada and the Canadian Institute for Health Information. The projected tSCI incidence for 2012 was validated with actual data from the Rick Hansen SCI Registry of the participating facilities. Using a medium growth scenario, in 2032, the projected median age of persons with tSCI is 57 and persons 61 and older will account for 46% of injuries. Admissions to acute and rehabilitation facilities in 2032 were projected to increase by 31% and 25%, respectively. Because of the demographic shift to an older population, an increase in total population life expectancy with tSCI of 13% was observed despite a 22% increase in total life years lost to tSCI between 2012 and 2032. Care cost increased 54%, and rest of life cost increased 37% in 2032, translating to an additional CAD $16.4 million. With the demographics and management of tSCI changing with an aging population, accurate projections for the increased demand on resources will be critical for decision makers when planning the delivery of healthcare after tSCI.

Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps

Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.

Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury

Evidence-based planning of rehabilitation interventions is important to improving cost efficiency while maintaining patient and system outcomes. This article aims to explore the relationship between rehabilitation therapy, functional outcome, bed utilization, and care costs after traumatic spinal cord injury (tSCI). A retrospective review of 262 persons with tSCI admitted to an inpatient rehabilitation facility from 2005–2012 was conducted. Treatment variables and outcome measures included rehabilitation length of stay (LOS), days to rehabilitation (onset), hours and intensity of therapy, and Functional Independence Measure (FIM). Polynomial regression models and generalized additive models were applied to explore the relationship between therapy hours and motor FIM change. Simulation modeling was used to assess the impact of hypothetically increasing therapy intensity. Patients were grouped by injury as: C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A,B,C; C5–8 AIS A,B,C; T1–S5 AIS A,B,C; and AIS D. The sample was 85% male, mean age 45.9, median LOS 102 days, and mean therapy intensity 5.7 h/week. Motor FIM change was positively associated with total hours of therapy (β = 0.40, p < 0.0001) up to a certain time point, adjusted for age, gender, injury, complications, and rehabilitation onset. Hypothetically increasing therapy intensity by 50% and 100% resulted in average motor FIM efficiency gain ranging between 0.04–0.07 and 0.1–0.17, respectively, across injury groups. The hypothetical changes resulted in reductions in the average LOS and bed utilization rate, translating to cost savings of $20,000 and $50,000 (2011 CAD) for the +50% and +100% scenarios, respectively. The results highlight the importance of monitoring functional change throughout rehabilitation after tSCI and the need for customized therapeutic strategies.

Geomapping of Traumatic Spinal Cord Injury in Canada and Factors Related to Triage Pattern

Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility (n = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.

Methodology of the Access to Care and Timing Simulation Model for Traumatic Spinal Cord Injury Care

Despite the relatively low incidence of traumatic spinal cord injury (tSCI), the management and care of persons with tSCI can be resource intensive and complex, spanning multiple phases of care and disciplines. Using a simulation model built with a system level view of the healthcare system allows for prediction of the impact of interventions on patient and system outcomes from injury through to community reintegration after tSCI. As has been previously described, the Access to Care and Timing (ACT) project developed a simulation model for tSCI care using techniques from operations research. The objective of this article is to briefly describe the methodology and the application of the ACT Model, as it was used in several of the articles in this focus issue. The approaches employed in this model provide a framework to look into the complexity of interactions both within and among the different SCI programs, sites, and phases of care.

Understanding Length of Stay after Spinal Cord Injury: Insights and Limitations from the Access to Care and Timing Project

Costs associated with initial hospitalization following spinal cord injury (SCI) are substantial, and a major driver of costs is the length of stay (LOS); that is, the time that the injured individual remains hospitalized prior to community reintegration. Our aim was to study the factors and variables that contribute to LOS following traumatic SCI. Modeling (process mapping of the SCI healthcare delivery system in Canada and discrete event simulation) and regression analysis using a national registry of individuals with acute traumatic SCI in Canada, existing databases, and peer-reviewed literature were used to examine the driver of LOS following traumatic SCI. In different jurisdictions, there is considerable variation in the definitions and methods used to determine LOS following SCI. System LOS can be subdivided into subcomponents, and progression through these is not unidirectional. Modeling reveals that healthcare organization and processes are important contributors to differences in LOS independent of patient demographics and injury characteristics. Future research is required to identify and improve understanding of contributors to LOS following traumatic SCI. This will help enhance system performance. Work in this area will be facilitated by the adoption of common terminology and definitions, as well as by the use of simulations and modeling.

Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part II: Background to a research strategy

STUDY DESIGN

Literature review/semi-structured interviews.

OBJECTIVE

To develop a spinal cord injury (SCI) research strategy for Australia and New Zealand.

SETTING

Australia.

METHODS

The National Trauma Research Institute Forum approach of structured evidence review and stakeholder consultation was employed. This involved gathering from published literature and stakeholder consultation the information necessary to properly consider the challenge, and synthesising this into a briefing document.

RESULTS

A research strategy 'roadmap' was developed to define the major steps and key planning questions to consider; next, evidence from published SCI research strategy initiatives was synthesised with information from four one-on-one semi-structured interviews with key SCI research stakeholders to create a research strategy framework, articulating six key themes and associated activities for consideration. These resources, combined with a review of SCI prioritisation literature, were used to generate a list of draft principles for discussion in a structured stakeholder dialogue meeting.

CONCLUSION

The research strategy roadmap and framework informed discussion at a structured stakeholder dialogue meeting of 23 participants representing key SCI research constituencies, results of which are published in a companion paper. These resources could also be of value in other research strategy or planning exercises.

SPONSORSHIP

This project was funded by the Victorian Transport Accident Commission and the Australian and New Zealand Spinal Cord Injury Network.

Right care, right time, right place: improving outcomes for people with spinal cord injury through early access to intervention and improved access to specialised care: study protocol

Background

Traumatic spinal cord injury is a devastating condition impacting adversely on the health and wellbeing, functioning and independence, social participation and quality of life of the injured person. In Australia, there are approximately 15 new cases per million population per year; economic burden estimates suggest 2 billion dollars annually. For optimal patient outcomes expert consensus recommends expeditious transfer (“<24 hours of injury”) to a specialist Spinal Cord Injury Unit, where there is an interdisciplinary team equipped to provide comprehensive care for the many and complex issues associated with traumatic spinal cord injury. No study of this patient population has been undertaken, that assessed the extent to which care received reflected clinical guidelines, or examined the patient journey and outcomes in relation to this. The aims of this study are to describe the nature and timing of events occurring before commencement of specialist care, and to quantify the association between these events and patient outcomes.

Methods and design

The proposed observational study will recruit a prospective cohort over two years, identified at participating sites across two Australian states; Victoria and New South Wales. Included participants will be aged 16 years and older and diagnosed with a traumatic spinal cord injury. Detailed data will be collected from the point of injury through acute care and subacute rehabilitation, discharge from hospital and community reintegration. Items will include date, time, location and external cause of injury; ambulance response, assessments and management; all episodes of hospital care including assessments, vital signs, diagnoses and treatment, inter-hospital transfers, surgical interventions and their timing, lengths of stay and complications. Telephone follow-up of survivors will be conducted at 6, 12 and 24 months.

Discussion

There is limited population level data on the effect of delayed commencement of specialist care (>24 hours) in a Spinal Cord Injury Unit. Examining current health service and clinical intervention pathways in this Australian population-based sample, in relation to their outcomes, will provide an understanding of factors associated with patient flow, resource utilisation and cost, and patient and family quality of life. Barriers to streamlined effective early-care pathways and facilitators of optimal treatment for these patients will be identified.

Hospital case volume and outcomes among patients hospitalized with severe sepsis

RATIONALE

Processes of care are potential determinants of outcomes in patients with severe sepsis. Whether hospitals with more experience caring for patients with severe sepsis also have improved outcomes is unclear.

OBJECTIVES

To determine associations between hospital severe sepsis caseload and outcomes.

METHODS

We analyzed data from U.S. academic hospitals provided through University HealthSystem Consortium. We used University HealthSystem Consortium's sepsis mortality model (c-statistic, 0.826) for risk adjustment. Validated International Classification of Disease, 9th Edition, Clinical Modification algorithms were used to identify hospital severe sepsis case volume. Associations between risk-adjusted severe sepsis case volume and mortality, length of stay, and costs were analyzed using spline regression and analysis of covariance.

MEASUREMENTS AND MAIN RESULTS

We identified 56,997 patients with severe sepsis admitted to 124 U.S. academic hospitals during 2011. Hospitals admitted 460 ± 216 patients with severe sepsis, with median length of stay 12.5 days (interquartile range, 11.1-14.2), median direct costs $26,304 (interquartile range, $21,900-$32,090), and average hospital mortality 25.6 ± 5.3%. Higher severe sepsis case volume was associated with lower unadjusted severe sepsis mortality (R2 = 0.10, P = 0.01) and risk-adjusted severe sepsis mortality (R2 = 0.21, P < 0.001). After further adjustment for geographic region, number of beds, and long-term acute care referrals, hospitals in the highest severe sepsis case volume quartile had an absolute 7% (95% confidence interval, 2.4-11.6%) lower hospital mortality than hospitals in the lowest quartile. We did not identify associations between case volume and resource use.

CONCLUSIONS

Academic hospitals with higher severe sepsis case volume have lower severe sepsis hospital mortality without higher costs.

Modeling the patient journey from injury to community reintegration for persons with acute traumatic spinal cord injury in a Canadian centre

Background

A patient’s journey through the health care system is influenced by clinical and system processes across the continuum of care.

Methods

To inform optimized access to care and patient flow for individuals with traumatic spinal cord injury (tSCI), we developed a simulation model that can examine the full impact of therapeutic or systems interventions across the care continuum for patients with traumatic spinal cord injuries. The objective of this paper is to describe the detailed development of this simulation model for a major trauma and a rehabilitation centre in British Columbia (BC), Canada, as part of the Access to Care and Timing (ACT) project and is referred to as the BC ACT Model V1.0.

Findings

To demonstrate the utility of the simulation model in clinical and administrative decision-making we present three typical scenarios that illustrate how an investigator can track the indirect impact(s) of medical and administrative interventions, both upstream and downstream along the continuum of care. For example, the model was used to estimate the theoretical impact of a practice that reduced the incidence of pressure ulcers by 70%. This led to a decrease in acute and rehabilitation length of stay of 4 and 2 days, respectively and a decrease in bed utilization of 9% and 3% in acute and rehabilitation.

Conclusion

The scenario analysis using the BC ACT Model V1.0 demonstrates the flexibility and value of the simulation model as a decision-making tool by providing estimates of the effects of different interventions and allowing them to be objectively compared. Future work will involve developing a generalizable national Canadian ACT Model to examine differences in care delivery and identify the ideal attributes of SCI care delivery.