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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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2
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Azad TD, Nair SK, Kalluri AL, Materi J, Ahmed AK, Khalifeh J, Abu-Bonsrah N, Sharwood LN, Sterner RC, Brooks NP, Alomari S, Musharbash FN, Mo K, Lubelski D, Witham TF, Theodore N, Bydon A. Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review. World Neurosurg 2023; 169:e121-e130. [PMID: 36441093 DOI: 10.1016/j.wneu.2022.10.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anita L Kalluri
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA; Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Lisa N Sharwood
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School-Northern, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Robert C Sterner
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nathaniel P Brooks
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Farah N Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kevin Mo
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Williamson T, Hodges S, Yang LZ, Lee HJ, Gabr M, Ugiliweneza B, Boakye M, Shaffrey CI, Goodwin CR, Karikari IO, Lad S, Abd-El-Barr M. Impact of US hospital center and interhospital transfer on spinal cord injury management: An analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2021; 90:1067-1076. [PMID: 34016930 PMCID: PMC8243877 DOI: 10.1097/ta.0000000000003165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic spinal cord injury (SCI) is a serious public health problem. Outcomes are determined by severity of immediate injury, mitigation of secondary downstream effects, and rehabilitation. This study aimed to understand how the center type a patient presents to and whether they are transferred influence management and outcome. METHODS The National Trauma Data Bank was used to identify patients with SCI. The primary objective was to determine association between center type, transfer, and surgical intervention. A secondary objective was to determine association between center type, transfer, and surgical timing. Multivariable logistic regression models were fit on surgical intervention and timing of the surgery as binary variables, adjusting for relevant clinical and demographic variables. RESULTS There were 11,744 incidents of SCI identified. A total of 2,883 patients were transferred to a Level I center and 4,766 presented directly to a level I center. Level I center refers to level I trauma center. Those who were admitted directly to level I centers had a higher odd of receiving a surgery (odds ratio, 1.703; 95% confidence interval, 1.47-1.97; p < 0.001), but there was no significant difference in terms of timing of surgery. Patients transferred into a level I center were also more likely to undergo surgery than those at a level II/III/IV center, although this was not significant (odds ratio, 1.213; 95% confidence interval, 0.099-1.48; p = 0.059). CONCLUSION Patients with traumatic SCI admitted to level I trauma centers were more likely to have surgery, particularly if they were directly admitted to a level I center. This study provides insights into a large US sample and sheds light on opportunities for improving pre hospital care pathways for patients with traumatic SCI, to provide the timely and appropriate care and achieve the best possible outcomes. LEVEL OF EVIDENCE Care management, Level IV.
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Affiliation(s)
| | - Sarah Hodges
- Duke University School of Medicine, Department of Neurosurgery
| | | | - Hui-Jie Lee
- Duke University Department of Biostatistics and Bioinformatics
| | - Mostafa Gabr
- Duke University School of Medicine, Department of Neurosurgery
| | - Beatrice Ugiliweneza
- University of Louisville, Kentucky Spinal Cord Injury Research Center, Department of Neurosurgery, School of Medicine
| | - Maxwell Boakye
- University of Louisville, Kentucky Spinal Cord Injury Research Center, Department of Neurosurgery, School of Medicine
| | | | - C Rory Goodwin
- Duke University School of Medicine, Department of Neurosurgery
| | | | - Shivanand Lad
- Duke University School of Medicine, Department of Neurosurgery
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Sharwood LN, Whyatt D, Vaikuntam BP, Cheng CL, Noonan VK, Joseph AP, Ball J, Stanford RE, Kok MR, Withers SR, Middleton JW. A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study. BMC Health Serv Res 2021; 21:292. [PMID: 33794879 PMCID: PMC8015029 DOI: 10.1186/s12913-021-06235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.
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Affiliation(s)
- Lisa N Sharwood
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia.
- University of New South Wales, Faculty of Medicine and Health, NSW Black Dog Institute, Sydney, Australia.
- University of Technology Sydney, Faculty of Engineering, Sydney, NSW, Australia.
- Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, VIC, Australia.
| | - David Whyatt
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Bharat P Vaikuntam
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Christiana L Cheng
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Vanessa K Noonan
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Anthony P Joseph
- Royal North Shore Hospital, Trauma Department, Reserve Road, St Leonards, NSW, 2065, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathon Ball
- Royal North Shore Hospital, Neurosurgery, St Leonards, NSW, 2065, Australia
| | - Ralph E Stanford
- Prince of Wales Hospital, Spinal Cord Injury Unit, Randwick, NSW, 2033, Australia
| | - Mei-Ruu Kok
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Samuel R Withers
- Australian Institute of Robotic Orthopaedics, Perth, Western Australia, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Reserve Road, St Leonards, NSW, 2065, Australia
- Agency for Clinical Innovation, NSW Health, Reserve Road, St Leonards, NSW, 2065, Australia
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5
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Fehlings MG, Noonan VK, Atkins D, Burns AS, Cheng CL, Singh A, Dvorak MF. Optimizing Clinical Decision Making in Acute Traumatic Spinal Cord Injury. J Neurotrauma 2018; 34:2841-2842. [PMID: 28056628 PMCID: PMC5653145 DOI: 10.1089/neu.2016.4926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Michael G Fehlings
- 1 Department of Surgery, University of Toronto , Toronto, Ontario, Canada
| | | | - Derek Atkins
- 3 Operations and Logistics Division, Sauder School of Business, University of British Columbia , Vancouver, British Columbia, Canada
| | - Anthony S Burns
- 4 Division of Physiatry, Department of Medicine, University of Toronto , Toronto, Ontario, Canada
| | | | - Anoushka Singh
- 5 SCI Clinical Research Unit, Toronto Western Hospital , Toronto, Ontario, Canada
| | - Marcel F Dvorak
- 6 Department of Orthopaedics, University of British Columbia , Vancouver, British Columbia, Canada
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