The Real Predictors of Disposition in Patients with Spinal Cord Injuries

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

Trends in the presentation and management of traumatic spinal cord lesions above T6: 20-Year experience in a tertiary-level hospital in Spain

OBJECTIVE

To analyze the changes in demographic and lesion characteristics of persons with acute traumatic spinal cord injury (ATSCI) above T6 over a period of 20 years, and to evaluate their impact on ICU resources use, length of stay and mortality.

DESIGN

Retrospective observational study.

SETTING

Intensive Care Unit (ICU) of the University Hospital Complex of A Coruña, Spain.

PARTICIPANTS

The study included 241 persons between 1998 and 2017 with an ATSCI above T6. For the purposes of the analysis, the overall study period was divided into three subperiods.

RESULTS

Both the mean age of the people with ATSCI (49 vs. 51 vs. 57 years; P = 0.046) and the Charlson Comorbidity Index were higher during the last subperiod (mean: 1.9 ± 2.2; P &lt; 0.01). The most frequent cause of the injury was falls, whose percentage increased over the years. The most common classification in the American Spinal Injury Association Impairment scale was grade A. An increase in the score of the Acute Physiology and Chronic Health Evaluation (APACHE II) score was observed (median: 9 vs. 10 vs. 15; P &lt; 0.01). The length of stay in the ICU has decreased significantly over the years (30 ± 19 vs. 22 ± 14 vs. 19 ± 13 days). No significant differences were found between the rates of ICU or in-hospital mortality recorded over the three subperiods.

CONCLUSIONS

Despite the progressive increase in the age, comorbidity, and APACHE II, the length of ICU stay decreased significantly, with no associated changes in the mortality rates.

Economic impact of traumatic spinal cord injuries in the United States

Individuals having sustained traumatic spinal cord injury (TSCI) in the United States are living longer as compared to historical trends, thanks to an ever-evolving understanding of the nature of this injury. Despite this, multiple barriers to care for TSCI patients remain including variations in government-issued veteran insurance, privatized insurance, and among uninsured individuals. The United States alone experiences 12,000 new TSCI cases every year, many of these are found to occur in a growing proportion of elderly individuals. It is crucial to understand both the short-term direct costs as wells as the long-term rehabilitation costs required by these TSCI patients. The lifetime financial burden for those having sustained a TSCI can be immense for patients, insurance companies, and hospital systems alike. Among those with TSCI, re-hospitalization rates are high, leading to increased healthcare resource utilization within this specific patient population. Costs can quickly balloon into hundreds of thousands of dollars and cause a profound financial burden for these patients. This review article seeks to communicate an understanding of the current financial landscape surrounding TSCI patients. The authors will also examine the costs of acute emergency room surgical care such as American spinal injury association grade, hospital length of stay, as well as the timing delay between injury and surgical decompression. Long-term costs associated with TSCI such as rehabilitation, care of secondary comorbidities, and post-injury employment prospects will be examined as well. These costs will be framed from the patient’s perspective as well as from both the hospital and insurance company’s perspectives. It is hoped a complete understanding as to what makes TSCI such a medically and financially burdensome injury will allow for improved healthcare resource utilization in this population.

Mortality and longevity after a spinal cord injury: systematic review and meta-analysis

BACKGROUND/AIMS

Mortality and longevity studies of spinal cord injury (SCI) are essential for informing healthcare systems and policies. This review evaluates the current evidence among people with SCIs worldwide in relation to the WHO region and country income level; demographic and lesion characteristics; and in comparison with the general population.

METHODS

A systematic review of relevant databases for original studies. Pooled estimates were derived using random effects meta-analysis, restricted to traumatic SCI.

RESULTS

Seventy-four studies were included. In-hospital mortality varied, with pooled estimates of 24.1% (95% confidence interval (CI) 14.1-38.0), 7.6% (95% CI 6.3-9.0), 7.0% (95% CI 1.5-27.4), and 2.1% (95% CI 0.9-5.0) in the WHO regions of Africa, the Americas, Europe and Western Pacific. The combined estimate for low- and middle-income countries was nearly three times higher than for high-income countries. Pooled estimates of first-year survival were 86.5% (95% CI 75.3-93.1), 95.6% (95% CI 81.0-99.1), and 94.0% (95% CI 93.3-94.6) in the Americas, Europe and Western Pacific. Pooled estimates of standardized mortality ratios in tetraplegics were 2.53 (2.00-3.21) and 2.07 (1.47-2.92) in paraplegics.

CONCLUSION

This study found substantial variation in mortality and longevity within the SCI population, compared to the general population, and between WHO regions and country income level. Improved standardization and quality of reporting is needed to improve inferences regarding the extent to which mortality outcomes following an SCI are related to healthcare systems, services and policies.

Association of insurance status with health outcomes following traumatic injury: statewide multicenter analysis

Introduction

Recognizing disparities in definitive care for traumatic injuries created by insurance status may help reduce the higher risk of trauma-related mortality in this population. Our objective was to understand the relationship between patients’ insurance status and trauma outcomes.

Methods

We collected data on all patients involved in traumatic injury from eight Level I and 15 Level IV trauma centers, and four non-designated hospitals through Arizona State Trauma Registry between January 1, 2008 and December 31, 2011. Of 109,497 records queried, we excluded 29,062 (26.5%) due to missing data on primary payer, sex, race, zip code of residence, injury severity score (ISS), and alcohol or drug use. Of the 80,435 cases analyzed, 13.3% were self-pay, 38.8% were Medicaid, 13% were Medicare, and 35% were private insurance. We evaluated the association between survival and insurance status (private insurance, Medicare, Medicaid, and self-pay) using multiple logistic regression analyses after adjusting for race/ethnicity (White, Black/African American, Hispanic, and American Indian/Alaska Native), age, gender, income, ISS and injury type (penetrating or blunt).

Results

The self-pay group was more likely to suffer from penetrating trauma (18.2%) than the privately insured group (6.0%), p<0.0001. There were more non-White (53%) self-pay patients compared to the private insurance group (28.3%), p<0.0001. Additionally, the self-pay group had significantly higher mortality (4.3%) as compared to private insurance (1.9%), p<0.0001.

A simple logistic regression revealed higher mortality for self-pay patients (crude OR= 2.32, 95% CI [2.07–2.67]) as well as Medicare patients (crude OR= 2.35, 95% CI [2.54–3.24]) as compared to private insurance. After adjusting for confounding, a multiple logistic regression revealed that mortality was highest for self-pay patients as compared to private insurance (adjusted OR= 2.76, 95% CI [2.30–3.32]).

Conclusion

These results demonstrate that after controlling for confounding variables, self-pay patients had a significantly higher risk of mortality following a traumatic injury as compared to any other insurance-type groups. Further research is warranted to understand this finding and possibly decrease the mortality rate in this population.

Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

OBJECTIVE

To determine the incidence of venous thromboembolism (VTE) among patients with traumatic spinal cord injury (TSCI) in acute care settings that is attributable to extended length of stay (LOS), insurance status, and access to rehabilitation.

DESIGN

Population-based, retrospective cohort study.

SETTING

Levels I through III and undesignated trauma centers.

PARTICIPANTS

Patients with acute TSCI (N=3389) discharged from all acute care hospitals in South Carolina from 1998 through 2009, and a representative sample of patients with TSCI (n=186) interviewed 1 year later.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

VTE while in acute care.

RESULTS

Annual incidence of TSCI is 67.2 per million in the state of South Carolina, while the cumulative incidence of VTE is 4.1%. Patients with TSCI who developed VTE were nearly 4 times more likely (odds ratio [OR], 3.98; 95% confidence interval [CI], 2.57-6.17) to have been those who stayed 12 days or longer in acute care after adjusting for covariates. The adjusted mean LOS in acute care was 32.0 days (95% CI, 27.7-37.2) for patients with TSCI who had indigent insurance versus 11.3 days (95% CI, 4.9-17.6) for Medicare, and 18.5 days (95% CI, 14.5-22.5) for commercial insurance after adjusting for VTE, disposition, and year of discharge. Only 20% of the persons under indigent care received rehabilitation from accredited rehabilitation facilities in contrast to 60% under commercial insurance.

CONCLUSIONS

Fewer patients with TSCI under indigent care received postacute rehabilitation compared with Medicare or commercial insurance. Insurance status remains a major barrier to timely transfer to rehabilitation, leading to protracted LOS in acute care with increased risk of VTE.

Cervical Spinal Cord Injury Associated with Near-Drowning Does Not Increase Pneumonia Risk or Mortality

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ2 and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.

The impact of co-morbidities on age-related differences in mortality after acute traumatic spinal cord injury

Despite the shift in demographics of spinal cord injury (SCI) due to an aging population, relatively little has been reported regarding the effect of age on outcomes after SCI. This study examines the potential confounding effect of co-morbidities on the age-related differences in the hospital mortality following acute traumatic SCI. All consecutive patients with SCI who were admitted to our spine center from 1996 to 2007 were included. Co-morbidities were classified using the Charlson Co-morbidity Index (CCI), Cumulative Illness Rating Scale, and the number of ICD-9 codes. Major potential confounders included age, gender, co-morbidity, and level and severity of SCI. There were 217 males and 80 females with ages from 15 to 96 years. Most patients had an incomplete cervical SCI following falls or motor vehicle accidents. The mean in-hospital mortality rate was 5.7%. Using univariate analyses, older age, relevant pre-existing medical conditions, and motor complete SCI were major risk factors for in-hospital death after acute SCI. Among the three co-morbidity assessments, the CCI was the most reliable co-morbidity index for prediction of hospital mortality in SCI patients after controlling for age in the Cox proportional hazard modeling. In addition, the CCI appears to be a major confounder, which accounts for the majority of age-related differences in mortality following SCI. Our findings have implications for future clinical trials of therapies for adult patients with acute SCI and for management strategies of elderly individuals with SCI.

Moving beyond traditional measurement of mortality after injury: evaluation of risks for late death

BACKGROUND

The purpose of this study was to evaluate long-term mortality after trauma, and to determine risk factors and possible disparities related to mortality after hospital discharge.

STUDY DESIGN

Level I trauma center registry data from a 6-year period (2000 through 2005) were linked to patient electronic medical records, the National Death Index with cause of death codes, and census data using geographic information science (GIS) methodologies. Census data provided supplemental demographic and socioeconomic information from patient neighborhoods.

RESULTS

The hospital mortality rate for 15,285 patients was 3.3%, and mortality after discharge was 4.8%. Overall mortality for the study period was 8.1% (average follow-up, 2.8 years, 1-year mortality, 5.4%). Mortality after discharge was related to the initial injury in 33%, possibly related in 23%, and unrelated in 44% of patients. Logistic regression analysis demonstrated that independent predictors of hospital mortality were age, Injury Severity Score, gunshot injury, significant head injury, fall, and spinal cord injury. In contrast, independent risk factors for mortality after discharge were age, hospital length of stay, discharge from the hospital to a locale other than home, and the presence of spinal cord injury. Intoxication at hospital admission and injury due to a gunshot wound or motor vehicle collision were protective for late mortality. Bivariate analysis of census data demonstrated that lower socioeconomic status was associated with improved hospital survival, and non-native status was associated with mortality after discharge.

CONCLUSIONS

There is significant mortality attributable to trauma for up to 1 year after hospital discharge. These findings suggest that mortality after trauma needs to be measured beyond hospital discharge in order to assess the complete impact of injury.

Insurance type is a determinant of 2-year mortality after non-neurologic trauma

BACKGROUND

Lack of health insurance (NO-INS) is associated with increased long-term mortality after head and spinal cord injuries (NEURO-TRA). Less is known about the influence of insurance type and long-term mortality following non-NEURO-TRA. We hypothesized that NO-INS would be associated with 2-y mortality after moderate to severe injury.

METHODS

Adults (>or=18) treated at a level-I trauma center following a moderate to severe blunt injury (ISS>15) and without NEURO-TRA from 2000-2005 and discharged alive were eligible for the study. Two-y mortality was determined utilizing the Social Security Administration Death Master File. Logistic regression analysis was used to determine if type of insurance [NO-INS, Private (PRIV-INS), Medicare/Medicaid; GOV-INS), or Other (OTH-INS)] was related to 2-y mortality.

RESULTS

One thousand nine hundred fifty-eight patients met study inclusion/exclusion criteria. Two-y risk of death was 2.96%. On univariate analysis, admission age, lactate, and insurance type were associated with 2-y mortality (P<0.25). However, race was not. After adjusting for admission age and lactate, compared with PRIV-INS, having either NO-INS or GOV-INS was significantly associated with increased 2-y mortality. The analysis was repeated without patients eligible for Medicare (Age>or=65), and GOV-INS was still associated with increased 2-y mortality (OR 4.47 P<0.05).

CONCLUSION

Following moderate to severe blunt, non-NEURO-TRA, having GOVT-INS or NO-INS was associated with increased 2-y mortality. The mechanism by which this association may be explained is unclear. Future research focused on elucidating mechanisms behind poor long-term outcomes should include an examination of socioeconomic status as a potential contributor to reduced long-term mortality after injury.

Traumatic spinal cord injury mortality, 1981-1998

BACKGROUND

We aim to assess the long-term trend of and identify risk factors for traumatic spinal cord injury (TSCI) mortality from 1981 through 1998 in the state of South Carolina (SC).

METHODS

We analyzed data from the TSCI surveillance system in SC. Poisson regression analyses were used to examine trends in TSCI mortality rates across subpopulations of interest. Multiple logistic regression was used to identify risk factors for TSCI mortality.

RESULTS

The rate of TSCI mortality was 27.4 per million population between 1981 and 1998. A significant 3% annual decrease in the TSCI mortality rate was found from 1981 through 1998. Specifically, TSCI mortality rates declined the most per year in motor vehicle crashes, males, and whites. Adjusted for covariates, individuals of older ages, black race, with a cervical TSCI, and with a more severe injury, as defined by both Frankel grade and Abbreviated Injury Scale, were associated with higher odds of in-hospital mortality. Females had lower odds of in-hospital mortality than males.

CONCLUSION

Although mortality rate is decreasing, TSCI remains a significant public health problem, with SC having higher rates of TSCI mortality than the United States. The association between gender and in-hospital mortality needs further exploration.