Characteristics of Non-traumatic Spinal Cord Dysfunction in Canada Using Administrative Health Data

Using Clinical Vignettes and a Modified Expert Delphi Panel to Determine Parameters for Identifying Non-Traumatic Spinal Cord Injury in Health Administrative and Electronic Medical Record Databases

OBJECTIVE

To obtain expert consensus on the parameters and etiologic conditions required to retrospectively identify cases of non-traumatic spinal cord injury (NTSCI) in health administrative and electronic medical record (EMR) databases based on the rating of clinical vignettes.

DESIGN

A modified Delphi process included 2 survey rounds and 1 remote consensus panel. The surveys required the rating of clinical vignettes, developed after chart reviews and expert consultation. Experts who participated in survey rounds were invited to participate in the Delphi Consensus Panel.

SETTING

An international collaboration using an online meeting platform.

PARTICIPANTS

Thirty-one expert physicians and/or clinical researchers in the field of spinal cord injury (SCI).

MAIN OUTCOME MEASURE(S)

Agreement on clinical vignettes as NTSCI. Parameters to classify cases of NTSCI in health administrative and EMR databases.

RESULTS

In health administrative and EMR databases, cauda equina syndromes should be considered SCI and classified as a NTSCI or TSCI based on the mechanism of injury. A traumatic event needs to be listed for injury to be considered TSCI. To be classified as NTSCI, neurologic sufficient impairments (motor, sensory, bowel, and bladder) are required, in addition to an etiology. It is possible to have both a NTSCI and a TSCI, as well as a recovered NTSCI. If information is unavailable or missing in health administrative and EMR databases, the case may be listed as "unclassifiable" depending on the purpose of the research study.

CONCLUSION

The Delphi panel provided guidelines to appropriately classify cases of NTSCI in health administrative and EMR databases.

Neurological Impairment Recovery in Surgically Treated Patients With Nontraumatic Spinal Cord Injury

The incidence of nontraumatic spinal cord injury (NTSCI) is reported to be higher than that of traumatic spinal cord injury in many countries, making it an area of growing significance.

A qualitative photo-elicitation study exploring the impact of falls and fall risk on individuals with subacute spinal cord injury

Background

Individuals living with chronic spinal cord injury or disease (SCI/D) are at an increased risk of falling. However, little is known about the impact of falls and fall risk in the subacute phase of SCI/D, despite this being a time when fall prevention initiatives are delivered. Hence, we explored the impact of falls and fall risk in individuals with subacute SCI/D as they transitioned from inpatient rehabilitation to community living.

Methods

This qualitative photo-elicitation study used an inductive thematic analysis. Eight individuals (7 male) undergoing inpatient rehabilitation at a Canadian tertiary rehabilitation hospital due to a new SCI/D participated. Six months following discharge, photo-elicitation interviewing was used to understand the impact of falls and fall risk. Over 7–14 days, participants completed a photo-assignment that involved taking photographs in response to questions, such as what increases/decreases your likelihood of falling? A semi-structured interview followed, in which participants described their photographs and discussed their experiences with falls, fall risk and fall prevention training.

Results

Four themes were identified. 1) Risk factors and strategies identified through lived experience. Participants discovered their fall risk factors and fall prevention strategies through “trial and error”. 2) Influences on the individual’s perception of their fall risk. Prior experience with falls, including falls experienced by themselves as well as friends and family, influenced their perception of fall risk. 3) Experiencing life differently due to increased fall risk. A high fall risk reduced participation, increased negative emotions and decreased independence and quality of life. 4) Falls training in rehabilitation can be improved. Prior experiences with falls training varied; however, participants expressed a desire for comprehensive and individualized training.

Conclusion

Although participants’ experiences with falls and fall prevention varied, falls and the risk of falling can have a significant impact on the first year of living with a SCI/D.

Epidemiology of non-traumatic spinal cord injury in Ireland - a prospective population-based study

Objective: To carry out a study of non-traumatic spinal cord injury (NTSCI) epidemiology in IrelandDesign: Prospective study of all new incident cases of NTSCI during 2017Setting: Republic of IrelandParticipants: All persons with a newly acquired NTSCIInterventions: NoneOutcome measures: Crude and age/sex specific incidences; ISCoS core dataset and non-traumatic dataset; population denominator was 2016 national census figures, adjusted to 2017.Results: Overall crude incidence of NTSCI in the Republic of Ireland in 2017 was 26.9 per million per year. Mean age at onset was 56.6 (SD 17.7) years. Females accounted for 51.2% of cases. Most frequent grade of ASIA impairment scale (AIS) was AIS D. Most common etiology was degenerate conditions (48.8%) followed by neoplastic (26.4%). The most common pattern of onset (51.2%) was lengthy (greater than one month).Conclusions: Incidence of NTSCI is more than double that for traumatic SCI in the Republic of Ireland. This suggests that the delivery of rehabilitation services to patients with spinal cord injuries requires prompt review and expansion.

Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute

CONTEXT

Insufficient recruitment is a barrier to research and limits statistical power. We describe an initiative aimed to streamline recruitment and consent processes for inpatients with spinal cord injury or disease (SCI/D) via implementation of a Central Recruitment (CR) process. The CR process adhered to ethical standards, reduced participant burden, and maximized research participation.

METHODS

In this CR process, the inpatient's nurse affirmed suitability for research approach based on fluency, cognition and health stability. A patient research liaison (PRL) was the sole contact for information regarding the research process, and introduced ongoing studies, screened for eligibility, and completed the consent process(es).

RESULTS

Over five and a half years, 1,561 inpatients with SCI/D were screened for eligibility upon admission, of whom 80% (1256/1561) were deemed suitable for the PRL approach. Of those suitable for the CR process, 80% (1001/1256) agreed to discuss current research opportunities, 46% (235/516) consented to participate in one or more studies, and 86% (856/1001) agreed to future research contact.

CONCLUSION

This process adhered to ethical procedures and reduced the burden of having multiple researchers approach each individual inpatient regarding research participation, with high consent rates for low-risk studies. Future evaluation of the process scalability is underway.

Impaired Function and Altered Morphology in the Skeletal Muscles of Adult Men and Women With Type 1 Diabetes

CONTEXT

Previous investigations on skeletal muscle health in type 1 diabetes (T1D) have generally focused on later stages of disease progression where comorbidities are present and are posited as a primary mechanism of muscle dysfunction.

OBJECTIVE

To investigate skeletal muscle function and morphology across the adult lifespan in those with and without T1D.

DESIGN

Participants underwent maximal contraction (MVC) testing, resting muscle biopsy, and venous blood sampling.

SETTING

Procedures in this study were undertaken at the McMaster University Medical Centre.

PARTICIPANTS

Sixty-five healthy adult (18-78 years old) men/males and women/females (T1D = 34; control = 31) matched for age/biological sex/body mass index; self-reported physical activity levels were included.

MAIN OUTCOME MEASURES

Our primary measure in this study was MVC, with supporting histological/immunofluorescent measures.

RESULTS

After 35 years of age ("older adults"), MVC declined quicker in T1D subjects compared to controls. Loss of strength in T1D was accompanied by morphological changes associated with accelerated aging. Type 1 myofiber grouping was higher in T1D, and the groups were larger and more numerous than in controls. Older T1D females exhibited more myofibers expressing multiple myosin heavy chain isoforms (hybrid fibers) than controls, another feature of accelerated aging. Conversely, T1D males exhibited a shift toward type 2 fibers, with less evidence of myofiber grouping or hybrid fibers.

CONCLUSIONS

These data suggest impairments to skeletal muscle function and morphology exist in T1D. The decline in strength with T1D is accelerated after 35 years of age and may be responsible for the earlier onset of frailty, which characterizes those with diabetes.

Prevalence of prescribed opioid claims among persons with nontraumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study

STUDY DESIGN

Cohort study.

OBJECTIVE

To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation.

SETTING

Ontario, Canada.

METHODS

We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals.

RESULTS

We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p < 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge.

CONCLUSION

Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Incidence of Acquired Nontraumatic Spinal Cord Injury in Finland: A 4-Year Prospective Multicenter Study

OBJECTIVES

To evaluate the incidence and epidemiologic characteristics of acquired nontraumatic spinal cord injury (NTSCI) in Finland.

DESIGN

Prospective 4-year epidemiologic multicenter study.

SETTING

Two of the 3 spinal cord injury (SCI) centers in Finland responsible for acute care, immediate rehabilitation, and lifelong follow-up for all SCI patients in a population of 3,073,052 (as of 2013).

PARTICIPANTS

All newly diagnosed NTSCI patients (N=430) admitted to Tampere University Hospital between 2012 and 2015 and Oulu University Hospital between 2013 and 2016 based on the evaluation of the designated rehabilitation teams. Patients with NTSCI resulting from congenital etiologies or progressive neurologic diseases were excluded.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence and variables, according to the International SCI Core Data Set and the International Standards for Neurological Classification of SCI, including etiology and the severity of injury.

RESULTS

The incidence of NTSCI was 54.1 per million per year. NTSCI was more common in men (n=260, 60.5%) than women (n=170, 39.5%). The mean age was 62.0±14.6 years old. Degenerative causes were the most common etiology (n=219, 50.9%), followed by malignant (n=88, 20.5%) and benign (n=41, 9.5%) neoplasms. The injury resulted in tetraplegia in 177 patients (41.1%) and paraplegia in 249 patients (57.9%). American Spinal Injury Association Impairment Scale grade D injuries were common, with an incidence of 71% (n=304). Specialized inpatient rehabilitation was needed in 44% (n=189) of the cases.

CONCLUSIONS

There are no previous studies on the epidemiology of NTSCI in Finland, and international reporting has been limited. The incidence of NTSCI in our study was substantially higher than in most previous studies, which was likely owing to our study including individuals with less severe lesions who did not require inpatient rehabilitation.

Describing the current state of post-rehabilitation health system surveillance in Ontario - an invited review

Context: Spinal cord injury (SCI) presents numerous physiological, psychosocial, and environmental complexities resulting in significant healthcare system resource demands. Objective: To describe the current health system surveillance mechanisms in Ontario, Canada and highlight gaps in health surveillance among adults with SCI across their lifespan. Methods: A review of administrative data sources capturing SCI-specific information took place via internet searching and networking among SCI rehabilitation and health services experts with emphasis on functionality, health service utilization, and quality of life data. Results: The review identified a distinct paucity of data elements specific to the health surveillance needs of individuals with SCI living in the community. The gaps identified are: (1) a lack of data usability; (2) inadequate linkage between available datasets; (3) inadequate/infrequent reporting of outcomes; (4) a lack of relevant content/patient-reported outcomes; and, (5) failure to incorporate additional data sources (e.g. Insurance datasets). Conclusion: Currently, SCI-specific health data is disproportionately weighted towards the first 3-6 months post injury with detailed data regarding pre-hospital care, acute management and rehabilitation, but little existing infrastructure supporting community-based health surveillance. Given this reality, the bolstering of meaningful community health surveillance of this population across the lifespan is needed. Addressing the identified gaps in health surveillance must inform the creation of a comprehensive community health dataset incorporating patient-reported outcome measures and enabling linkage with existing administrative and/or clinical databases. A future harmonized data surveillance strategy would, in turn, positively impact function, health services, resource utilization and health-related quality of life surveillance.

Methods for development of structure, process and outcome indicators for prioritized spinal cord injury rehabilitation Domains: SCI-High Project

Background: High-quality rehabilitation care following spinal cord injury or disease (SCI/D) is critical for optimizing neurorecovery and long-term health outcomes. This manuscript describes the methods used for developing, refining, and implementing a framework of structure, process, and outcome indicators that reflect high-quality rehabilitation among adults with SCI/D in Canada. Methods: This quality improvement initiative was comprised of the following processes: (1) prioritization of care Domains by key stakeholders (scientists, clinicians, therapists, patients and stakeholder organizations); (2) assembly of 11 Domain-specific Working Groups including 69 content experts; (3) conduct of literature searches, guideline and best practice reviews, and outcome synthesis by the Project Team; (4) refinement of Domain aim and construct definitions; (5) conduct of cause and effect analysis using Driver diagrams; (6) selection and development of structure, process and outcome indicators; (7) piloting and feasibility analysis of indicators and associated evaluation tools; and, (8) dissemination of the proposed indicators. Result: The Project Team established aims, constructs and related structure, process, and outcome indicators to facilitate uniform measurement and benchmarking across 11 Domains of rehabilitation, at admission and for 18 months thereafter, among adult Canadians by 2020. Conclusion: These processes led to the selection of a feasible set of indicators that once implemented should ensure that adults with SCI/D receive timely, safe, and effective rehabilitation services. These indicators can be used to assess health system performance, monitor the quality of care within and across rehabilitation settings, and evaluate the rehabilitation outcomes of the population to ultimately enhance healthcare quality and equity.

Validation of Algorithm to Identify Persons with Non-traumatic Spinal Cord Dysfunction in Canada Using Administrative Health Data

Background: Administrative health data, such as the hospital Discharge Abstract Database (DAD), can potentially be used to identify patients with non-traumatic spinal cord dysfunction (NTSCD). Algorithms utilizing administrative health data for this purpose should be validated before clinical use. Objective: To validate an algorithm designed to identify patients with NTSCD through DAD. Method: DAD between 2006 and 2016 for Southern Alberta in Canada were obtained through Alberta Health Services. Cases of NTSCD were identified using the algorithm designed by the research team. These were then validated by chart review using electronic medical records where possible and paper records where electronic records were unavailable. Measures of diagnostic accuracy including sensitivity, specificity, and positive and negative predictive values and 95% confidence intervals (CI) were computed. Results: Two hundred and eighty cases were identified to have both the administrative codes for neurological impairments and NTSCD etiology. Twenty-eight cases were excluded from analysis as 5 had inadequate medical record information, 17 had traumatic spinal cord injury, and 6 were considered "other" non-spinal cord conditions. Measures of diagnostic accuracy that were computed were sensitivity 97% (95% CI, 94%-98%), specificity 60% (95% CI, 47%-73%), positive predictive value (PPV) 92% (95% CI, 88%-95%), and negative predictive value (NPV) 80% (95% CI, 65%-90%). The most prevalent etiologies were degenerative (36.9%), infection (19.0%), oncology malignant (15.1%), and vascular (10.3%). Conclusion: Our algorithm has high sensitivity and PPV and satisfactory specificity and NPV for the identification of persons with NTSCD using DAD, though the limitations for using this method should be recognized.

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.