Emergency room visits and hospitalizations among participants with spinal cord injury

Differences in personal characteristics and health outcomes between ambulatory and non-ambulatory adults with traumatic spinal cord injury

OBJECTIVE

To identify differences in personal characteristics, health outcomes, and hospital utilization as a function of ambulatory status among adults with chronic SCI.

DESIGN

Prospective cohort study linked to state administrative billing data.

SETTING

Population-based SCI Registry from the Southeastern United States.

PARTICIPANTS

1,051 adults (>18 years old) with chronic (>1-year), traumatic SCI.

OUTCOME MEASURES

The self-report assessment (SRA) included demographic, injury and disability characteristics, health status, psychological and behavioral factors, and participation and quality of life (QOL) variables. We linked cases to administrative billing data to assess hospital utilization, including Emergency Department (ED) visits and inpatient (IP) admissions (through the ED and direct IP) in non-federal state hospitals within the year following the SRA.

RESULTS

There were 706 ambulatory and 345 non-ambulatory participants. We found significant differences across all sets of factors and significant differences in hospital utilization metrics. Ambulatory adults had fewer ED visits (36% vs 44%), IP admissions through the ED (11% vs 25%) and IP only admissions (9% vs 19%) and spent fewer days in the hospital for both admissions through the ED (0.9 vs 4.6 days) and IP only admissions (0.7 vs 3.1 days). They also reported having fewer past year ED visits (44% vs 62%) and IP admissions (34% vs 52%).

CONCLUSIONS

We identified differences in personal characteristics, ED visits and IP admissions between ambulatory and non-ambulatory adults with SCI, providing a better understanding of the characteristics of those with SCI. The findings suggest the need for separate analyses based on ambulatory status when assessing long-term health outcomes including hospital utilization.

International spinal cord injury socio-demographic basic data set (version 1.0)

STUDY DESIGN

Consensus based on the literature.

OBJECTIVE

Create an International Spinal Cord Injury (SCI) Socio-Demographic Basic Data Set (Version 1.0).

SETTING

International.

METHODS

The development included an iterative process where the authors reviewed existing variables containing socio-demographic variables and created a first dataset draft, which was followed by several revisions through email communications. In addition, the work was conducted in parallel with a similar endeavour within the National Institute of Neurological Disorders and Stroke SCI Common Data Elements project in the United States. Subsequently, harmonization between the two projects was sought. Following this, a review process was initiated, including The International SCI Data Sets Committee, the American Spinal Injury Association (ASIA) Board, and the International Spinal Cord Society (ISCoS) Scientific and Executive Committees, and then by publishing on the respective websites for membership feedback. The draft was sent to about 40 national and international organizations and several interested individuals for feedback. All review comments were discussed in the working group and responded to before the final draft was developed, and finally approved by ASIA Board and the ISCoS Scientific and Executive committees.

RESULTS

The final International SCI Socio-Demographic Basic Data Set includes the following variables: Date of data collection, Marital status, Household member count, Years of formal education, and Primary occupation.

CONCLUSION

The International SCI Socio-Demographic Basic Data Set will facilitate uniform data collection and reporting of socio-demographic information at the time of injury as well as at post-injury follow-ups to facilitate the evaluation and comparisons across studies.

The Relationship of Secondary and Chronic Health Conditions With Emergency Department Visits and Related Hospitalizations Among People With Traumatic Spinal Cord Injury

OBJECTIVE

Identify the relationship of health conditions with self-reported emergency department (ED) visits and ED-related hospitalizations among people with traumatic spinal cord injury (SCI), while controlling for demographic, injury, and socioeconomic factors.

DESIGN

Cross-sectional.

SETTING

A regional SCI model system in the Southeastern United States.

PARTICIPANTS

Participants (N=648) were adults with chronic traumatic SCI at least 1 year postinjury who were identified through their Form II annual follow-up within the SCI Model Systems.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Self-reported ED visits and ED-related hospitalizations within the 12 months prior to the study.

RESULTS

Several types of factors were significantly related to ED visits, with fewer related to ED hospitalizations. Men (odds ratio [OR]=1.58); those divorced, widowed, or separated (OR=1.57); and those with more severe SCI (C1-C4, or American Spinal Injury Association Impairment Scale A/B) had greater odds of having at least 1 ED visit; education and employment factors were not significant. Of health conditions, acute secondary health conditions including falls (OR=1.45), urinary tract infections (UTIs; OR=2.40), and pressure injuries (OR=1.58) were all associated with a greater odds of ED visits, whereas chronic health conditions were not. Being unemployed was associated with greater odds of an ED hospitalization (OR=1.79), as was having at least 1 UTI (OR=2.24) and at least 1 pressure injury (OR=2.37).

CONCLUSIONS

The current findings suggest acute secondary health conditions, particularly UTIs and pressure injuries, were much more highly related to ED visits and related hospitalizations compared to chronic health conditions (eg, diabetes, hypertension). Greater attention needs to be paid to fall, UTI, and pressure injury prevention to reduce the ED burden related to SCI.

The relationship between health behaviors and emergency department visits and hospitalizations after traumatic spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To identify demographic, injury, and behavioral predictors of emergency department (ED) visits and ED-related hospitalizations among individuals with chronic traumatic spinal cord injury (SCI).

SETTING

An academic medical center in the Southeastern United States.

METHODS

4057 participants who were at least 18 years of age and 1 year post traumatic SCI with residual neurologic impairment were identified from three cohorts: a rehabilitation specialty hospital in the Southeastern USA and two SCI Surveillance System Registries, one in the Midwestern and one in the Southeastern USA. The participants completed a self-reported assessment on ED visits and ED hospitalizations (yes/no) in the past 12 months. Logistic regression models were used to examine the relationship between ED visits/hospitalizations and eight behavioral indicators, including body weight, healthy diet, drinking, smoking, non-medical substance usage, prescription medication usage, prescription medication misuse, and the planned exercise.

RESULTS

During the study period, 41% of participants reported having at least one ED visit and 21% participants reported hospitalization after ED visit in the past 12 months. High frequency of prescription medication usage, prescription medication misuse, and lack of planned exercise were associated with greater odds of at least one ED visit and at least one ED-related hospitalization, while smoking was only associated with ED visits.

CONCLUSIONS

Health care professionals should be aware that ED visit and related hospitalization prevalence remain high among people with chronic SCI, and there is significant need for intervention of managing risk behaviors and promoting healthy behaviors after SCI.

Emergency Department Visits, Related Hospitalizations, and Reasons for Emergency Department Utilization After Traumatic Spinal Cord Injury

OBJECTIVE

To identify the self-reported frequency of emergency department (ED) visits, ED-related hospitalizations, and reasons for ED visits among people with traumatic spinal cord injury (SCI) and compare them with general population data from the same geographic area.

DESIGN

Cross-sectional.

SETTING

A specialty hospital in the Southeastern United States.

PARTICIPANTS

The participants (N=648) were community-dwelling adults (18 years and older) with a traumatic SCI, who were at least 1 year postinjury. A comparison group of 9728 individuals from the general population was retrieved from the 2017 National Health Interview Survey (NHIS).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed self-report assessments on ED visits, ED hospitalizations, and reasons for ED visits in the past 12 months using items from the NHIS.

RESULTS

A total of 37% of participants with SCI reported at least 1 ED visit, and 18% reported at least 1 ED hospitalization in the past 12 months. Among those having at least 1 ED visit, 49% were admitted to hospitals. After controlling for sex, age, and race/ethnicity, participants with SCI were 151% more likely to visit the ED (odds ratio [OR], 2.51) and 249% more likely to have at least 1 ED hospitalization than the NHIS sample (OR, 3.49). Persons with SCI had a higher percentage of ED visits because of severe health conditions, reported an ED was the closest provider, and were more likely to arrive by ambulance. NHIS participants were more likely to visit the ED because no other option was available.

CONCLUSIONS

Compared with those in the general population, individuals with SCI have substantially higher rates of ED visits, yet ED visits are not regularly assessed within the SCI Model Systems. ED visits may indicate the need for intervention beyond the acute condition leading directly to the ED visits and an opportunity to link individuals with resources needed to maintain function in the community.

The association between participation and quality of life indicators with hospitalizations in ambulatory adults with spinal cord injury

STUDY DESIGN

Statistical modeling of self-report assessments (SRA) as predictors of future hospitalizations, measured by administrative billing data.

OBJECTIVES

To examine the relationships between self-reported participation and quality of life (QOL) indicators and future hospital admissions among ambulatory adults with chronic spinal cord injury (SCI).

SETTING

Data were collected from participants living in and utilizing hospitals in the state of South Carolina.

METHODS

Participants were identified through the South Carolina SCI Surveillance System Registry. Between 2011 and 2015, 615 ambulatory adults (>18 years old) with chronic (>1-year), traumatic SCI completed mailed SRA. Participant socio-demographic, injury, health, participation, and QOL indicators were assessed using self-report data. Administrative billing data were used to measure hospital utilization in nonfederal, South Carolina hospitals in the year following the SRA.

RESULTS

Prior year discharges, current pressure ulcers, number of chronic conditions, walking 150 feet more often (never, less than once per week, at least once per week, once or twice per day, or several times per day), and greater home life satisfaction were associated with an increased risk of subsequent hospitalization. Walking 10 feet more frequently and greater global satisfaction were associated with a decreased risk of hospital admission.

CONCLUSIONS

Specific participation and QOL items may increase the risk of hospitalization in ambulatory adults with SCI. Further study is necessary to understand better the relationships between walking distance and frequency, home life and global satisfaction, and inpatient admissions.

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.

Outcomes in socioeconomically disadvantaged patients with spinal cord injury: a systematic review

OBJECTIVEIndividuals with a spinal cord injury (SCI) in socioeconomically disadvantaged settings (e.g., rural or low income) have different outcomes than their counterparts; however, a contemporary literature review identifying and measuring these outcomes has not been published. Here, the authors' aim was to perform a systematic review and identify these parameters in the hope of providing tangible targets for future clinical research efforts.METHODSA systematic review was performed to find English-language articles published from 2007 to 2017 in the PubMed/MEDLINE, EMBASE, and SCOPUS databases. Studies evaluating any outcomes related to patients with an SCI and in a low-resource setting were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a flowchart was created. Of the 403 articles found, 31 underwent complete review and 26 were eligible for study inclusion. According to the current study criteria, any case studies, studies in less developed countries, studies including and not separating other types of neurological disorders, studies not assessing the effects of a low-resource setting on outcomes in patients with SCI, and studies evaluating the causes of SCI in a low-resource setting were excluded.RESULTSIn SCI patients, a lower income was a predictor of death (OR 2.1, 95% CI 1.7-2.6, p = 0.0002). Moreover, secondary outcomes such as pain intensities (OR 3.32, 95% CI 2.21-4.49, p < 0.001), emergency room visits (11% more likely, p = 0.006), and pressure ulcer formation (OR 2.1, 95% CI 1.5-3.0, p < 0.001) were significantly higher in the lower income brackets. Rurality was also a factor and was significantly associated with increased emergency room visits (OR 1.5, 95% CI 1.1-2.1, p = 0.01) and lower outpatient service utilization (incidence rate ratio [IRR] 0.57, 95% CI 0.35-0.93, p < 0.05).CONCLUSIONSThe authors showed that individuals in a low-resource setting who have suffered an SCI have significantly different outcomes than their counterparts. These specific outcomes are promising targets for future research efforts that focus on improving health conditions among this population.

Wheelchair use in ultra-lightweight wheelchair users

PURPOSE

The goal of this study was to describe how ultra-lightweight wheelchair users use their wheelchairs during everyday mobility.

METHOD

We instrumented a convenience sample of 69 ultra-lightweight wheelchair users with a seat switch to measure their occupancy, and an accelerometer on their wheel to measure distance wheeled, time spent wheeling and daily bouts of mobility.

RESULTS

On the median day, subjects wheeled 83 bouts and 1.4 km over 45 min. A typical bout of mobility was 8.3 m in length, lasting 20 s and occurring at a speed of 0.44 m/s. Fast (>1 m/s) and long (>2 min) bouts represented less than 4% of bouts and were more common among younger participants and those who were employed or a student.

CONCLUSIONS

Highly functional manual wheelchair users present with a significant mobility disability, moving far less than their ambulating peers despite moving with similar mobility characteristics. The typical bout characteristics - short and slow bouts - are consistent with indoor mobility and transitions between functional activities. For wheelchair users, it highlights the importance of manoeuverability and the need for prescription and training to emphasize manoeuverability. Implications for Rehabilitation Measurement of wheelchair use, both how and how much, might provide unique insight to what equipment would be most appropriate for an individual. Participants who used an ultralight wheelchair presented with a significant mobility disability, wheeling only 1.7 km/day on average. Fast (>1 m/s) and long (>2 min) bouts are uncommon, representing less than 4% of bouts. Younger participants and those who were employed or a student were more likely to wheel one fast and long bout per day. Because wheelchair mobility was dominated by short, slow bouts, prescription and training need to emphasize maneuverability.