Understanding patient experiences and challenges to osteoporosis care delivered virtually by telemedicine: a mixed methods study.

This study sought to understand patient experiences, benefits, and challenges to osteoporosis care delivered virtually by telemedicine. Telemedicine bridges the access gap to specialized osteoporosis care in remote areas. Improving coordination of investigations, access to allied health members, and future initiatives may improve osteoporosis-related morbidity and mortality in this population. INTRODUCTION: There is limited research on the role of telemedicine (TM) in the management of osteoporosis (OP). We previously reported that OP patients assessed by TM had a higher prevalence of fragility fractures, co-morbidities, and need for allied health resources than those serviced by the outpatient clinic. The purpose of this study is to understand the experiences, benefits, and challenges associated with receiving OP care by TM from the patient perspective. METHODS: We adopted a convergent, mixed methods study design whereby both a quantitative component (mailed survey) and qualitative component (30-min telephone interviews) were conducted simultaneously. In addition to reporting survey data, thematic analysis was applied to interview data. RESULTS: Participants were comfortable with virtual technology and perceived that their quality of care by TM was comparable to in-person visits. Expressed benefits included the convenience of timely care close to home, reduced burden of travel and costs, and enhanced sense of confidence with being assessed by an osteoporosis specialist. Perceived barriers included poor follow-up with allied health professionals in the TM program (e.g., physiotherapist) and coordination of tests and investigations. Many participants indicated interest in an OP self-management program, with content focusing on diet and lifestyle factors. CONCLUSION: The TM program bridges the access gap for those living with OP in underserviced and remote areas. However, we identified the need to improve the existing processes to better coordinate access to allied health team members and arrangements for investigations. Participants also expressed interest for a virtual osteoporosis self-management program.

Factors influencing fall prevention for patients with spinal cord injury from the perspectives of administrators in Canadian rehabilitation hospitals.

BACKGROUND: Fall prevention is a priority in Canadian tertiary rehabilitation hospitals. We aimed to understand the perspectives of hospital administrators on the challenges experienced when implementing fall prevention policies/procedures for patients with spinal cord injury (SCI) in tertiary rehabilitation hospitals. METHODS: Semi-structured interviews were conducted with 10 administrators employed in six Canadian tertiary rehabilitation hospitals. Guided by an interpretive description framework, interviews were analyzed using a constant comparison approach. RESULTS: Challenges with fall prevention experienced by administrators fell into the three categories: 1) fall prevention policy and procedural challenges (e.g. fall prevention policy not SCI-specific, expectation of zero falls, determining contributing factors, learning from falls, and overall effectiveness of the fall prevention policy), 2) clinician-related challenges (e.g. variable staff adherence with the organizations' fall prevention procedures, inconsistent delivery of fall prevention education, and integrating individualized fall risks to guide clinical practice), and 3) patient-related challenges (e.g. balancing risk vs independence and rehabilitation progress, responsibility for fall prevention, and non-preventable falls). CONCLUSIONS: Fall prevention policies/procedures required by the hospitals were insufficient for clinical practice in SCI rehabilitation.

The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27 607 patients.

AIMS: The aims of this study were to establish the incidence of acute Achilles tendon rupture (AATR) in a North American population, to select demographic subgroups and to examine trends in the management of this injury in the province of Ontario, Canada. PATIENTS AND METHODS: Patients ≥ 18 years of age who presented with an AATR to an emergency department in Ontario, Canada between 1 January 2003 and 31 December 2013 were identified using administrative databases. The overall and annual incidence density rate (IDR) of AATR were calculated for all demographic subgroups. The annual rate of surgical repair was also calculated and compared between demographic subgroups. RESULTS: A total of 27 607 patients (median age, 44 years; interquartile range 26 to 62; 66.5% male) sustained an AATR. The annual IDR increased from 18.0 to 29.3 per 100 000 person-years between 2003 and 2013. The mean IDR was highest among men between the ages of 40 and 49 years (46.0/100 000 person-years). The annual rate of surgical repair dropped from 20.1 in 2003 to 9.2 per 100 AATRs in 2013. There was a noticeable decline after 2009. CONCLUSION: The incidence of AATR is increasing in Ontario, while the annual rate of surgical repair is decreasing. A sharp decline in the rate of surgical repair was noted after 2009. This coincided with the publication of several high-quality RCTs which showed similar outcomes for the 'functional' non-operative management and surgical repair. Cite this article: Bone Joint J 2017;99-B:78-86.

Low-trauma fractures and bone mineral density testing in adults with and without intellectual and developmental disabilities: a population study.

Individuals with intellectual and developmental disabilities (IDD) are at risk for low-trauma fractures. We investigated the rate of low-trauma fractures and the odds of BMD testing in adults with/without IDD. Adults with IDD were more likely to have a low-trauma fracture, but there was no difference in bone mineral density (BMD) testing rates. INTRODUCTION: Individuals with IDD are at increased risk for developing osteoporosis which contributes to high rates of low-trauma fracture. Low-trauma fractures can lead to significant pain and further decrease mobility. It is therefore important to effectively manage osteoporosis, for example, by monitoring BMD in persons with IDD. The objective of this study was to examine the rates of low-trauma fracture and BMD testing among a population-based cohort of people with IDD and compare them to those without IDD. METHODS: Using administrative data, we created a cohort of adults with IDD between the ages of 40 and 64. They were compared to a random 20 % sample of those without IDD. The number of low-trauma fractures and BMD tests in each group were determined for Ontario residents between April 1, 2009 and March 31, 2010. RESULTS: Adults with IDD were approximately three times more likely to experience a low-trauma fracture than adults without IDD. The largest disparity in prevalence of low-trauma fractures between those with and without IDD was for men, older adults (60-64 years old) and those living in rural or lower-income neighbourhoods. Post low-trauma fracture, there was no significant difference in the likelihood of receiving a BMD test between individuals with and without IDD. CONCLUSIONS: The findings of this study have a number of important implications related to early detection, prevention and proper management of osteoporosis and low-trauma fractures among persons with IDD.

Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee.

OBJECTIVE: The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA. DESIGN: PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence. RESULTS: 212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66). CONCLUSIONS: Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI). SETTING: Community-dwelling individuals with traumatic SCI living across Canada. METHODS: Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS). RESULTS: Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively). CONCLUSION: Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

Vitamin D supplementation in a healthy, middle-aged population: actual practices based on data from a French comprehensive regional health-care database.

BACKGROUND/OBJECTIVES: The debate surrounding recommendations for vitamin D supplementation in middle-aged patients (that is, 20-60 years of age) with low serum concentrations of 25-hydroxyvitamin D (25(OH)D) is growing. Our aim was to describe practices regarding vitamin D supplementation in this age group, which are basically unknown. SUBJECTS/METHODS: We performed an analysis using exhaustive reimbursement data from the individuals in Rhône-Alpes area, a French region regrouping more than 6 million of inhabitants. The data were collected from the French Insurance Health-care System. Patients who were 20-60 years of age, had no severe comorbidities, had a 25(OH)D assay between 1 December 2008 and 31 January 2009 were identified. Those who received a subsequent prescription for vitamin D were included in this analysis. We described patterns of vitamin D supplementation by frequency and daily dose. RESULTS: The sample in this study included 1311 patients. The mean age was 47.7 years (s.d.: 9.5) and the median age was 50.2 years. Most of the participants (that is, 85.9%) were women. A total of 372 distinct prescription patterns for vitamin D supplementation were observed. The two most frequent (that is, 32.6% in total) involved a unique dispensation of a high dose of either 200,000 (17.5%) or 100,000 IU (15.1%). Most prescribed supplements were based on vitamin D3 (65%), and the most prescribed forms were high dose ampoules (81.6%). Only 48.9% of the participants were given a maintenance prescription after the initial loading phase. CONCLUSIONS: Our results reveal a significant variability in the prescriptions for vitamin D supplementation from physicians in the French population. Moreover, less than half of the patients receive maintenance therapy after the initial loading phase of supplementation.

Clinical assessment of reactive postural control among physiotherapists in Ontario, Canada.

Reactive postural control, the ability to recover from an external perturbation to stability, ultimately determines whether an individual will fall following a loss of balance and should be routinely incorporated in balance assessment. The purpose of this study was to identify (1) methods used to assess reactive postural control in clinical practice and (2) factors associated with regular assessment of reactive postural control. A cross-sectional survey was conducted. Three hundred and fifty-seven physiotherapists in Ontario, Canada who treated adults with balance impairments answered questions about the components of balance they assess and how they assess reactive control in their practice. Of the 273 respondents who assessed reactive postural control at least some of the time, 15.4% used a standardized measure, 79.1% used a non-standardized approach, and 5.5% used both. Forty-five methods of assessing reactive control were reported. The most common methods used were non-standardized perturbations (43.5%; 104/239 respondents) and movement observation (18.8%; 45/239). The remaining 43 methods were each used by less than 8% of respondents. Practice area had the strongest association with regular assessment of reactive postural control (>60% of the time), and respondents working with neurological disorders were more likely to regularly evaluate reactive control than those working with people with orthopedic conditions. Despite the availability of valid standardized measures to evaluate reactive postural control, respondents relied primarily on non-standardized approaches and observational assessment. Future work should examine the factors influencing choice of reactive control assessment tools and awareness of standardized measures for reactive postural control.

Direct costs of adult traumatic spinal cord injury in Ontario.

STUDY DESIGN: Retrospective economic analysis. OBJECTIVES: To determine the total direct costs of publicly funded health care utilization for the three fiscal years 2003/04 to 2005/06 (1 April 2003 to 31 March 2004 to 1 April 2005 to 31 March 2006), from the time of initial hospitalization to 1 year after initial acute discharge among individuals with traumatic spinal cord injury (SCI). SETTING: Ontario, Canada. METHODS: Health system costs were calculated for 559 individuals with traumatic SCI (C1-T12 AIS A-D) for acute inpatient, emergency department, inpatient rehabilitation (that is, short-stay inpatient rehabilitation), complex continuing care (CCC) (i.e., long-stay inpatient rehabilitation), home care services, and physician visits in the year after index hospitalization. All care costs were calculated from the government payer's perspective, the Ontario Ministry of Health and Long-Term Care. RESULTS: Total direct costs of health care utilization in this traumatic SCI population (including the acute care costs of the index event and inpatient readmission in the following year after the index discharge) were substantial: $102 900 per person in 2003/04, $100 476 in 2004/05 and $123 674 in 2005/06 Canadian Dollars (2005 CDN $). The largest cost driver to the health care system was inpatient rehabilitation care. From 2003/04 to 2005/06, the average per person cost of rehabilitation was approximately three times the average per person costs of inpatient acute care. CONCLUSION: The high costs and long length of stay in inpatient rehabilitation are important system cost drivers, emphasizing the need to evaluate treatment efficacy and subsequent health outcomes in the inpatient rehabilitation setting.

Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury?

STUDY DESIGN: Retrospective cohort with linkage of administrative data sets. OBJECTIVES: To describe the patterns (for example, number of visits by year post-injury) and characteristics of the emergency department (ED) visits (for example, acuity level, timing of visits, reasons for visits) made by persons with traumatic spinal cord injury (TSCI) over a 6-year period following injury. SETTINGS: Ontario, Canada. METHODS: Rates of ED utilization and reasons for ED visits were calculated between the fiscal years 2003-2009. Reasons for visits were categorized by acuity level: potentially preventable visits were defined as visits related to ambulatory sensitive conditions; low acuity and high acuity visits were defined by the Canadian Triage and Acuity Scale. RESULTS: The total number of ED visits for the 6-year period is 4403 (n=1217). Of these visits, 752 (17%) were classified as potentially preventable, 1443 (33%) as low acuity and 2208 (50%) as high acuity. The majority of patients, regardless of acuity level, did not see a primary care practitioner on the day of the ED visit and most visits occurred during the weekday (Mon-Fri 0700-1659 hours). ED use was highest in the first year but remained high over the subsequent years. For potentially preventable visits, the majority of visits were related to urinary tract infections (n=385 visits, 51.2%), followed by pneumonia (n=91, 12.1%). CONCLUSION: Given the high rates of ED use for low acuity and potentially preventable conditions, these results suggest that the ED is being used as an inappropriate substitute for primary care for individuals with TSCI 50% of the time.

Quality of fracture risk assessment in post-fracture care in Ontario, Canada.

UNLABELLED: As fracture risk assessment is a basis for treatment decisions, accurate risk assessments on bone mineral density (BMD) reports are important. Over 50 % of sampled BMD reports for Ontarians with fracture histories underestimated fracture risk by a single category. Risk assessments in Ontario may not accurately inform treatment recommendations. INTRODUCTION: The shifting emphasis on fracture risk assessment as a basis for treatment recommendations highlights the importance of ensuring that accurate fracture risk assessments are present on reading specialists' BMD reports. This study seeks to determine the accuracy of fracture risk assessments on a sample of BMD reports from 2008 for individuals with a history of fracture and produced by a broad cross section of Ontario's imaging laboratories. METHODS: Forty-eight BMD reports for individuals with documented history of fragility fracture were collected as part of a cluster randomized trial. To compute fracture risk, risk factors, and BMD T-scores from reports were abstracted using a standardized template and compared to the assessments on the reports. Cohen's kappa was used to score agreement between the research team and the reading specialists. RESULTS: The weighted kappa was 0.21, indicating agreement to be at the margin of "poor to fair." More than 50 % of the time, reported fracture risks did not reflect fracture history and were therefore underestimated by a single category. Over 30 % of the reports containing a "low" fracture risk assessment were assessed as "moderate" fracture risk by the research team, given fracture history. Over 20 % of the reports with a "moderate" fracture risk were assessed as "high" by the research team, given fracture history. CONCLUSIONS: This study highlights the high prevalence of fracture risk assessments that are underestimated. This has implications in terms of fracture risk categorization that can negatively affect subsequent follow-up care and treatment recommendations.

MENOPOST--calcium and vitamin D supplementation in postmenopausal osteoporosis treatment: a descriptive cohort study.

SUMMARY: Adequate vitamin D/calcium supplementation during osteoporosis (OP) treatments seems insufficient. This cohort study within a national claims database evaluated calcium/vitamin D co-prescription in postmenopausal women initiating an OP treatment. A high co-prescription rate was observed with three quarters of women supplemented with calcium and/or vitamin D in agreement with current recommendations. INTRODUCTION: Adequate calcium/vitamin D supplementation should be taken in combination with antiresorptive drugs in OP treatment. Despite guidelines, supplementation appears to be insufficient. The objective of this study was to describe and estimate co-prescription rates of calcium/vitamin D among postmenopausal women initiating an OP treatment. METHODS: All women over 50 years with a first claim for a bisphosphonates, raloxifene, or strontium prescription filled between May and August 2010 were included in a retrospective cohort study. Data source was the health insurance claims database of the Rhône-Alpes area. RESULTS: Among 4,415 women, 77.0 % had co-prescription of calcium or vitamin D with initial OP treatment, of which 2,150 (49.7 %) had both calcium and vitamin D. The proportion of women with calcium and/or vitamin D (81.7 %) was significantly higher when OP treatment was a bisphosphonate compared to strontium (70.9 %) or raloxifene (67.0 %) (p < 0.05). Among women prescribed both calcium and vitamin D, 7.6 % received a bisphosphonate and vitamin D ± calcium fixed-combination pack. General practitioners prescribed two thirds of initial supplementation treatment (66.9 %). Patients were twice as likely to be prescribed supplementation when the prescriber was a rheumatologist (OR = 2; 95 % CI = 1.57-2.54). CONCLUSION: Three quarters of women initiating OP treatment were supplemented with calcium and/or vitamin D in agreement with current recommendations. This represents a high co-prescription rate.

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial.

UNLABELLED: We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management. INTRODUCTION: To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control). METHODS: A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications. RESULTS: Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0). CONCLUSIONS: A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.

Moving balance and mobility evidence in to action: a primer in knowledge translation.

Knowledge generated by research into the control of posture and gait has many implications for individuals with balance and mobility impairments. Communicating such knowledge through conference presentations and peer-reviewed manuscripts is appropriate for some audiences, but does not effectively reach all potential knowledge users (for example: clinicians, policy-makers, and the public). Expanding interest in promoting evidence-based decision-making and practice to ensure that research results reach the target end-user has lead to the emergence of the field of knowledge translation (KT). The focus of KT is to improve the dissemination and uptake of knowledge in decision-making, and is grounded in a number of theoretical frameworks and its own rapidly expanding literature base. As many general principles of KT can be applied to the optimization of balance and mobility, the purpose of this review is to serve as a primer for gait and posture researchers. Two major models of KT are summarized: the National Institutes of Health (NIH) Roadmap and Knowledge-to-Action Framework. The principles outlined in these frameworks are applied to guidelines to assist researchers with developing their own evidence-based KT strategies. Examples of balance and mobility-specific KT activities are provided when appropriate, but there is a need for more studies that attempt to use evidence-based KT strategies to change practice in this particular field.

Osteoporosis quality indicators using healthcare utilization data.

SUMMARY: Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying dual-energy X-ray absorptiometry (DXA) testing (sensitivity = 98%, specificity = 93%) and osteoporosis pharmacotherapy (κ = 0.81) with minimal measurement error. INTRODUCTION: In osteoporosis, key quality indicators among older women include risk assessment by DXA and/or pharmacotherapy within 6 months following fracture. METHODS: The purpose of this study was to examine healthcare utilization data for use as quality indicators of osteoporosis management. We linked data from 858 community-dwelling women aged over 65 years who completed a standardized telephone interview about osteoporosis management to their healthcare utilization (medical and pharmacy claims) data. Agreement between self-report of osteoporosis pharmacotherapy and pharmacy claims was examined using kappa statistics. We examined the sensitivity and specificity of medical claims to identify DXA testing as well as the sensitivity and specificity of medical and pharmacy claims to identify those with DXA-documented osteoporosis (T-score ≤ -2.5). RESULTS: Participants were aged 75 (SD = 6) years on average; 96% were Caucasian. Agreement between self-report and claims-based osteoporosis pharmacotherapy was very good (κ = 0.81; 95% CI = 0.76, 0.86). The sensitivity of medical claims to identify DXA testing was 98% (95% CI = 95.9, 99.1), with estimated specificity of 93% (95% CI = 89.8, 95.4). We abstracted DXA results from test reports of 359 women, of whom 114 (32%) were identified with osteoporosis. Medical (osteoporosis diagnosis) and pharmacy (osteoporosis pharmacotherapy) claims within a year after DXA testing had a sensitivity of 80% (95% CI = 71.3, 86.8) and specificity of 72% (95% CI = 66.2, 77.8) to identify DXA-documented osteoporosis. CONCLUSION: Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying DXA testing and osteoporosis pharmacotherapy (care processes) with minimal measurement error. However, medical and pharmacy claims alone do not provide a good means for identifying women with underlying osteoporosis.

The Ontario Osteoporosis Strategy: implementation of a population-based osteoporosis action plan in Canada.

In the last decade, there have been a number of action plans published to highlight the importance of preventing osteoporosis and related fractures. In the province of Ontario Canada, the Ministry of Health provided funding for the Ontario Osteoporosis Strategy. The goal is to reduce morbidity, mortality, and costs from osteoporosis and related fractures through an integrated and comprehensive approach aimed at health promotion and disease management. This paper describes the components of the Ontario Osteoporosis Strategy and progress on implementation efforts as of March 2009. There are five main components: health promotion; bone mineral density testing, access, and quality; postfracture care; professional education; and research and evaluation. Responsibility for implementation of the initiatives within the components is shared across a number of professional and patient organizations and academic teaching hospitals with osteoporosis researchers. The lessons learned from each phase of the development, implementation, and evaluation of the Ontario Osteoporosis Strategy provides a tremendous opportunity to inform other jurisdictions embarking on implementing similar large-scale bone health initiatives.

Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada.

STUDY DESIGN: Cohort study. OBJECTIVES: To provide recent estimates of the incidence of traumatic spinal cord injury (SCI) in adults living in Ontario. SETTING: Ontario, Canada. METHODS: The study included all men and women aged 18 years and older living in Ontario. The two primary data sources used for this study were the census data provided by Statistics Canada and the hospital Discharge Abstract Database (DAD) provided by the Canadian Institute for Health Information. Incidence was estimated for the fiscal years 2003/04-2006/07, and examined by age, gender, mechanism and seasonality of injury, the level of injury, the presence of comorbidity and in-hospital mortality. RESULTS: The incident cases had a mean age of 51.3 years (s.d. 20.1). The majority of the cases was male (74.1%) and had a cervical SCI caused by falls (49.5%). The age-adjusted incidence rate was stable over the 4-year study period, from 24.2 per million (95% CI: 21.2-27.6) in 2003 to 23.1 per million (95% CI: 20.2-26.3) in 2006. CONCLUSION: Despite worldwide trends that have indicated motor vehicle collisions (MVCs) as the leading cause of injury, falls emerged as the leading cause of traumatic SCI in this study. This finding, and the fact that the number of fall-induced injuries increased steadily with age, may indicate that there is growing concern for the consequences of falls in the elderly. Further work is needed to understand this trend in age and gender and the causes of falls to develop effective fall prevention strategies.

Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study.

STUDY DESIGN: Retrospective cohort design. OBJECTIVES: To compare socio-demographic, impairment characteristics and utilization (physician and emergency department (ED) visits) for non-traumatic (NTSCI) and traumatic (TSCI) spinal cord injury 1 year post inpatient rehabilitation. SETTING: Ontario, Canada. METHODS: Inpatient stays (2003-2006) were identified from the National Rehabilitation Registry System. Exclusions were: in-hospital mortality; discharge after 31 March 2006; death within 1 year after discharge. Multivariate logistic regression analyses were used to determine factors predicting high utilization. RESULTS: NTSCI cases (n=1002) were greater than TSCI (n=560). NTSCIs were older (mean=61.6, s.d.=15.8) with more co-morbidities, paraplegic (39.5%) and female (P<0.001). NTSCI had higher FIM admission and discharge scores but lower change scores. Mean number of physician visits for NTSCI and TSCI were 31.2 (median=24) and 29.7 (median=22), with no significant differences in mean specialist visits (NTSCI 16.5: TSCI 17.0). Factors predicting 30 or more physician visits included age 60 years or above (OR=1.5; 95% CI=1.2-1.9), urban living (OR=1.59; 95% CI=1.12-2.22) and lowest quartile (18-88) discharge FIM (OR=1.8; 95% CI=1.4-2.3). Charlson score of 3 or more (OR=2.1; 95% CI=1.3-3.2), urban living (OR=1.92; 95% CI=1.3-2.86) and lowest quartile discharge FIM (OR=1.5; 95% CI=1.2-2.0) were associated with 20 or more specialist visits. Factors for high ED use were: rurality (OR=1.5; 95% CI=1.1-2.1), low income (OR=1.4; 95% CI=1.1-1.9) and low (18-88) discharge FIM (OR=1.7; 95% CI=1.3-2.2). CONCLUSION: Both demonstrated significant health care utilization requiring attention to health care needs; particularly for those living in rural settings, with low income and/or low functional ability.

Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.

STUDY DESIGN: This is a cohort study with 1-year follow-up. OBJECTIVES: The aim of this study was to examine 1-year rehospitalization rates following spinal cord injury (SCI) onset and health system factors affecting rehospitalization. METHODS: All persons who had an acute care hospitalization for traumatic SCI in Ontario between 1 April 2003 and 31 March 2006 were identified according to International Classification of Diseases, Tenth Revision codes and followed for 1 year following acute care discharge through record linkage of administrative databases. Index cases with an SCI admission the year before 2003 as well as persons who died within 1 year after the index hospitalization were excluded from the analysis. Factors associated with 1-year rehospitalization were assessed using multivariate logistic regression analyses and included age, sex, rurality, length of stay, comorbidity, level of injury, discharge disposition, in-hospital complication, physician visits and specialist visits measure and etiology of injury. RESULTS: A total of 559 individuals met the inclusion criteria and 27.5% (n=154) were rehospitalized 1 year after initial acute care discharge. Factors significantly associated with 1-year rehospitalization were length of stay, rural residence, 50+ outpatient physician visits and 50+ specialists visits following the index admission. The main causes of rehospitalization were musculoskeletal, respiratory, gastrointestinal and urological disorders. CONCLUSION: This study presents recent data on rehospitalization and yet rehospitalization rates continue to remain high. Our findings have significant implications for healthcare policy and planning in Ontario, Canada with respect to the management of SCI to achieve optimal health outcomes, in particular in rural areas.

Physician utilization among adults with traumatic spinal cord injury in Ontario: a population-based study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To describe the physician utilization patterns (family physicians (FP), specialist and emergency department (ED) visits) of adults with traumatic spinal cord injury (SCI) 1 year after the initial injury. SETTING: Ontario, Canada. METHODS: A total of 559 individuals with a traumatic SCI were identified. Five administrative databases were linked to examine health-care utilization in acute care, inpatient rehabilitation, chronic care rehabilitation, outpatient physician visits and ED visits. Factors predicting frequent physician, specialist and ED use were identified. RESULTS: The mean number of physician visits for traumatic SCI patients during the first year after their injury onset was 31.7 (median 26). FPs had the greatest number of visits (mean 11.6, median 7) followed by physiatrists (mean 6.1, median 2). Factors predicting 50 or more physician visits included age 70 or above (OR=3.6, 95% CI=2.0-6.5), direct discharge to chronic care (OR=3.6, 95% CI=1.0-13.1) and in-hospital complication (OR=2.34, 95% CI=1.3-4.3). Age 70 or less (OR=0.19, 95% CI=0.0-0.9) and direct discharge to chronic care were associated with 50 or more specialist visits. Only rurality predicted two or more visits to the ED. CONCLUSIONS: Individuals with traumatic SCI show significant physician utilization, especially among their FPs and physiatrists. Although the factors predicting higher physician and specialist utilization may reflect individuals with the most severe impairment, comorbid conditions or lack of social support, the model for higher ED visits may point to limited accessibility to/availability of primary care services for SCI patients in rural regions.