Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis.

Osteoporosis is affecting over 200 million people worldwide. Despite available guidelines, care for these patients remains sub-optimal. We developed an osteoporosis tool to address the multiple dimensions of chronic disease management. Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment, so we are revising this tool to include multiple chronic conditions including an update of evidence about osteoporosis. Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis. We searched bibliometric databases for randomized controlled trials (RCTs) in any language evaluating osteoporosis disease management interventions in adults at risk for osteoporosis. Reviewer pairs independently screened citations and full-text articles, extracted data, and assessed risk of bias. Analysis included random effects meta-analysis. Primary outcomes were osteoporosis investigations and treatment, and fragility fractures. Fifty-five RCTs and one companion report were included in the analysis representing 165,703 patients. Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications, and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations. No significant impact was found for any type of intervention to reduce fracture. Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment. Patient education appears to be an important component in osteoporosis disease management.

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.

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.

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.