Relations Between Self-Reported Prescription Hydrocodone, Oxycodone, and Tramadol Use and Unintentional Injuries Among Those With Spinal Cord Injury.

OBJECTIVE: To identify the relations of 3 frequently used prescription opioids (hydrocodone, oxycodone, tramadol) with unintentional injuries, including fall-related and non-fall-related injuries among adults with chronic, traumatic spinal cord injury (SCI). DESIGN: Cross-sectional cohort study. SETTING: Community setting; Southeastern United States. PARTICIPANTS: Adult participants (N=918) with chronic traumatic SCI were identified from a specialty hospital and state population-based registry and completed a self-report assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported fall-related and non-fall-related unintentional injuries serious enough to receive medical care in a clinic, emergency room, or hospital within the previous 12 months. RESULTS: Just over 20% of participants reported ≥1 unintentional injury in the past year, with an average of 2.16 among those with ≥1. Overall, 9.6% reported fall-related injuries. Only hydrocodone was associated with any past-year unintentional injuries. Hydrocodone taken occasionally (no more than monthly) or regularly (weekly or daily) was related to 2.63 (95% confidence interval [CI], 1.52-4.56) or 2.03 (95% CI, 1.15-3.60) greater odds of having ≥1 unintentional injury in the past year, respectively. Hydrocodone taken occasionally was also associated with past-year non-fall-related injuries (OR, 2.20; 95% CI, 1.12-4.31). Each of the 3 opioids was significantly related to fall-related injuries. Taking hydrocodone occasionally was associated with 2.39 greater odds of fall-related injuries, and regular use was associated with 2.31 greater odds. Regular use of oxycodone was associated with 2.44 odds of a fall-related injury (95% CI, 1.20-4.98), and regular use of tramadol was associated with 2.59 greater odds of fall-related injury (95% CI, 1.13-5.90). CONCLUSIONS: Injury prevention efforts must consider the potential effect of opioid use, particularly hydrocodone. For preventing fall-related injuries, each of the 3 opioids must be considered.

Relationships of Self-reported Opioid Use and Misuse and Pain Severity With Probable Major Depression Among Participants With Spinal Cord Injury.

OBJECTIVES: To examine the relations of pain intensity, opioid use, and opioid misuse with depressive symptom severity and probable major depression (PMD) among participants with spinal cord injuries (SCI), controlling for demographic, injury, and socioeconomic characteristics. STUDY DESIGN: Cohort study. SETTING: Medical University in the Southeastern United States (US). PARTICIPANTS: Participants (N=918) were identified from 1 of 2 sources including a specialty hospital and a state-based surveillance system in the Southeastern US. Participants were a minimum of 18 years old at enrollment and had SCI with non-complete recovery. Participants were on average 57.5 years old at the time of the study and an average of 24.4 years post SCI onset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed a self-report assessment that included frequency of prescription opioid use and misuse, based on the National Survey on Drug Use and Health (NSDUH), and the PHQ - 9 to measure depressive symptom severity and PMD. RESULTS: Opioid use, opioid misuse, and pain intensity were related to elevated depressive symptom severity and higher odds of PMD. Non-Hispanic Blacks had fewer depressive symptoms and lower odds of PMD, as did those with higher incomes. Veterans had lower risk of PMD, whereas ambulatory participants had a higher risk of PMD. Age at SCI onset had a mixed pattern of significance, whereas years of education and years since injury were not significant. CONCLUSIONS: The relation between pain intensity with depressive symptom severity and PMD was profound, consistent with the biopsychosocial model of pain. The greater risk of PMD and higher depressive symptom severity among those using opioids and misusing opioids raises further concern about long-term prescription opioid use. Alternative treatments are needed.

Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVE: To identify five-year longitudinal changes in employment, health, participation, and quality-of-life outcomes (QOL) among participants with chronic spinal cord injury (SCI) and to compare the amount of change in these outcomes between those surviving and those not surviving until follow-up. METHODS: Participants were 1157 individuals from the SCI Longitudinal Aging Study, who have completed at least two self-report assessments separated by five-year intervals. The main outcome measures were 13 indicators related to employment, health, participation, and QOL/psychosocial indicators. Survival status measured at follow-up. RESULTS: Those who survived to follow up had a history indicating a greater likelihood of employment, better health, participation, and QOL/psychosocial indicators. Among survivors, longitudinal declines were limited to the percent employed and participation indicators, whereas those deceased by follow-up had significant undesirable changes in employment, participation, health, and QOL/psychosocial indicators. More specifically, compared to the survivors, those deceased by follow-up experienced a greater increase in hospitalizations, decreases in nights away from home, and declines in global satisfaction over the five-year interval. CONCLUSIONS: Longitudinal declines in employment and some aspects of participation are common among long-term survivors and may be part of the natural course of outcomes after SCI. However, more dramatic increases in hospitalizations, fewer nights away from home, and declining satisfaction may be red flags for declining longevity.

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.

Staying Pressure Injury Free: The Role of Modifiable Behaviors.

OBJECTIVE: To investigate the association of behavioral factors with retrospective reports of staying free from pressure injuries (PIs) during a 12-month period for people with chronic spinal cord injury (SCI). DESIGN: Cross-sectional survey. SETTING: Data collection was completed at an academic medical center in the Southeastern United States in collaboration with a specialized treatment center and 2 public health registries that use population-based approaches to identify all incident cases of SCI within the state. PARTICIPANTS: The participant cohort was composed of 3817 adults (N=3817) with traumatic SCI of at least 1-year duration. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported recall of staying PI-free for 12 months vs having 1 or more PIs. RESULTS: Among the 3817 participants, 74% were male, 76% were non-Hispanic White, and mean age was 48 years, with an average of 12 years post SCI. Based on self-report assessment, 67% reported being PI-free in the past year. After controlling for the demographic and injury characteristics, we found that those in the clinical cohort and those who reported healthy diets and planned exercise at least once a week were more likely to be PI-free; being underweight and high frequency of prescription medication use for spasticity, pain, and depression were negatively associated with being PI-free. Smoking, alcohol use, nonmedical substance use, and prescription medication misuse were not statistically significant in the multivariate model. CONCLUSIONS: There are several significant behavioral predictors of being PI-free, and consideration of these factors may be used to develop tailored strategies to promote healthy skin maintenance and the prevention of multiple, severe, and recurrent PI.

Psychoactive Substance Use Among Individuals With Chronic Spinal Cord Injury: Patterns and Characteristics.

OBJECTIVE: To identify the patterns of nonprescription psychoactive substance (PAS) use among persons with spinal cord injury (SCI) and the relationships with demographic and injury characteristics. DESIGN: Cross-sectional, self-report assessment (SRA). SETTING: A medical university in the southeastern United States. PARTICIPANTS: The participants (N=4670) were identified through a specialty hospital and 2 state-based surveillance registries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed SRAs and reported the past 3 months' use of the following substances for which they did not have a prescription: cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives/hypnotics and sleeping pills, hallucinogens, and opioids. PAS use was grouped into 4 categories: none, cannabis use only, use of cannabis and other PAS, and use of other PAS only. RESULTS: Of the 4577 participants who responded to the PAS use questions, 24.1% reported using at least 1 PAS without a prescription. Cannabis was the most frequently reported substance (16.4%), followed by sedatives or sleeping pills (8.0%). By PAS use group, 12.1% reported use of cannabis use only, followed by use of other PAS only (7.7%) and use of cannabis and other PAS (4.3%). There were significant differences among the groups of use by nearly all personal characteristics. CONCLUSIONS: The use of nonprescription PASs is prevalent among adults with chronic SCI, and there are clear differences in patterns and characteristics of use.

Rehospitalization During the First 5 Years After the Onset of Traumatic Spinal Cord Injury: A Population-Based Study Using Administrative Billing Records.

OBJECTIVE: Our objective was to identify the number, length of stay, and charges of rehospitalizations during the subsequent 5 years after discharge from the initial hospitalization by using administrative billing records from a population-based cohort with spinal cord injury (SCI) in the southeastern United States. DESIGN: Analysis of administrative billing data. SETTING: State-based surveillance data analyzed by an academic medical center in the southeastern United States. PARTICIPANTS: A total of 1872 individuals (N=1872) from a state-based surveillance system in the southeastern United States whose onset was between January 1, 1998, and January 1, 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome measures were the number of rehospitalization episodes, length of stay, and total hospital charges for each episode of rehospitalization. RESULTS: Seventy percent of participants were rehospitalized during the first 5 years after initial discharge, and the highest rehospitalization rates were in the first year (54%), being relatively stable in years 2-5 (21%-22%). Adjusted to 2019 US dollars, the average total rehospitalization charges were $214,716 per person during the 5 years. Participants who could walk independently had fewer rehospitalizations, fewer rehospitalization days, and less rehospitalization charges than the nonambulatory participants. College education was also associated with less rehospitalization charges. CONCLUSIONS: Rehospitalization is a significant cost after SCI. Further longitudinal study on the population cohorts and billing data are needed to quantify these changes over time.

Mediating Effects of Pain Interference on the Relationships Between Pain Intensity and Probable Major Depression Among Participants With Spinal Cord Injury.

OBJECTIVE: To evaluate whether pain interference mediates the relationship between pain intensity and probable major depression (PMD) among persons with spinal cord injury (SCI), accounting for differences in the frequency of prescription medication use and resilience. DESIGN: Cross-sectional analysis using self-report assessment. SETTING: Medical university in the Southeastern United States. PARTICIPANTS: There were a total of 4670 participants (N=4670), all of whom had traumatic SCI of at least 1-year duration, identified from the Southeastern Regional SCI Model System and 2 state-based surveillance systems. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Patient Health Questionnaire-9 was used to define PMD. Covariates included demographic and injury characteristics, pain severity, pain interference, and resilience. Separate sets of multistage logistic regression analyses were conducted for 3 levels of prescription pain medication use (daily, occasional/weekly, none). RESULTS: Pain intensity was related to a greater risk of PMD (odds ratio [OR]daily pain medication user, 1.28; 95% confidence interval [CI], 1.21-1.35; ORoccasional/weekly pain medication user, 1.26; 95% CI, 1.16-1.36; ORnonpain medication user, 1.44; 95% CI, 1.33-1.56), but this relationship disappeared after consideration of pain interference (ORdaily pain medication user, 0.97; 95% CI, 0.90-1.04; ORoccasional/weekly pain medication user, 0.94; 95% CI, 0.84-1.05; ORnonpain medication user, 1.07; 95% CI, 0.95-1.20), which indicates pain interference was a mediator between pain intensity and PMD and there was no direct relationship between pain intensity and PMD. Resilience was protective of PMD in each model but was not a mediator. CONCLUSIONS: Although pain intensity was associated with PMD, the relationship was mediated by pain interference. Resilience was an important protective factor. Therefore, clinicians should assess pain interference when screening for PMD and direct treatment at reducing pain interference. Building resilience may further reduce the risk of PMD.

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 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.

Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVE: Previous research has indicated that socioeconomic factors affect longevity after traumatic spinal cord injury (SCI). Our purpose was to evaluate whether social participation mediates the relationship between socioeconomic factors and survival status after SCI. SETTING: Medical university in the southeastern United States. METHODS: Participants (N = 1540) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and having residual impairment from SCI. The main outcome measures were a) survival status as of December 31, 2019, identified by the National Death Index (NDI) search, b) socioeconomic status (SES), measured by education, employment status, and family income, and c) participation, measured by marital/relationship status, hours out of bed per day, days leaving home per week, and nights away home during the past year. RESULTS: Thirty nine percent of participants (n = 602) were decreased by the end of 2019. Socioeconomic factors were associated with longevity controlling for demographic, injury characteristics, and health status. However, the association of SES with longevity was mediated by three social participation mobility indicators (hours out of bed, days out of house, and nights away from home), such that SES was no longer significantly related to longevity after inclusion of the participation variables. CONCLUSIONS: Although socioeconomic factors are related to longevity, their relationship appears to be mediated by social participation mobility indicators. Intervention studies are needed to address the modifiable factors that may promote longevity, including promoting an active lifestyle.

The primary and secondary causes of hospitalizations during the first five years after spinal cord injury.

STUDY DESIGN: Cohort study. Retrospective analysis of uniform billing discharge data (UB-04). OBJECTIVES: To compare and contrast the primary and secondary causes of hospitalization by type of admission, emergency department (ED) versus inpatient only (IP), during the first five years after the traumatic spinal cord injury (SCI). SETTING: Academic Medical University in the Southeastern USA. METHODS: At total of 2569 adults with traumatic SCI were identified from a population-based registry and matched to billing data. The main outcome measures were primary and secondary diagnoses associated with hospital admissions in non-federal, state hospitals. RESULTS: Overall, there were 9733 hospital admissions in the five years after SCI onset, not including the initial hospitalization; 53% were admissions through the ED. The primary causes of hospitalizations after SCI varied by year post injury and admission type (ED versus IP). The top 15 secondary diagnoses included several secondary health conditions associated with SCI, as well as chronic health conditions. CONCLUSIONS: Rehabilitation diagnoses were much more prominent during the first year, compared with subsequent years. Septicemia was the leading cause of admissions through the ED, whereas chronic ulcers of the skin were prominent for IP only admissions. This is consistent with the acute nature of septicemia compared with more planned hospitalization for rehabilitation and skin ulcers. These conditions should be targeted for prevention strategies that include patient/family education and early and appropriate access to primary care.

Opioid Use Among Individuals With Spinal Cord Injury: Prevalence Estimates Based on State Prescription Drug Monitoring Program Data.

OBJECTIVE: To identify the prevalence of opioid use in individuals with chronic spinal cord injury (SCI) living in South Carolina. DESIGN: Cohort study. SETTING: Data from 2 statewide population-based databases, an SCI Registry and the state prescription drug monitoring program, were linked and analyzed. PARTICIPANTS: The study included individuals (N=503) with chronic (>1y) SCI who were injured between 2013 and 2014 in South Carolina and who survived at least 3 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Filled opioid prescriptions over a 2-year period (months 13-36 after injury). The main outcomes were total number of days with an opioid prescription over the 2-year period, length of coverage period [(final day of prescription coverage+the days supplied)-first day of prescription coverage], average daily morphine milligram equivalents (MME) over the coverage period, and concurrent days covered by an opioid and a prescription for benzodiazepines, sedatives, or hypnotics. RESULTS: A total of 53.5% of the cohort (269 individuals) filled at least 1 opioid prescription during their second or third year after SCI. In total, there were 3386 opioid fills during the 2-year study. On average, the total number of opioid prescription days was 293±367. The average coverage period was 389±290 days, and the average daily MME during the coverage period was 41±70 MME. Of those who filled an opioid prescription, 23% had high-risk fills (>50 MME), and 38% had concurrent prescriptions for benzodiazepines, sedatives, or hypnotics. CONCLUSIONS: The prevalence of opioid use was high among individuals with chronic SCI, exceeding rates observed in the general population. Also concerning were the rates of high-risk fills, based on average daily MME and concurrent benzodiazepine, sedative, or hypnotic prescriptions. These findings, taken together with those of earlier studies, should be used by providers to assess and monitor opioid use, decrease concurrent high-risk medication use, and attenuate the risk of adverse outcomes.

Assistive devices and future fall-related injuries among ambulatory adults with spinal cord injury: a prospective cohort study.

STUDY DESIGN: Prospective cohort study with two times of measurement. OBJECTIVE: To assess the relationship between use of assistive devices for walking (at baseline) and the number of annual fall-related injuries (at follow-up) among a cohort of ambulatory adults with spinal cord injury (SCI). SETTING: Medical University in the Southeastern United States. METHODS: There were 622 ambulatory adults who met the eligibility criteria, 317 of whom completed both baseline and follow-up assessments. The participants completed a mailed self-report assessment (SRA) that measured self-reported number of fall-related injuries in the previous year, and the use of orthopedic equipment (assistive devices) for walking, including cane(s), crutches, walker, and braces, was assessed at both baseline and follow-up. RESULTS: The percentage of at least one self-reported fall-related injury decreased from 22% at baseline to 13% at the follow-up. Walker and cane use at baseline was significantly associated with fall-related injuries at follow-up. Participants using one walking device related to 194% greater number of fall injures, and using multiple device related to 730% greater number of fall injures than those who used no devices. We also found walker users were associated with 214% greater number of fall injures, while cane users were associated with 160% greater number of fall injures. CONCLUSIONS: The probability of fall-related injury remained high among persons who are ambulatory after SCI. Health care professionals should be aware of the balance between the goal of ambulation and the potential increased risk of fall-related injuries associated with assistive device use.

Behavioral Factors and Unintentional Injuries After Spinal Cord Injury.

OBJECTIVE: To identify the relationships of behavioral factors with unintentional injuries among participants with traumatic spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Medical university in the Southeastern United States. PARTICIPANTS: Participants (N=4670) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and residual impairment from SCI (noncomplete recovery). Of these, 2516 were identified from a specialty hospital and 2154 were identified from population-based state surveillance systems. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed self-report assessments including multiple behavioral variables, SCI variables, and demographic characteristics. Primary outcome was unintentional injuries during the past 12 months. RESULTS: Twenty-three percent (n=969) reported at least 1 unintentional injury in the past year serious enough to receive medical care in a clinic, emergency department, or hospital, and the average number of times injured was 1.82 among those with at least 1 injury. Prescription medication use for pain and depression, nonmedical medication use, use of prescription medication for purposes other than prescribed, and binge drinking were associated with a greater odds of unintentional injury. There were some differences between fall-related and non-fall-related unintentional injuries, with ambulation associated with greater odds of fall-related injuries but lower odds of non-fall-related injuries. Participants identified through population-based systems were at greater risk of falls compared with those identified through a traditional specialty hospital. CONCLUSIONS: Unintentional injuries were prevalent among people with SCI. After controlling for injury and demographic characteristics, multiple risk behaviors were related to the odds of unintentional injuries. Intervention studies are needed to address modifiable behaviors that may reduce the risk of injury.

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.

Correction: Prevalence of chronic health conditions and hospital utilization in adults with spinal cord injury: an analysis of self-report and South Carolina administrative billing data.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Trends in nonroutine physician visits and hospitalizations: findings among five cohorts from the Spinal Cord Injury Longitudinal Aging Study.

STUDY DESIGN: Longitudinal cohort study OBJECTIVE: To evaluate lifetime variation in healthcare utilization among individuals with a chronic spinal cord injury (SCI). SETTING: Medical university in the Southeastern United States (US). METHODS: Participants were identified from two Midwestern University hospitals and a specialty hospital in the Southeastern US and were enrolled in 1973-1974, 1984-1985, 1993-1994, and 2003-2004. Generalized linear mixed models were used to explore changes in nonroutine physician visits, hospitalizations, and days hospitalized within the 24 months prior to the study. RESULTS: Significant temporal linear spline change was found for nonroutine physician visits. The proportion of participants reporting ≥10 nonroutine physician visits in the 24 months prior to assessment kept relatively constant over the 30 years post injury (p value of trend: p = 0.605) and sharply increased afterwards (pknot = 30 years since injury = 0.016). The trajectory for hospitalization and days hospitalized followed a quadratic pattern (pyears post injury2 < 0.001) for all participants. The proportion of individuals who had at least one hospitalization and were hospitalized for more than 1 week significantly declined from the onset of SCI to 25-30 years post injury, then significantly increased thereafter. CONCLUSIONS: The natural course of changes in three indices of healthcare utilization was curve-linearly, rather than linearly related to years post injury. People with SCI tended to have significant changes in healthcare utilization after about 30 years injury.

Concentration of Costs Among High Utilizers of Health Care Services Over the First 10 Years After Spinal Cord Injury Rehabilitation: A Population-based Study.

OBJECTIVE: The purpose of this study was to (1) categorize individuals into high, medium, and low utilizers of health care services over a 10-year period after the onset of spinal cord injury (SCI) and (2) identify the pattern of causes of hospitalizations and the characteristics associated with high utilization. DESIGN: Retrospective analysis of self-report assessment linked to administrative data. SETTING: Data were collected from participants living in and utilizing hospitals in the state of South Carolina. PARTICIPANTS: Adult participants with traumatic SCI were identified through a state SCI Surveillance System Registry, a population-based system capturing all incident cases treated in nonfederal facilities. Among 963 participants who completed self-report assessments, we matched those with a minimum of 10 years of administrative records for a final sample of 303 participants (N=303). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Costs related to health care utilization for emergency department visits and hospitalizations, as measured operationally by hospital charges at full and established rates; causes of hospitalizations RESULTS: Over two-thirds of the total $49.4 million in charges for hospitalization over the 10-year timeframe (69%) occurred among 16.5% of the cohort (high utilizers), whereas those in the low utilizer group comprised 53% of the cohort with only 3.5% of the charges. The primary diagnoses were septicemia (50%), other urinary tract disorder (48%), mechanical complication of device, implant, or graft (48%), and chronic ulcer of skin (40%). Primary diagnoses were frequently accompanied by secondary diagnoses, indicating the co-occurrence of multiple secondary health conditions. High utilizers were more likely to be male, minority, have a severe SCI, have reported frequent pressure ulcers and have income of less than $35,000 per year. CONCLUSIONS: The high cost of chronic health care utilization over a 10-year timeframe was concentrated in a relatively small portion of the SCI population who have survived more than a decade after SCI onset.

Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: Identify the risk and protective factors of all-cause and cause-specific mortality among persons with traumatic spinal cord injury (SCI). SETTING: Rehabilitation specialty hospital in the Southeastern United States. METHODS: A prospective cohort study was conducted with 3070 adults with traumatic SCI who were a minimum of 1 year post-injury at assessment. Prospective data were collected in 1997-1998 and 2007-2010, with mortality determined as of 31 December, 2016. The deceased were classified into six categories based on underlying cause of death: septicemia, pneumonia and influenza, cancer, heart and blood vessel diseases, unintentional injuries, and all other causes. The competing risk analysis strategy applied to each of the specific causes. RESULTS: There were a total of 803 observed deaths among the 2979 final study sample. After controlling for demographic and injury characteristics, general health, pressure ulcer history, and symptoms of infections were significantly associated with all-cause mortality. Except for cancer, they were also related with at least one of the specific causes of death, whereas orthopedic complications and subsequent injuries were unrelated to any cause. CONCLUSIONS: Three health domains, global health, pressure ulcers, and symptoms of illness or infection, were significantly associated with mortality after SCI, and the patterns of association varied as a function of specific cause of death.