Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry.

OBJECTIVE: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. DESIGN: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. SETTING: Dallas, TX, USA. PARTICIPANTS: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. OUTCOME MEASURES: Data included demographic and clinical characteristics, charges, and healthcare utilization. RESULTS: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. CONCLUSION: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Community-based InterVentions to prevent serIous Complications (CIVIC) following spinal cord injury in Bangladesh: protocol of a randomised controlled trial.

INTRODUCTION: In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh. METHODS AND ANALYSIS: A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBERS: ACTRN12615000630516, U1111-1171-1876.

Catastrophic medical malpractice payouts in the United States.

Catastrophic medical malpractice payouts, $1 million or greater, greatly influence physicians' practice, hospital policy, and discussions of healthcare reform. However, little is known about the specific characteristics and overall cost burden of these payouts. We reviewed all paid malpractice claims nationwide using the National Practitioner Data Bank over a 7-year period (2004-2010) and used multivariate regression to identify risk factors for catastrophic and increased overall payouts. Claims with catastrophic payouts represented 7.9% (6,130/77,621) of all paid claims. Factors most associated with catastrophic payouts were patient age less than 1 year; quadriplegia, brain damage, or lifelong care; and anesthesia allegation group. Compared with court judgments, settlement was associated with decreased odds of a catastrophic payout (odds ratio, 0.31; 95% confidence interval [CI], 0.22-0.42) and lower estimated average payouts ($124,863; 95% CI, $101,509-144,992). A physician's years in practice and previous paid claims history had no effect on the odds of a catastrophic payout. Catastrophic payouts averaged $1.4 billion per year or 0.05% of the National Health Expenditures. Preventing catastrophic malpractice payouts should be only one aspect of comprehensive patient safety and quality improvement strategies. Future studies should evaluate the benefits of targeted interventions based on specific patient safety event characteristics.

The costs and outcomes of treating a deep pressure ulcer in a patient with quadriplegia .

 The cost of pressure ulcers, especially Stage III and Stage IV ulcers, is substantial. A 27-year-old man with a 6-year history of quadriplegia developed an ischial pressure ulcer. Twelve months of treatment with wet-to-dry dressings were followed by admission to several facilities and 15 months of care with biological dressings and negative pressure wound therapy (NPWT). When admitted to the authors' wound care center, the wound measured 4.5 cm x 3.2 cm with exposed bone. A review of his insurance records showed that paid claims totaled $242,350, including $52,992 for NPWT rental costs. The patient was considered a good candidate for minimally invasive surgical intervention with external tissue expanders. Following a 14-day course of antibiotics to treat his infection, the wound was debrided and the tissue expanders applied. After 16 days, the wound was closed. The patient returned to work 6 weeks after the procedure. At the 23-month follow-up, the wound remained closed. Insurance payments for the care that resulted in wound closure totaled $43,814. This case study illustrates the potential of the external tissue expansion technique to close deep pressure ulcers within a relatively short amount of time at comparatively lower cost. Studies including control treatments are needed to confirm these conclusions.

A cost analysis of conservative management of spinal cord-injured patients in Nigeria.

STUDY DESIGN: A prospective study. OBJECTIVES: To determine the cost of acute phase of injury (ASCI) among spinal cord-injured patients managed conservatively in Nigeria. SETTINGS: Gwagwalada, Abuja. METHODS: Over a 1-year period (1 January 2009 to 31 December 2009), the cost of ASCI of consecutive spinal cord-injured patients, gainfully employed preinjury, who paid the hospital bill directly from their purses and could estimate their daily income, and who were managed conservatively for 6 weeks before discharge to rehabilitation, was prospectively examined. RESULTS: A total of 34 cases of spinal cord-injured patients with a mean age of 35.4 ± 12.8 years were included in this study. The mean cost of ASCI over 6 weeks was $1598.29, an average of 6.4-232.8% of patients' annual income where >50% of the people live on less than a dollar a day. The mean cost of hospitalization was 14.9% of the total cost of ASCI in this study. It was significantly more expensive to treat tetraplegics compared with paraplegics. CONCLUSION: This study identified the cost of acute phase of spinal cord injury in Nigeria to assist clinicians in planning treatment that could reduce financial burden on the patients but optimize patients' care.

Early intensive hand rehabilitation after spinal cord injury ("Hands On"): a protocol for a randomised controlled trial.

BACKGROUND: Loss of hand function is one of the most devastating consequences of spinal cord injury. Intensive hand training provided on an instrumented exercise workstation in conjunction with functional electrical stimulation may enhance neural recovery and hand function. The aim of this trial is to compare usual care with an 8-week program of intensive hand training and functional electrical stimulation. METHODS/DESIGN: A multicentre randomised controlled trial will be undertaken. Seventy-eight participants with recent tetraplegia (C2 to T1 motor complete or incomplete) undergoing inpatient rehabilitation will be recruited from seven spinal cord injury units in Australia and New Zealand and will be randomised to a control or experimental group. Control participants will receive usual care. Experimental participants will receive usual care and an 8-week program of intensive unilateral hand training using an instrumented exercise workstation and functional electrical stimulation. Participants will drive the functional electrical stimulation of their target hands via a behind-the-ear bluetooth device, which is sensitive to tooth clicks. The bluetooth device will enable the use of various manipulanda to practice functional activities embedded within computer-based games and activities. Training will be provided for one hour, 5 days per week, during the 8-week intervention period. The primary outcome is the Action Research Arm Test. Secondary outcomes include measurements of strength, sensation, function, quality of life and cost effectiveness. All outcomes will be taken at baseline, 8 weeks, 6 months and 12 months by assessors blinded to group allocation. Recruitment commenced in December 2009. DISCUSSION: The results of this trial will determine the effectiveness of an 8-week program of intensive hand training with functional electrical stimulation. TRIAL REGISTRATION: NCT01086930 (12th March 2010)ACTRN12609000695202 (12th August 2009).

Personal assistance, income and employment: the spinal injuries survey instrument (SISI) and its application in a sample of people with quadriplegia.

INTRODUCTION: Our aim was to ascertain what effect access to personal care package (PCP) has on the labour market activities of people who have a spinal cord injury (SCI). We developed a new instrument called the spinal injuries survey instrument (SISI). The SISI is a 35-item instrument, which contains items on health, education, employment, along with measures of personal assistance, mobility and psychological attribution style. MATERIALS AND METHODS: The SISI was administered, with the Short Form 36 (SF-36) health status instrument, to 250 people with an SCI. The response rate was 72%. A retrospective, matched case-control sampling approach matched individuals who received a PCP, with a cohort who did not. The matching criteria included the site and severity of spinal lesion, age and gender. RESULTS: Although data on the reliability of the instrument are currently lacking, our empirical results are consistent with other studies: (1) mean annual health care costs (AUD$8741) are comparable with Walsh's estimates (2) SF-36 data support Kreuter's contention that mental health is resilient to SCI and (3) a post-injury employment rate of 29.7% corroborates Murphy et al. We present additional data describing income, educational attainment and family support. DISCUSSION: Our discussion borrows a conceptualization of disability by Sen, that includes both an 'earning handicap' (an impediment to earn income) and a 'conversion handicap' (an impediment to the enjoyment of income). Our application of the SISI provides evidence of both. The labour income of people with quadriplegia is AUD$10,007 per annum, while diminished health status, increased out-of-pocket health expenditure and loss of time suggest a conversion handicap.

Health care costs for patients with chronic spinal cord injury in the Veterans Health Administration.

BACKGROUND/OBJECTIVE: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, > 2 years after injury). METHODS: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted. RESULTS: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample. CONCLUSIONS: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization.

Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs.

In Ile-Ife, Nigeria, traumatic brain injuries are largely due to traffic accidents caused mainly by the bad maintenance of the roads and unsafe driving. Young men in the productive stage of their lives are those most affected. The resultant disabilities include quadriplegia (in more than half the patients) and paraplegia. The cost of treating and providing adequate facilities for these patients imposes a heavy economic burden upon developing countries.

Rehospitalization following compensable work-related tetraplegia.

DESIGN: Descriptive study. OBJECTIVES: To document the characteristics of rehospitalization following work-related tetraplegia, investigate risk factors for rehospitalization and identify opportunities for rehospitalization prevention. SETTING: Workers' compensation administrative database with national coverage. METHODS: The administrative database of a large workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In all, 61 cases were identified where detailed rehospitalization information was available. Medical payment data were extracted, rehospitalization reasons were coded, and rates, costs and length of stay were calculated. RESULTS: In all, 62% of cases were rehospitalized at some time during the period for which data were available. The average number of days the study group spent rehospitalized per year was 9.2 and the average annual cost was 14,197 US dollars. The most common reasons for rehospitalization were dermatological (23%), orthopedic (18%) and urological (14%). It was found that as many as 74% of the total number of days persons spent rehospitalized, 64% of the monies spent on rehospitalization, and 47% of rehospitalizations could have been prevented. CONCLUSIONS: Consistent with earlier research, the ability to identify risk factors for rehospitalization was limited. However, the current study does highlight the extent to which rehospitalizations disrupt the lives of people with work-related tetraplegia and that a substantial proportion of rehospitalizations can be avoided. SPONSORSHIP: The research was supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research National Model SCI Systems (Grant no. H133N00024).

Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study.

PURPOSE: More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly. METHODS: Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery. RESULTS: Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed. CONCLUSIONS: Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.

Work-related tetraplegia: cause of injury and annual medical costs.

STUDY DESIGN: Descriptive study. OBJECTIVE: To describe the demographics, cause of injury, and annual-paid medical costs for the 5 years following injury for cases of work-related tetraplegia. SETTING: A single United States workers' compensation (WC) claims database. METHODS: Tetraplegia cases with initial date of injury from 1 January 1989 to 31 December 1999 were selected by cross-referencing word search terms pertaining to body part injured and nature of injury. The main outcome measures were injury causes and annual-paid medical payments (adjusted to year 2000 medical consumer price index) of work-related tetraplegia by injury group for each year postinjury over a 5-year time period. RESULTS: A total of 62 claimants with work-related tetraplegia injured between 1 January 1989 and 31 December 1999. The vast majority of those identified were male claimants (92%) and more than a quarter worked in the construction industry (26%). Other highly represented industries included transportation and retail (15% each), manufacturing (13%), and agriculture and utility (11% each). The majority of injuries were the result of falls (36%) and vehicular accidents (34%). The mean Year 1 cost was US dollars 560524 for those with a high-level tetraplegia (C2-4 ASIA A-C), US dollars 431033 for a low-level injury (C5-8 ASIA A-C), and US dollars 178041 for those with an ASIA D tetraplegia injury. The mean cost of subsequent years (Years 2-5) was US dollars 130992 for a high-level, US dollars 129250 for a low-level, and Us dollars 34352 for an ASIA D tetraplegia injury. CONCLUSIONS: Mean costs for Year 1 postinjury in WC cases are similar to previously published estimates. Comparing the current results with those of previous spinal cord injury cost studies suggests that those with work-related tetraplegia may receive more injury-related paid medical benefits after the first year postinjury than cases who do not receive WC-supported benefits. SPONSORSHIP: Supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research (NIDDR) (Grant # H133N00024).

Services provided following compensable work-related tetraplegia.

DESIGN: Descriptive study. OBJECTIVE: To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI). SETTING: Workers' compensation claims database. METHODS: The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories. RESULTS: Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications/supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher. CONCLUSIONS: Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.

A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample.

OBJECTIVE: To examine the effects of age at injury on lengths of stay, treatment costs, and outcomes using a matched sample of tetraplegic spinal cord injury (SCI) patients. DESIGN: Differences were examined by separating the sample into three age categories (18 to 34, 35 to 64, and 65+ years old) matched for American Spinal Injury Association (ASIA) Motor Impairment Classification and level of neurologic preservation bilaterally. Analysis of variance was used to examine age group differences for lengths of stay, medical expenses, and functional outcome. SETTING: Sixteen medical centers in the federally sponsored Spinal Cord Injury Model Systems Project. PARTICIPANTS: Three hundred seventy-five adult patients with tetraplegic SCI admitted between 1988 and 1996 were assessed at acute care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. MAIN OUTCOME MEASURES: ASIA Motor Index and Functional Independence Measure (FIM) admission, discharge, and efficiency scores; acute care and rehabilitation lengths of stay and medical care charges; and discharge disposition. RESULTS: Analyses revealed equivalent lengths of stay and charges for all age groups. There were no age-related differences in ASIA and FIM Motor scores at acute care and inpatient rehabilitation admission. Younger patients' scores on the FIM Motor subscale improved significantly more than did middle and older patients'. The two younger groups of patients had a more significant improvement than did older patients, as indicated by ASIA Motor Index scores. When taking lengths of stay into account, the FIM motor scores of the youngest group of patients improved more quickly than those of the two older groups. Furthermore, the younger and middle age groups demonstrated greater treatment efficiency than the older patient group based on ASIA Motor Index score ratios. Younger patients were least likely to be discharged to institutional settings. CONCLUSIONS: Along with neurologic and functional status, age should be considered when formulating treatment plans and prognostic statements. For older patients, alternative rehabilitation settings with lower-intensity treatment and lower charges may prove to be a more efficacious use of resources.

Relation of disability costs to function: spinal cord injury.

OBJECTIVE: This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community. DESIGN: A cross-sectional study. SUBJECTS: One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation. RESULTS: A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance. CONCLUSION: The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.

Investigation of the social status of paraplegic individuals after medical rehabilitation.

The social services of the German centres for spinal cord injuries compiled social data on 2000 recently injured paraplegics. The aim of the study was to determine whether and to what extent patients had been reintegrated to jobs after completion of physical rehabilitation treatment. A 31-point questionnaire surveyed all relevant data pertaining to the projected professional vita. The results for the medically rehabilitated population (n = 651) indicate that 45% returned to their previous job, school or college. Intensified use of computers and advanced academic backgrounds of afflicted individuals contribute to a higher chance for reintegration at a previous job. Our social statistics also include data on living conditions and social support. Household caretaking support is offered by family members in 73% of cases, while 5% permanently live in nursing homes.