Rehospitalization and Healthcare Utilization After Initial Rehabilitation in SCI

Individuals with SCI face complex and life-long challenges related to secondary health complications. When compared to the general population, individuals with SCI are at an increased risk of developing secondary health complications (Middleton et al. 2004; Savic 2000). The most frequently reported secondary health complications in individuals with SCI include UTI, pressure ulcers, respiratory, cardiovascular, and psychosocial issues (Piatt et al. 2016). These complications may occur at any time point throughout injury and often lead to rehospitalization and frequent usage of health services (Piatt et al. 2016). Not only are ongoing complications and rehospitalization costly, they often disrupt quality of life, interpersonal relationships, and work (Brinkhof et al. 2016). In this sense, there has been much interest in understanding the patterns and antecedents of rehospitalization and healthcare utilization to inform effective preventative strategies.

Discussion

Rehospitalization

Due to differences in methods of data collection, duration of follow-up, calculation of readmission rates, specific inclusion criteria, and regional healthcare systems (i.e., Australia, Canada, Italy, Turkey, United Kingdom, United States), direct comparison of the articles included for review is challenging. However, it is clear that hospital readmission is a significant issue across all regions, with universally high rehospitalization rates (Cai et al. 2020; Cardenas et al. 2004; Charlifue et al. 2004; Dorsett & Geraghty 2008; Dryden et al. 2004; Franceschini et al. 2003; Jaglal et al. 2009; Middleton et al. 2004; Paker et al. 2006; Savic 2000).

Cardenas et al. (2004) noted an average rehospitalization rate of 55% (defined as the number of patients rehospitalized within a particular anniversary of injury year) for the first-year post-injury and then rates of 36-38% from 5-20 years post-injury. This analysis was conducted using the multi-center United States model systems dataset (n=8668) between 1995-2002. Similarly, Charlifue et al. (2004) reported that 41% of patients were rehospitalized within five years following injury. Eventually, this reduced to 35-36% in the years thereafter, which was not surprising as they both used the same database, albeit, over different years (1973-1998).

Jaglal et al. (2009) defined rehospitalizations as occurring within the first year following initial rehabilitation discharge; thereby, circumventing the primary limitation of most other studies that have a variable follow-up period. Additionally, multiple administrative healthcare databases were linked to overcoming variances observed with self-reported data. The authors reported a rehospitalization rate of 27.5% -approximately half that reported in the United States. Likewise, Dorsett and Geraghty (2008) reported similar rates over a similar time period in Queensland, Australia, with 36.6% over the first two years and 52% by year 10.

Middleton et al. (2004) reported a slightly higher 10-year rehospitalization rate in New South Wales, Australia, with 58.6% of persons rehospitalized due to an SCI-related issue and an additional 10.8% admitted for a non-SCI-related issue. This is consistent with a study from Canada by Dryden et al. (2004), who reported a rehospitalization rate of 57.3% for persons with SCI over a 6-year follow-up period. In another study, Savic et al. (2000) longitudinally interviewed community-dwelling individuals with SCI three times over six years. Similarly, they reported an overall readmission rate of 64%.

Overall, it appears as though rehospitalization rates tend to decline in the first two years following discharge (Cardenas et al. 2004; Charlifue et al. 2004; Middleton et al. 2004). However, in the United States, rehospitalization rates within the first year post-discharge tend to be higher than in other regions (i.e., Australia and Canada). It is difficult to speculate why this may be given the variation between these countries in terms of health care and social systems. However, this may be related to a shortened rehabilitation stay, as the United States has the shortest rehabilitation LOS compared to any other jurisdiction reporting data (Cardenas et al. 2004).

Across several studies, the primary reasons for hospital readmission following inpatient SCI rehabilitation are consistent (Cardenas et al. 2004; Dorsett & Geraghty 2008; Dryden et al. 2004; Franceschini et al. 2003; Jaglal et al. 2009; Mashola et al. 2019; Middleton et al. 2004; Paker et al. 2006; Ruediger et al. 2019; Savic 2000; Sharwood et al. 2019; Skelton et al. 2019). All studies reported issues associated with the skin (e.g., pressure ulcers) and the genitourinary system (e.g., UTIs and to a lesser extent complications of the upper urinary tract) as the most frequent reasons for readmission. The impact of pressure ulcers is even more consequential when taking into account the subsequent long LOS for treatment, specialized equipment, care, dressings, and surgery, often associated with this specific complication (Middleton et al. 2004; Savic 2000). Other issues that were associated with significant rates of readmission included respiratory issues (e.g., infections, especially in persons with tetraplegia), musculoskeletal complaints (e.g., spasticity, pain), and digestive system problems (e.g., bowel). Of note, musculoskeletal issues were the most prominent cause of readmission within the first year post-discharge from rehabilitation (Jaglal et al. 2009), with twice as many admissions than any other issue.

Upon regression analysis of the United States Model Systems dataset, Cardenas et al. (2004) reported that the two most significant predictors of rehospitalization within the first year were motor FIM scores at discharge and the payer (i.e., those with lower motor score state or federal funded persons versus those with private insurance were more likely to be hospitalized). Additionally, predictors of readmission later included the payer, motor FIM, and race. A similar analysis was conducted by Jaglal et al. (2009) and the factors most significantly associated with rehospitalization in the first year were the longer length of rehabilitation stay, rural residence, 50 or more outpatient physician visits, and 50 or more specialist visits following the initial admission. Charlifue et al. (2004) noted that both the number and length of rehospitalizations were predicted by older age at injury, increased severity of SCI, marital status (unmarried), presence of an indwelling catheter, and hospitalization within 5 years. Middleton et al. (2004) reported shorter times to readmission in individuals with more severe impairment, with AIS grades A-C readmitted between 26-36 months and AIS grade D readmitted within 60 months.

Healthcare Utilization

Individuals with SCI utilize many aspects of the healthcare system more frequently than others, especially in the first year following rehabilitation discharge. Three Canadian studies determined the rates of physician contacts for persons with SCI returning to the community following initial rehabilitation. Guilcher et al. (2010) and Munce et al. (2009) examined several Ontario administrative healthcare databases and found similar numbers of overall physician visits for those with non-traumatic versus traumatic SCI. However, differences were observed in the types of physicians seen between the two groups. Women with SCI had significantly more physician visits than men in the first year following discharge and were more likely to visit their family physician, whereas men had significantly more visits to their physiatrist (Munce et al. 2009). Additionally, several individual factors were associated with a greater likelihood of physician visits including age, lower FIM scores, discharge to chronic care or other rehabilitation facilities, urban versus rural residence, or the presence of comorbidities/prior (in-hospital) complications (Guilcher et al. 2010; Munce et al. 2009). Using similar methodologies, Dryden et al. (2004) found the median number of physician visits was significantly higher in the first year. This is supported by Ronca et al. (2020), who found that 51% of participants attended their annual check-up within the first year. However, this declined dramatically by year two and year six. In all cases, age, gender, and geographically matched control subjects had significantly fewer physician visits each year. While no long-term data is available for physical and occupational therapy use, Martini et al. (2020) found that 78.1% of individuals received physical therapy within 12 months, and only 29.3% received occupational therapy. This is likely due to differences in SCI characteristics, level of impairment, and time since injury.

In Australia, a 5-year longitudinal study examining utilization patterns of Medicare-funded services in a randomly selected sample of 193 individuals with SCI, found substantially higher rates of family physician visits in comparison to the general population, matched for age and gender (Amsters et al. 2014). Young men (25-34 years) were found to have the highest utilization. Interestingly, individuals with motor complete paraplegia were found to have the greatest need for primary health care, which may reflect increased autonomy, mobility, and fewer environmental barriers, or perhaps how persons with tetraplegia may access services differently (e.g., through public hospital clinics).

Donnelly et al. (2007) compared services received from family physicians and spinal injury specialists in the United States, Canada, and the United Kingdom, as well as the level of accessibility and satisfaction with those services in individuals aging with a chronic SCI. The authors reported that individuals with chronic spinal cord injuries seek out suitable primary healthcare and preventive services in variable ways, depending on the health delivery model. While the family doctor was the first choice for most people irrespective of country, significantly different utilization patterns emerged. Canadians were most likely to receive health care from family physicians, while Americans were most likely to receive care from specialists. Areas of service overlapped for ongoing spinal-related issues, such as bowel and bladder problems, and pain. However, concerns such as sexual health, alcohol use, functioning in the community and at work, relationships, and emotional issues were not addressed by either the family doctor or a spinal injuries specialist in 75% of the respondents.

More recently, Noonan et al. (2017) conducted a large community survey of 1549 people with SCI living in Canada and found that almost 90% of individuals visit their general practitioner yearly, while only 16% visit a physiatrist and 7.5% have SCI peer support. They demonstrated that multimorbidity and inappropriate healthcare utilization were associated with lower physical and mental health status, as well as lower quality of life. These authors proposed that individuals at risk of inappropriate health care utilization (e.g., rehospitalization, not being able to access care) should be flagged and their complex health needs addressed proactively by an interdisciplinary team. They suggested that a yearly check-up with such a team and the initiation of self-management programs may prevent long-term health problems and visits to an emergency department for preventable and low acuity conditions. Other researchers have also reported high rates of emergency department use for low acuity and potentially preventable conditions, suggesting that the emergency department may be used as an improper substitute for primary care for individuals with traumatic SCI up to 50% of the time (Guilcher et al. 2013). In particular, rurality was noted to be a significant predictor of emergency department utilization, reflecting that access to and availability of primary care physicians is more challenged in rural than in urban centers.

Despite several studies demonstrating that most people with SCI had visited a primary care provider and/or specialty care provider within the previous 12 months, around 20-25% of people are not satisfied with the service they received (Donnelly et al. 2007; Jakimovska et al. 2017). Similarly, in a national SCI survey of Canada, Noreau et al. (Noreau et al. 2014) reported around 13-15% of individuals receiving specialized or general care are somewhat or very dissatisfied with the support received from government agencies, community, and other organizations. In a survey of 108 wheelchair-dependent individuals living with SCI in the community, Stillman et al. (2014) reported that accessibility barriers were encountered during both primary and specialty care visits. The most prevalent barriers were inaccessible examination tables, lack of transfer aids, and lack of staff capable of assisting with patient transfers. Most participants had not been weighed during their visit and had been examined while fully clothed and sitting in their wheelchairs. Additionally, a high proportion of individuals did not receive routine and preventive screening tests, including colonoscopy over 50 years of age, mammogram in women aged over 50 years within last year, Pap smear within previous 3 years, or ever had a bone density scan.

Sippel et al. (2019) reviewed outcomes of veterans with SCI/D in the United States, who received a specialized home care program that included a comprehensive annual assessment and at least one home visit by a physician along with 1-2 monthly visits by a registered nurse, as well as by a social worker as needed. Although there were no changes in the number of emergency department visits, the number of hospital admissions, or LOS after the program, increased home care visits and mental health comorbidities significantly predicted more hospital admissions. Ullrich et al. (2013) showed that the combined presence of pain and depression or pain alone significantly predicted more admissions to a specialized center than did depression alone or having neither condition.

Most recently, Rapidi et al. (2018) published a European evidence-based position paper to guide professional practice in Physical and Rehabilitation Medicine (PRM) for persons with SCI, based on a systematic review of the literature and expert consensus process. The recommendations on aspects of health promotion, long-term follow-up, and early intervention to reduce rehospitalization and unwarranted healthcare utilization after rehabilitation, included that:

• PRM physicians monitor closely for complications and at a minimum annually review persons with SCI for neu­rogenic bladder dysfunction and their overall health sta­tus.

• Long-term follow-up, prevention, and management of secondary complica­tions (including pressure ulcers, neurogenic blad­der, bowel dysfunction, spasticity, neuropathic and nociceptive pain, heterotopic ossifi­cations, osteoporosis, sarcopenia, low energy fractures, orthostatic hypotension, cardiovascular and respiratory function including autonomic dysreflexia, sexuality-reproductive issues) are dealt with by the PRM physician and the multi-professional rehabilitation team.

• A robust system of primary healthcare and/or community-based rehabilitation, acces­sible to people with SCI, is offered, under the supervi­sion of a PRM physician, including annual comprehensive examination and appropriate specialized services by the multi-professional rehabilitation team as part of the long-term follow-up and provision of care for persons with SCI.
• PRM physicians continue long-term follow-up of persons with SCI, also when age­ing, aiming to meet the individualized needs of the per­son using diverse treatment strategies along with the lifespan of these persons with a life-long disability (see also EBPP for aging persons with disabilities).

Conclusions

Across several studies, there is level 2 evidence (from one cohort study: Cai et al. 2020), level 3 evidence (from one case control study: Dryden et al. 2004), and level 4 evidence (from seven case series: Charlifue et al. 2004; Dorsett & Geraghty 2008; Franceschini et al. 2003; Jaglal et al. 2009; Middleton et al. 2004; Paker et al. 2006; Savic 2000) and level 5 evidence (from one observational study: Cardenas et al. 2004) that hospital readmission is a significant issue for individuals with SCI in all regions.

There is level 5 evidence (from two observational studies: Cardenas et al. 2004; Charlifue et al. 2004) and level 4 evidence (from one case series: Middleton et al. 2004) that hospital re-admission rates are highest in the first year post-injury and then tend to decline in the first two years following injury.

There is level 4 evidence (from two case series: Dorsett & Geraghty 2008; Jaglal et al. 2009) that rehospitalization rates stabilize at a significantly high rate over time.

There is level 2 evidence (from four cohort studies: Mashola et al. 2019; Ruediger et al. 2019; Sharwood et al. 2019; Skelton et al. 2019), level 3 evidence (from one case control: Dryden et al. 2004) supported by level 4 evidence (from 6 case series: Dorsett & Geraghty 2008; Franceschini et al. 2003; Jaglal et al. 2009; Middleton et al. 2004; Paker et al. 2006; Savic 2000) and level 5 evidence (from one observational study: Cardenas et al. 2004) that urinary problems (UTIs), pressure ulcers, respiratory infections, and musculoskeletal problems are consistently among the most frequent causes of emergency department visits and hospital readmissions in persons with SCI.

There is level 4 evidence (from three case series: Charlifue et al. 2004; Jaglal et al. 2009; Middleton et al. 2004) and level 5 evidence (from two observational studies: Cardenas et al. 2004; Sippel et al. 2019) that factors such as increased age, lower motor function, greater severity of injury, prior contact with the health system, rural habitation, mental health comorbidities and being unmarried are associated with a greater risk of hospital readmission.

There is level 3 evidence (from one case control study: Guilcher et al. 2010) supported by level 5 evidence (from two observational studies: Guilcher et al. 2013; Munce et al. 2009) that several factors are associated with a greater likelihood of physician visits including older age, lower FIM scores, discharge to chronic care or other rehabilitation facilities, rural residence, comorbidities or in-hospital complications.

There is level 3 evidence (from one case control study: Dryden et al. 2004) supported by level 5 evidence (from one observational study: Amsters et al. 2014) that persons with SCI have an increased number of physician contacts as compared to matched controls from the general population, especially in the first year post-injury.

There is level 5 evidence (from four observational studies: Amsters et al. 2014; Donnelly et al. 2007; Munce et al. 2009; Noonan et al. 2017) that individuals with chronic SCI seek out family physicians rather than specialists, irrespective of country. However, many critical health concerns (e.g., sexual health, emotional issues, or community reintegration) are not addressed by family physicians or specialists.

There is level 5 evidence (from one observational study: Guilcher et al. 2013) that emergency departments are often used as an improper substitute for primary care in individuals with SCI, particularly in rural areas, reflecting a lack of access to care for preventable conditions.

There is level 5 evidence (from four observational studies: Donnelly et al. 2007; Jakimovska et al. 2017; Noreau et al. 2014; Stillman et al. 2014) that a significant proportion of individuals with SCI experience accessibility barriers during physician visits, and do not receive routine screening or preventative testing and are not satisfied with the services received.