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Rehabilitation Practices

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.

Author Year; Country
Research Design
PEDro Score
Sample Size

 Methods

Outcomes
Rehospitalization

Cai et al. 2018; USA
Retrospective Cohort
Ninitial=300, Nfinal=300

 Population: Hospitalization Cohort (n=212): Mean age: 57.2±16.4yr; Gender: male=97.9%, female=2.1%, Level of injury: C4 and above=26, C5-C8=25, T1 and below=39: AISA A-C=90, D=105.
Emergency Department Cohort (n=145): Mean age: 58.2±16.3yr; Gender: male=98.1%, female=1.9%, Level of injury: C4 and above=23, C5-C8=12, T1 and below=26: AISA A-C=61, D=72.
Intervention: No intervention. Retrospective review of veteran affairs (VA) hospital utilization versus non-VS hospital and emergency department utilization in veterans with SCI from 1999 to 2014.
Outcome measures: Emergency Department (ED) visits and hospitalizations.
  1. Emergency department visits:
    1. Within one year of initial rehabilitation, 47% of veterans visited the ED for a total of 168 times, with a mean of 1.16 visits per person.
      1. 42.6% visited an ED once
      2. 30.9% visited twice
      3. 26.5% visited three or more times
    2. ED visits were equally distributed between VA and non-VA facilities (44% versus 56%).
  2. Hospitalizations:
    1. Within one year of initial rehabilitation, there were 247 hospitalizations among 212 veterans, with a mean of 1.17 hospitalizations per person.
      1. 51.5% were never hospitalized
      2. 49.5% experienced at least one hospitalization
      3. 18.1% were hospitalized twice
      4. 39.1% were hospitalized three or more times
    2. The majority of hospitalizations were admitted to VA facilities (67%) versus non-VA facilities.

Mashola et al. 2019; South Africa
Retrospective Cohort
Ninitial=543, Nfinal=543

 Population: Age range=7-87yr; Gender: male=407, female=136, Level of injury: paraplegia=331, tetraplegia=208, unknown=4; Severity of injury: complete=317, incomplete=149, unknown=4.
Intervention: No intervention. Retrospective review of readmission rates within 5yr of rehabilitation in patients with SCI in South Africa.
Outcome measures: Readmission rate, cause of readmission.
  1. Of the total population, 100 patients were readmitted.
  2. Of the patients readmitted;
    1. 28 were admitted for a second readmission
    2. 10 were admitted for a third readmission
    3. 2 were admitted for a fourth readmission
  3. The most common cause of readmission was secondary health conditions (80%), followed by further need for rehabilitation (12%).
  4. The most common secondary health conditions were:
    1. Pressure ulcers (39%)
    2. Urinary tract infections (12%)
    3. Deteriorating neurological status (6%)
    4. Constipation (3%).

Rate of readmission was greater for those with paraplegia than those with tetraplegia (p=.0), as well as those with incomplete injury (p=.001).

Ruediger et al. 2019; USA
Cohort
Ninitial=176, Nfinal=176

 Population: Mean age=44.2±19.9yr; Gender: male=121, female=4, Level of injury: paraplegia=46%, tetraplegia=54%, low tetraplegia=31; Severity of injury: AIS A-C=116, D=27.
Intervention: Specialized medical home care: medication education, one month of discharge medications, proactive phone calls to patients, 24/7 hotline to reach physician/nurses, multidisciplinary outpatient follow-up and proactive case management.
Outcome measures: Hospital readmission and emergency department (ED) visits.
  1. Within the first year following discharge from an inpatient rehabilitation hospital, 30% of individuals were readmitted.
  2. Within the first year of SCI onset, 24% were readmitted.
  3. Of those admitted, 81% of readmissions were related to SCI.
  4. The most common causes for readmission were urologic pathologies (39%), respiratory complications (19%), infections (15%) and cardiovascular problems (11%).
  5. Within the first year following discharge from an inpatient rehabilitation hospital, 41% visited the ED.
  6. Within the first year of SCI onset, 36% visited the ED.
  7. Of visits to the ED, 55% resulted in admission.

Of ED visits that did not result in admission, 85% were related to SCI.

Sharwood et al. 2019; Australia
Retrospective Cohort
Ninitial=740, Nfinal=740

 Population: Mean age=not reported; Gender: male=638, female=102, Level of injury: cervical=161, thoracic=258, lumbosacral=424; Severity of injury: not reported.
Intervention: No intervention. Retrospective review of health and health service costs related to readmission in patients who sustained work-related traumatic SCI in New South Wales, Australia from 2013-2016.
Outcome measures: Readmission, reason for readmission, cost of readmission.
  1. Within 28 days of discharge, 8% experienced unplanned readmission episodes, with over half relating to a primary diagnosis of care involving rehabilitation.
  2. Other reasons for readmission included device complications/infections (7.5%), genitourinary or respiratory infections (10%) or mental health needs (4.3%).

The mean readmission cost was $6946±$14 532 per patient.

Skelton et al. 2019; USA
Retrospective Cohort
Ninitial=2414742, Nfinal=2414742

 Population: Inpatient Hospitalizations: Cervical, Quadriplegia (n=690 742) Mean age=51±33yr; Gender: male=70.3%, female=29.7%;
Thoracic, Lumbar, Sacral, Paraplegia (n=967 273) Mean age=52±34yr; Gender: male=66.3.3%, female=33.7%.
C (n=690 742) Mean age=51±33yr; Gender: male=70.3%, female=29.7%.
ED Visits: Cervical, Quadriplegia (n=197 147) Mean age=46±31yr; Gender: male=75.1%, female=24.9%.
Thoracic, Lumbar, Sacral, Paraplegia (n=398 424) Mean age=45±31yr; Gender: male=72.1%, female=27.9%.
Intervention: No intervention. Retrospective review and cost analysis of emergency department (ED) visits and inpatient hospitalizations for genitourinary (GU) complications in patients with SCI from 2006 to 2015.
Outcome measures: Incidence of GU complication, ED visit, hospitalization, mortality, medical costs.
  1. The proportion of SCI-related hospitalizations due to GU complications increased 2.5% annually from 2006 to 2011 and 0.9% from 2011 to 2015.
  2. Hospitalized patients tended to be:
    1. Male (57-70%)
    2. Non-Hispanic white (54-64%)
    3. Older than those released from the ED
    4. Principle diagnoses were septicemia (13.4%), rehabilitation care (6.8%) and UTIs (6.7%)
  3. Age (55 to 80), level of injury (cervical injuries or quadriplegia) and payer source (underinsured or uninsured) were positively correlated to in hospital mortality.
  4. Patients with cervical injuries or quadriplegia were 72% more likely to die in hospital and twice as likely to die during an ED visit.
  5. Patients that are uninsured or underinsured were 25% more likely to die in hospital and 67% more likely to die during an ED visit.
  6. The costs of GU-relayed health care use exceeded $4 billion over the study period.

Sippel et al. 2018; USA
Observational
Ninitial=180, Nfinal=125

 Population: Mean age: 63±12.5yr; Gender: male=121, female=4, Level of injury: paraplegia=39, high tetraplegia=15, low tetraplegia=31; Severity of injury: AIS A=35.2%, C=20%, D=19.2%, E=3.2%, unknown=12.8%.
Intervention: No intervention. Retrospective review of Spinal cord injury home care program (SCIHCP) on health care utilization and mortality in patients with SCI.
Outcome measures: VA North Texas Health Care System (VANTHCS) hospital admissions, LOS, Emergency Department (ED) visits, mortality.
  1. No significant changes in number of ED visits, number of hospital admissions, or LOS were observed (p>0.05).
  2. Increased home care visits and mental health comorbidities significantly predicted more hospital admissions (p<0.05).
  3. Older patients and those with more mental health comorbidities were more significantly likely to experience increased LOS (p<0.05).
  4. Prediction models were significant after adjusting for injury level, age, race, time since SCI and number of medical comorbidities.
  5. More home care visits were significantly associated with lower likelihood of mortality post-enrollment (p<0.05).

Noonan et al. 2014; Canada
Observational
N=1549

 Population: Traumatic SCI; Mean age: 48.3±13.3yr; mean time since injury: 18.5±13.1yr; Gender: male=806, female=331, Injury group: tetraplegia, AIS A/B=229; tetraplegia, AIS C/D=301; paraplegia, A/B=361; paraplegia, C/D=184; unknown=62.
Intervention: No intervention. Community survey of people with SCI living in Canada.
Outcome measures: Health care utilization (HCU), categorized into three groups: group 1, did not receive needed care and/or rehospitalized; group 2, received needed care but rehospitalized; and group 3, received needed care and not rehospitalized. Other measures included multimorbidity (number of 30 comorbidities/ complications); secondary health conditions; Short Form-12.
  1. 26.1% of all participants reported being rehospitalized at least once in the last 12 months (with an average length of stay 23.5±46.7 days).
  2. Most participants (89.4%) reported seeing at least one health care professional (HCP) in outpatient setting in the previous 12 months. The mean frequency of HCP contact was 32.7±62.0 times, with a mean of 3.5±2.7 different types of HCPs seen.
  3. The most common type of HCP seen was a general practitioner (79.5%), followed by an allied health professional (57.6%). Among specialist physicians, seeing a urologist was common (38.6%).

Multimorbidity was significantly associated with inappropriate HCU (group 1, did not receive needed care and/or rehospitalized) and together these factors were associated with lower health status.

Ullrich et al. 2013; USA
Observational
Ninitial=448, Nfinal=286

 Population: Mean age=53yr; Gender: male=97%, female=3%; Level of injury: T2-S4/S5=49%, C5-T1=38%, C1-C4=13%; Severity of injury: not reported.
Intervention: No intervention. Standardized psychological evaluations were reviewed from 2005 to 2008 to examine comorbid pain and depression in patients with SCI at a specialty care centre.
Outcome measures: Medical and demographic information, depression scale, pain scale. 
  1. Approximately 20% of the sample showed elevated pain and depression at one yr.
  2. Patients with elevated pain and depression showed higher scores on those measures than patients with either pain or depression alone.
  3. Pain scores were stable over time.
  4. Depression scores improved over three years, however, patients with more pain and depression showed less improvement on depression scores that those with depression alone.
  5. Presence of pain and depression and pain alone were associated with significantly more inpatient admissions to a SCI specialty centre than for depression alone or neither condition.
  6. Presence of pain and depression and depression alone were associated with significantly more outpatient and psychology visits to a SCI specialty centre than for pain alone or neither condition.

Dryden et al. 2004; Canada
Case Control
Ninitial=233, Nfinal=233

 Population: Traumatic SCI; Median age: 34.0yr; Gender: males=176, females=57; Level of injury: Cervical=117, Thoracic, Lumbar, Sacral or Cauda Equina=98; Severity: Complete=43, Incomplete=69, Unknown=121.
Intervention: Retrospective analysis (population-based) of cases of traumatic SCI between 1992-1994 from 5 administrative healthcare databases (Province of Alberta). Control subjects registered with the Alberta health system were matched by age, gender and region at a ratio of 5:1).
Outcome Measures: Rehospitalization, Health care utilization, mortality and secondary complications followed over a 6yr period post-injury.
  1. 57.3% of persons were rehospitalized over the 6 yr follow-up period with a median LOS of 4.0 d/hospital stay.
  2. After initial discharge, persons with SCI had 2.6 more hospital visits than matched controls.
  3. Persons with SCI had a median # of physician contacts of 22.0 in yr 1, declining to 8.0 by yr 2 and to 4.0 by yr 6. Controls had fewer physician contacts for each year (median =3.0).
  4. 20 (8.6%) died during initial hospitalization and 16 (7.5%) died during 6 mo follow-up and this was a greater mortality rate with SCI as compared to controls (p<0.001). Over the 6 yr follow-up 47.6% were treated for a UTI, 33.8% for pneumonia, 19.7% for decubitus ulcer and 15.5% for septicemia.

Jaglal et al. 2009; Canada
Case Series
Ninitial=559, Nfinal=559

 Population: Traumatic SCI; Age: 47.3±18.4 yr; Gender: males=423, females=136; Level of injury: Cervical=350, Thoracic=126, Lumbar=62, Other=21.
Intervention: Retrospective analysis (population-based) of cases of traumatic SCI between 2003-2006 from six administrative healthcare databases (Province of Ontario).
Outcome Measures: Rehospitalization rates, causes, predictors collected over a 1-yr period following rehabilitation discharge.
  1. 27.5% were rehospitalized to acute care in the 1st yr following initial rehab discharge.
  2. Main causes were musculoskeletal (23.1%), respiratory (11.5%), gastrointestinal (11.0%), urological (10.5%), cardiovascular (10.3%), psychological (9%) and skin (7.3%) disorders.
  3. Factors significantly associated with 1-yr rehospitalization in multivariate logistic regression were longer length of rehabilitation stay, rural residence, >50 outpatient physician visits and >50 specialist visits following the initial admission. Individual factors with highest likelihood (i.e., highest odds ratios) of being rehospitalized included: Total physician visits ≥ 50 (OR=3.69), Total specialist visits ≥ 50 (OR=2.95), rural residence (OR=1.94), presence of comorbidities with Charlson score ≥ 3 (OR=2.08), >70 years old (OR=1.72). Patients with SCI who were rehospitalized had significantly higher healthcare utilization. They had twice as many total physician and visits with specialists than their counterparts who were not rehospitalized. The mean number of total outpatient physician visits was 49.6 for the rehospitalized group (versus 25.8 for the not-rehospitalized group).

Cardenas et al. 2004; USA
Observational
NInitial=8668, Nfinal=1252

 Population: SCI: Level of injury: C1-4, C5-8, T1-S5; Severity of injury: AIS: A-D.
Intervention: Retrospective analysis of cases of traumatic SCI for persons with anniversary dates of 1, 5, 10, 15 or 20yr post-discharge occurring between 1995-2002 within the United States Model Systems database.
Outcome Measures: Discharge destination, causes for rehospitalization, predictors of rehospitalization.
  1. 90% of patients were discharged home from acute rehabilitation.
  2. The most common reasons for rehospitalizations included:
    1. Diseases of the genitourinary system.
    2. Diseases of skin and subcutaneous tissue.
    3. Diseases of the respiratory system.
    4. Other unclassified diseases.
    5. Diseases of the musculoskeletal system.
  3. At first yr follow up the average number of rehospitalizations were significantly higher than other follow-up yr (p<0.001). Rate was 55% in first yr and 36-38% thereafter.
  4. Rehospitalization rates were not significantly different among the different age groups.
  5. At 1 yr follow-up, rehospitalization was significantly related to:
    1. Lower motor FIM scores (p=0.000).
    2. Patients funded by state or federal programs (p=0.010).
  6. At 5 yr follow-up, rehospitalization was significantly related to:
    1. Lower motor FIM scores (p=0.000).
    2. Race, with Hispanics (p=0.009) and other races (p=0.027) were less likely than African Americans.

At 10 yr follow-up, only payer remained significantly related to rehospitalization rates (p=0.004).

Charlifue et al. 2004; USA
Case Series
Ninitial=7981, Nfinal=7981

 Population: Traumatic SCI: Age n=3254 ≤40 yr, 2908 ≥41 yr; Level of injury: All levels; Severity of injury: AIS: A-D.
Intervention: Retrospective analysis of cases of traumatic SCI with onset between 1973-1998 from the United States Model Systems database.
Outcome Measures: Number and causes of rehospitalization, days rehospitalized, number of pressure ulcers, self-assessed health status and Satisfaction with Life Scale collected at 1, 5, 10, 15, 20 and 25yr post-injury.
  1. Rate of rehospitalization was 41% in yr 5 and significantly less (35-36%) thereafter (p=0.000)
  2. Average number of days rehospitalized was highest at year 5 (6.0 days) and significantly less thereafter in a progressive fashion (from 5.4 days at year 10 to 3.7 days by year 25). (p=0.002)
  3. Perceived health status and SWLS was generally high and pain scores generally low

Both # of rehospitalizations and a greater # of days rehospitalized were predicted by being older at injury, being unmarried, having an indwelling catheter, having a more severe SCI and having been hospitalized 5 years earlier.

Middleton et al. 2004; Australia
Case Series
Ninital=432, Nfinal=432

 Population: Individuals with SCI rehospitalized between 1990-1991, 1999-2000; Traumatic SCI; Gender: males=338, females=94; Level of injury: paraplegia=199, tetraplegia=229, unclassified=4; Severity of injury: AIS: A=206, B=27, C=67, D=132.
Intervention: Data from spinal cord injured patients was retrospectively analyzed.
Outcome Measures: Causes for rehospitalization, predictors of rehospitalization.
  1. 253 persons (58.6%) (³12 months post injury) required rehospitalization for a spinal-related cause on at least one occasion during the 10yr study period (total readmissions =977; 15,127 bed-days; avg length of stay =15.5d; median 5d).
  2. ~ 10% were readmitted five times or more.
  3. Overall rehospitalization rate in the first 12 mo post discharge =0.64 readmissions per person at risk and decreases to ~0.4 readmissions per person at risk 10yr post acute admission).
  4. Average length of stay was significantly longer for those with AIS A, B and C (22.2 – 17.0 d) compared to AIS D (11.3 d).
  5. The most common causes for rehospitalization included:
    1. Complications of the genitourinary system (n=235 (24.1%)), (125 persons (28.9%))
    2. Gastrointestinal (GIT)-related (n=107 (11.0%)), (69 persons (16.0%))
    3. Skin pressure areas (n=87 (8.9%)), (40 persons (9.3%))
    4. Musculoskeletal (n=84 (8.6%)), (60 persons (13.9%))
    5. Other causes included Neurological (n=30 (3.1%)); Respiratory (n=44 (4.5%)); Cardiovascular (n=47 (4.8%)); Endocrine (n=7 (0.7%)); Psychiatric (n=66 (6.8%)); Other (n =270 (27.6%))
  6. The costliest cause of readmission in terms of bed-occupancy, were the skin-related complications (pressure sores: 6.6% of all readmissions, accounted for 27.9% of bed-days and average length of stay=65.9 d)
  7. Depending on the complication, age and level and completeness of neurological impairment influenced differential rates of readmission; AIS D=43.2%; AIS A, B and C=55.2-67.0% (p<0.0001)
  8. Mean duration to first readmission=46 mo (AIS A-C=26-36 mo, AIS D=60 mo). Overall rehospitalization (and bed occupancy) rates trended downwards over time, yet rates were high in the first 4 yr after discharge (0.64 readmissions per person, 12.6 bed-days) before decreasing to 0.35 (2.0 bed-days) as the 10th yr approached.

Franceschini et al. 2003; Italy
Case Series
Ninitial=251, Nfinal=146

 Population: All individuals with SCI hospitalized 1989-1994. Mean age =37.8 yr; Gender: males=104, females=42; Level of injury: Cervical=36.4%, Thoracolumbar=63.7%; Severity of injury (Frankel): A=44.6%, B=2.7%, C=13%, D=39.7%; Time since injury=6.1 yr; Traumatic =74.7%, Non-traumatic 25.3%.
Intervention: Cross-sectional telephone questionnaire of various rehabilitation outcomes.
Outcome Measures: Custom questionnaire including rehospitalization among other things (i.e., state of health, occupation, mobility, autonomy, social and partner relationships, satisfaction with QoL) collected at mean of 6.1 yr post-discharge.
  1. 25.3% respondents had been hospitalized once in the past year, most frequently for urological problems (22.9%), spasticity (11.4%) and rehab treatment (11.4%).

Savic et al. 2000; UK
Case Series
Ninitial=198, Nfinal=198

 Population: Mean age: 57.5 yr; Gender: males =84.8%, females=15.2%; Level and severity of injury (AIS): paraplegic ABC=97, tetraplegic ABC=61, D=40; Time since injury=33 yr.
Intervention: Individuals with SCI were interviewed three times 1990-1996 and their medical records were reviewed.
Outcome Measures: Readmission rates, reasons for readmission, LOS, FIM score, CHART score.
  1. 64% of patients had 1 or more readmissions between 1990 and 1996.
  2. Mean length of stay per readmission was 12.03d.
  3. Reasons for readmission included:
    1. Urinary system complications (40.5%).
    2. Skin problems (17%).
    3. Digestive system (10%).
    4. Musculoskeletal system (8.7%).
    5. Nervous system complications (6.9%).
  4. Highest reason for bed occupancy was skin problems.
  5. No significant difference in readmission rates was seen in:
    1. Level of injury of the patients.
    2. Current age of patients.
  6. Patients with Frankel/AIS grade D had significantly shorter LOS than patients with A, B or C grade (p=0.005).
  7. There was significant difference between hospitalized patients and non-hospitalized patients in:
    1. Patients hospitalized were paralyzed for 2yr longer than the non hospitalized group (p=0.012).
    2. Hospitalized patients had a lower FIM score than non-hospitalized (p=0.031).

Hospitalized patients had a lower CHART physical independence score (p=0.003) and CHART occupation score (p=0.001).
Healthcare Utilization

Ronca et al. 2020; Switzerland
Observational
Ninitial=1294, Nfinal=1294

 Population: Median age=57yr; Gender: male=918, female=376, Level of injury: paraplegia=811, tetraplegia=341; Severity of injury: complete=416, incomplete=736.
Intervention: No intervention. Community survey of facilitators and barriers to using SCI-specialized outpatient and inpatient care from the Swiss Spinal Cord Injury Cohort Study conducted between 2017 and 2018.
Outcome measures: attendance of annual check-up at SCI-specialized treatment facility, utilization of SCI-specialized outpatient care, utilization of SCI-specialized inpatient care.
  1. In the last 12 months, 51% of the participants attended their annual check-up, 33% utilized SCI-specialized outpatient care, 44% were hospitalized at a SCI center.

Martini et al. 2020; Germany
Observational
Ninitial=1479, Nfinal=1479

 Population: Mean age=55.3±14.6yr; Gender: male=1076, female=401, Level of injury: paraplegia=730, tetraplegia=696; Severity of injury: complete=489, incomplete=964.
Intervention: No intervention. Survey to determine the utilization of physical therapy and occupational therapy following SCI, over a period of 12mo.
Outcome measures: Physical therapy and occupational therapy utilization.
  1. In the past 12mo, 78.1% received physical therapy and 29.3% received occupational therapy.
  2. Physical therapy and occupational therapy were significantly associated with time since SCI occurrence, participation in lifelong care programs, and electric wheelchair dependency (p<.05).
  3. SCI characteristics, level of impairment and time since SCI had a greater impact on occupational therapy than on physical therapy utilization.

Jakimoversuska et al. 2017; Norway
Observational
Ninitial=165, Nfinal=147

 Population: Mean age: 50±9yr; Gender: male=120, female=27, Level of injury: tetraplegia=53, paraplegia=94; Severity of injury: AIS A=99, B=11, C=11, D=18, E=5.
Intervention: No intervention. Retrospective review of health-status/psychological distress and self-reported utilization of healthcare services in patients with SCI (interviewed in 2004/05).
Outcome measures: Health service use and satisfaction, General Health Questionnaire-20 (GHQ-20).
  1. Most participants received SCI follow-up health services at least once after their initial rehabilitation; 34% were satisfied, 51% neutral, and 18% not satisfied with services received.
  2. 34 cases of psychological distress were identified using the GHQ-20. These cases did not significantly differ from non-cases in terms of demography, time since injury, cause of injury, injury severity, marital status or employment status.

Amsters et al. 2014; Australia
Observational
Ninitial=270, Nfinal=193

 Population: Mean age: 43yr; Gender: male=159, female=34, Level of injury: paraplegia=87, tetraplegia=106; Severity of injury: AIS A=83, B=20, C=16, D=74.
Intervention: No intervention. Analysis of general practitioner (GP) utilization patterns in individuals with SCI, over a 5yr period.
Outcome measures: General Practitioner use.
  1. Compared to the general population, young men with SCI used GP services significantly more (p<0.05).
  2. Individuals with paraplegia used GP services significantly more than individuals with tetraplegia (p<0.05).
  3. There is a need for specialist SCI outreach teams.

Noreau et al. 2014; Canada
Observational
Ninitial=1549, Nfinal=1549

 Population: Mean age: 49.6±13.9yr; Gender: male=67.2%, female=32.8%, Level of injury: paraplegia=57.8%, tetraplegia=42.2%; Severity of injury: AIS A=36.7%, B=7.5%, C=19.5%, D=20.6%, E=2.4%, unknown=13.3%.
Intervention: No intervention. Survey examining the life situation of people with SCI living in Canada.
Outcome measures: Community survey examining demographic, health, SCI-specific needs, community participation, employment, quality of life, health care utilization, satisfaction and overall health. 
  1. SCI-specialized health care needs met in 60% and 65% of individuals with traumatic and non-traumatic injuries, respectively.
  2. Some major needs for services to support community living (e.g., equipment and technical aids, health care, transportation, and accessible housing) are met for 75% of a population living with SCI. This proportion decreased to less than 50% for individuals requiring income support, healthy living, emotional counselling or job training.
  3. Complications are highly prevalent for some health issues, including pain, sexual dysfunction, spasticity, UTI and musculoskeletal disorders.
  4. Extent of community participation varies tremendously among daily activities and social roles based on values and preferences.
  5. Some dimensions of quality of life are rated positively (e.g., family life) while others are disrupted (e.g., sex life and physical health).
  6. 13.2% of Individuals receiving general care and 14.7% of individuals receiving SCI-specialized care are somewhat or very dissatisfied with the ability of government agencies, community and other organizations ability to meet their needs.
  7. These findings varied significantly between people with traumatic and non traumatic lesions (p<0.05).

Stillman et al. 2014; USA
Observational
Ninitial=108, Nfinal=108

 Population: Mean age: 48±14yr; Gender: male=55.6%, female=44.4%, Level of injury: tetraplegia=43.5%, paraplegia=52.8%; Severity of injury: complete SCI=61.1%, incomplete SCI=38%; Time since injury: 18±13yr.
Intervention: No intervention. Observational study using an internet-based survey to determine to healthcare utilization and barriers experienced by individuals with SCI.
Outcome measures: Health care utilization during the past year, barriers encountered when accessing health care facilities, and receipt of routine care and preventative screenings.
  1. All but one participant had visited a primary care provider within the past 12 mo and 85% had ≥1 visit to speciality providers.
  2. Accessibility barriers were encountered during both primary care (91.1%) and specialty care (80.2%) visits.
  3. The most prevalent barriers were inaccessible examination tables (primary care 76.9%; specialty care 51.4%) and lack of transfer aids (primary care 69.4%; specialty care 60.8%), as well as lack of staff capable of assisting with patient transfers (in about 40%).
  4. Most participants had not been weighed during their visit (89%) and had been examined while fully clothed and sitting in their wheelchair (85.2%).
  5. A high proportion of individuals did not receive routine and preventive screening tests, including colonoscopy over 50 years of age (40%), mammogram in women aged over 50 years within last year (60%), Pap smear within previous 3 years (40%), or ever had a bone density scan (55%).

Guilcher et al. 2013; Canada
Observational
Ninitial=1515, Nfinal=1217

 Population: Mean age=49.5±19.1yr; Gender: male=912, female=305; Level of injury: cervical=773, thoracic=277, lumbar=127, other=40; Severity of injury: not reported; Time since injury: 6yr period following injury.
Intervention: No intervention. Retrospective analysis of administrative data sets from 2003-2009 to determine the patterns and characteristics of emergency department visits (ED) in individuals with SCI.
Outcome measures: Number of emergency department (ED) visits by year post-injury, acuity level, timing of visits, reasons for visits.
  1. The total number of ED visits over 6-yr period was 4403, 1443 (33%) as low acuity and 2208 (50%) as high acuity.
  2. Of the total number of visits, 752 (17%) were classified as potentially preventable, with the majority of these related to UTI (51.2%), followed by pneumonia (12.1%).
  3. The majority of individuals, regardless of acuity level, did not see a primary care practitioner on the day of the ED visit.
  4. The number of visits was higher in the first year following injury, with 110 visits per 100 persons (45.3% of sample visited the ED), and remained substantially high up until 6 years following injury (34.5% of sample 6yr post-injury visited ED).
  5. Differences in ED patterns were observed based on the rurality index, as higher ED use was noted for individuals living in rural areas compared with those in more urban settings.

Guilcher et al. 2010; Canada
Case Control
Ninitial=1562, Nfinal=1562

 Population: Non-traumatic (n=1002) and Traumatic (n=560) SCI; Age at admission: 46.9±17.3 and 61.6±15.8yr; Gender: males =75.4% and 52.2%, females =24.6% and 47.8%; Level of injury: Paraplegia =38.6% and 39.5%, Tetraplegia =47.1% and 18.6%, Other =14.3% and 41.9%.
Intervention: Retrospective analysis (population-based) of cases of traumatic SCI between 2003-2006 from 3 administrative healthcare databases (Province of Ontario).
Outcome Measures: Health care utilization collected over a 1yr period following rehabilitation discharge. Predictors of health care utilization included length of stay in rehab, FIM score, rurality index, comorbidities (Charlson Index), Socioeconomic Status.
  1. Mean number of overall physician visits was 31.2 and 29.7 for non trauma and trauma respectively. 16.5 and 17.0 for specialist visits. In both cases there was no significant difference in number of visits between non-traumatic and traumatic although there were differences in the types of physicians being visited.
  2. Individual factors with highest likelihood (i.e., highest odds ratios) of ≥ 30 physician visits included: lowest quartile FIM @ discharge (OR=1.83), urban (OR=1.59), comorbidities (OR=1.56), ≥ 60 yr old (OR=1.54).
  3. Individual factors with highest likelihood (i.e., highest odds ratios) of ≥ 20 specialist visits included: comorbidities (OR=2.05), urban (OR=1.92), paraplegia (OR=1.53), lowest quartile FIM @ discharge (OR=1.51).

Munce et al. 2009; Canada
Observational
Ninitial=936, Nfinal=559

 Population: Traumatic SCI; Age: 47.3±18.4yr; Gender: males=423, females=136; Level of injury: Cervical=350, Thoracic=126, Lumbar=62, Other=21. Severity of injury: not reported.
Intervention: No intervention. Retrospective review of physician utilization patterns (family physicians (FPs), specialist and emergency department visits) 1-yr after initial injury in population-based cohort of cases of traumatic SCI between 2003/04-2005/06 from 5 administrative healthcare databases (Province of Ontario).
Outcome Measures: Physician utilization (including family physician, specialist, emergency physician, etc.), rurality index, comorbidities (Charlson Index) collected over a 1-yr period following rehabilitation discharge.
  1. Mean number of physician visits during the first yr after injury onset was 31.7.
  2. Women had significantly more physician visits than men (37.0 versus 30.0, p=0.006)
  3. FPs has the greatest number of visits, followed by physiatrists.
  4. Women had significantly more visits to their family physician than men (15.4 versus 10.3, p<0.001)
  5. Men had significantly more visits to their physiatrists than women (6.6 versus 4.5, p<0.028).
  6. Individual factors with highest likelihood (i.e., highest odds ratios) of 50 or more physician visits included: >70 years old (OR=3.64), direct discharge to chronic care (OR=3.62), in-hospital complication (OR=2.34), thoracic injury level (OR=1.81), direct discharge to rehabilitation (OR=1.69).
  7. Individual factors with highest likelihood (i.e., highest odds ratios) of 50 or more specialist visits included: direct discharge to chronic care (OR=11.52), direct discharge to rehabilitation (OR=2.45), in-hospital complication (OR=1.99).
  8. Only rurality significantly predicted two or more visits to the emergency department (p<0.05).

Dorsett & Geraghty 2008; Australia
Case Series
Ninitial=53, Nfinal =46

 Population: Mean age=32yr; Gender: males =42, females=4; Level of injury: paraplegia=19, tetraplegia=27; Severity of injury: complete=16, incomplete=30.
Intervention: 10yr data from those with acute traumatic SCI discharged from the Spinal Injuries Unit of the Queensland Spinal Cord injuries Service from November 1992 to March 1994 was assessed.
Outcome Measures: Mortality, Life situation questionnaire, medical service utilization, hospital admission (including reason for admission) and occurrence of pressure sores collected at discharge, 12mo, 24mo, 36mo and 10yr.
  1. 9% mortality rate was seen within 3 yr of study.
  2. Life situation questionnaire mean scores remained consistent over the 10 yr.
  3. The highest percentage of medical service utilization (10 or more) was at 2 yr, while the lowest was at the 10th yr (only 3) 9%.
  4. No significant change was seen in the number of hospitalizations or length of stay over time.
  5. Overall 32% of patients were rehospitalized in the first 2 yr and 52% by the 10th yr.
  6. Only 11% of individuals required rehospitalization for longer than 28 d.
  7. Common reasons for rehospitalization included: pressure sores, UTI, bowel obstructions, pneumonia, surgical removal spinal instrumentation, fractures and renal tract calculi.
  8. At 2 yr, reasons for rehospitalization were directly related to SCI, while at 10th yr SCI complications were not related to rehospitalization.
  9. Pressure sore occurrence was highest at the 2nd yr, however no significant change in the number of pressure sores occurred over time.

Half the patients reported no pressure sores over the study period, while 30% tended to have pressure sores at multiple points of time.

Donnelly et al. 2007
United States, Canada and United Kingdom
Observational
Ninitial=373, Nfinal =373

 Population: Community survey: Mean age (combined sample)=58.7±9.5yr; mean time since injury=35.9±7.5yr; Gender: males=315, females=56; Injury group: tetraplegia, AIS A-C=130; paraplegia, AIS A-C =160; All AIS D lesions=76.
Intervention: No intervention. Cross-sectional study of long-term health following a spinal cord injury, with comparison across three distinct health-care delivery models in Canada, United States and United Kingdom.
Outcome Measures: Health Care Questionnaire to measure utilization, access and satisfaction with health services.
  1. Almost all individuals (93%) reported having a family doctor, whereas only two-thirds had a spinal injuries specialist (63%) and 56% had both a family doctor and spinal injuries specialist.
  2. About half (49%) of sample saw another medical specialist besides the spinal injuries specialist.
  3. The average number of specialist contacts/yr was 1.5.
  4. Over two-thirds of individuals consult their family doctor for new problems, spinal cord injury-related problems (such as fatigue, pain, bowel and bladder problems), preventive health services (annual physical, female breast exam, blood tests and urine specimen) and personal problems.
  5. Unique items for spinal injuries specialists are routine rehabilitation follow-up, urinary ultrasound and neurological exam.
  6. In more than 75% of participants, issues such as sexual health, alcohol use, community functioning and emotional issues were not addressed by either family doctor or spinal injuries specialist.
  7. Significant differences were found in utilization among Canada, United States and UK, with Canadians most likely to receive health care from family physicians and Americans most likely to receive care from specialists. Access to and satisfaction with health services were similar.

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.

Hospital readmission occurs frequently for persons with SCI (particularly the first year post-injury), with UTIs, pressure ulcers, respiratory infections, and musculoskeletal problems among the most frequent causes.

Persons with SCI have more physician contacts than the general population, particularly in the first year post-injury.

Persons with chronic SCI are more likely to seek out family physicians than specialists; however, a significant proportion are not satisfied with the services received as accessibility barriers, lack of routine screening, and critical health concerns are often not addressed.

A lack of access to care for preventable conditions often leads to emergency department visits as a substitute for primary care, particularly in rural areas.

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