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Rehabilitation Practices

Rehabilitation Length of Stay

Several authors have made comparisons of rehabilitation LOS between countries or across other jurisdictions (Burke et al. 1985) (Chan & Chan 2005; Muslumanoglu et al. 1997; Pagliacci et al. 2003). Additionally, others have noted the trend for progressively shorter LOS over the past several decades, especially in the United States (De Vivo et al. 1991; M. DeVivo 2007; Eastwood et al. 1999; SA. 1999) although there is also data from Israel that shows this as well (Ronen et al. 2004). Stover (1995) noted that reductions in the 1970s and early 1980s were likely due to increased efficiency of rehabilitation teams. More recent reductions in the United States have been attributed to restrictions imposed by payers (SA. 1999). Table 2 summarizes various reports in the literature for LOS organized by jurisdiction and also by the time period for which the data was collected. Data were only included in this table if the underlying sample was deemed representative of an overall heterogeneous population of individuals with SCI (i.e., unselected sample of a single or multi-centre study). Some data was included and grouped for evaluating specific issues and this has been appropriately indicated. In addition, data from studies for which it was not clear that the purpose of admission was for comprehensive inpatient rehabilitation (and may have involved acute care) were not included.

Study
Jurisdiction
Population
N, Trauma &/or Nontrauma

Sample Period

Length of Rehabilitation Stay
(Days)
(Mean unless otherwise stated)

Franceschini et al. 2020; Switzerland
(multi-centre)
497, Trauma

2013-2014 135 (Median)

Scivoletto et al. 2020; Italy
(single centre)
414, Trauma & nontrauma

1996-2020 180.4±93 (1)
154.5±84.8 (2)
(1) Complications versus (2) No Complications

Zhenrong et al. 2020; China
(single centre)
2110, Trauma

2010-2019 113.5

Halvorsen et al. 2019; Norway
(single centre)
349, Trauma

2012-2016 120

Burns et al. 2017; Canada
(multi-centres)
16,579, Trauma

2004-2015
2007-2008
2012-2013
2010-2015
2007-2010
2010
2003-2014
2009-2010
2002-2007
2005-2008
2000-2009
2004-2008
2006-2010
2000-2007

89
138
60
36
17
25
28
227.6
207
55.8
169
55
41.3
73.6
(Median)

Ponfick et al. 2017; Germany
(single centre)
113, Trauma & nontrauma
2013-2016 57.7

Whiteneck et al. 2012; USA
(multi-centre)
1,376, Trauma

2007-2009 55.7
Zanca et al. 2013; USA
(multi-centre)
1,357, Trauma
2007-NR 57

Whiteneck et al. 2011; USA
(multi-centre)
600, Trauma

2007-2008 54.6
National SCI Statistical Centre 2009; USA
(multi-centres)
26,852, Trauma
1973-1979
1980-1984
1985-1989
1990-1994
1995-1999
2000-2004
2005-2009

98
86
73
58
44
42
38
(Median)

DeVivo 2007; USA
(multi-centres)
24,332, Trauma

1973-1981
1982-1986
1987-1991
1992-1996
1997-2001
2002-2006
108
89
80
59
50
45

Pollard & Apple 2003; USA
(single-centre)
95, Trauma

47.3
Tooth et al. 2003; Australia
(single centre)
167, Trauma
1993-1998 83.0 (Median)
Ronen et al. 2004; Israel
(single centre)
1367, Trauma & Nontrauma
1962-1970
1971-1980
1981-1990
1991-2000
1996-2002

265±183 (1) 107±85 (2)
210±137 (1) 124±90 (2)
210±116 (1) 115±222 (2)
231±108 (1) 91±81 (2)
102±59 (1) 106±51 (2)
(1) Trauma versus (2) Nontrauma

Scivoletto et al. 2005; Italy
(single centre)
150, Trauma & Nontrauma

1997-2001 112.4±69.3

Scivoletto et al. 2003; Italy
(single centre)
150, Trauma & Nontrauma

1997-2001 98.7±68.13

Pagliacci et al. 2003; Italy
(multi-centre)
684, Trauma

1997-1999 135.5
Sumida et al. 2001; Japan
(multi-centre)
123, Trauma
1994-1997

185.6±130.4 (N=60) (1)
267.8±171.6 (N=63) (2)
(1) Early versus (2) delayed admission

Eastwood et al. 1999; USA
(multi-centre)
3,904, Trauma

1990
1991
1992
1993
1994
1995
1996
1997

74.0±41.1
77.3±42.0
80.9±46.9
70.1±44.0
57.6±35.5
60.1±37.1
54.3±34.9
60.8±38.7

Morrison 1999; USA
(single centre)
127, Trauma

1991
1995
95.8 (N=66)
54.2 (N=61)

Yarkony et al. 1990; USA
(single centre)
1382, Trauma

1972-1986 68.1 (1986 data only)
Heinemann et al. 1989; USA
(single centre)
338, unknown
1981-1985

84.9 (N=185) (1)
87.7 (N=153) (2)
1 Specialist versus 2 more general care

Yarkony et al. 1987; USA
(single centre)
711, Trauma

1973-1980

84.9 (N=185) (1)
87.7 (N=153) (2)
(1) Specialist versus (2) more general care

Rehabilitation LOS is also known to vary according to neurological status and data from studies reporting LOS organized by level of injury (i.e., paraplegia versus tetraplegia) or completeness are shown in Table 3. This is organized by jurisdiction (country) and the time period over which the sample was analyzed.

Study
Jurisdiction
Population
N, Trauma &/or Nontrauma
Sample Period

Length of Stay Result
(Mean – in days)
(±SD if available)

Whiteneck et al. 2012; USA
(multi-centre)
1,376, Trauma

2007-2009 · AIS ABC paraplegia – 44.8 (N=373)
· AIS ABC high tetraplegia – 74.5 (N=294)
· AIS ABC low tetraplegia – 66.5 (N=204)
· AIS D tetraplegia – 32.7 (N=161)
Whiteneck et al. 2011; USA
(multi-centre)
600, Trauma
2007-2008

· AIS ABC paraplegia – 44.9 (N=223)
· AIS ABC high tetraplegia – 74.1 (N=132)
· AIS ABC low tetraplegia – 64.9 (N=151)
· AIS D tetraplegia – 33.6 (N=94)

Chan & Chan 2005; China (Hong Kong)
(single centre)
33, Trauma

2002 · AIS D paraplegia – 79.42±20.07 (N=3)
· AIS ABC low paraplegia – 52.00±1.41 (N=2)
· AIS ABC high paraplegia – 55.8±43.0 (N=2)
· AIS D tetraplegia – 143.75±69.25 (N=4)
· AIS ABC low tetraplegia – 215.9±56.1 (N=7)
· AIS ABC high tetraplegia – 146.5±75.4 (N=6)

Ronen et al. 2004; Israel
(single centre)
1367, Trauma & Nontrauma

1962-2002 · A 267±182 (1) 231±128 (2)
· B 340±213 (1) 153±108 (2)
· C 203±130 (1) 112±77 (2)
· D 156±96 (1) 73±183 (2)
1 Trauma versus 2 Nontrauma

Tooth et al. 2003; Australia
(single centre)
167, Trauma

1993-1998

· Incomplete paraplegia – 43.0
· Complete paraplegia – 96.5
· Incomplete tetraplegia – 64.5
· Complete tetraplegia – 206.0
(Median)

Morrison 1999; USA
(single centre)
127, Trauma
1995
1991

· Paraplegia -46.7 Tetraplegia – 61.9
· Paraplegia -82.2 Tetraplegia – 110.9

DeVivo et al. 1990; USA
(single centre)
661, Trauma

1973-1985

· Incomplete paraplegia – 46.3 (1), 50.6 (2)
· Complete paraplegia – 62.2 (1), 62.9 (2)
· Incomplete tetraplegia – 59.7 (1), 71.3 (2)
· Complete tetraplegia – 90.4 (1), 83.8 (2)
((1) Early (N=284) versus (2) later (N=377) admitted patients)

Yarkony et al. 1990; USA
(single centre)
1382, Trauma

1972-1986 · Paraplegia – 54.3 (1986 data only)
· Tetraplegia – 82.8

Heinemann et al. 1989; USA
(single centre)
338, unknown

1981-1985

· Paraplegia – 68.7 (1), 70.7 (2)
· Tetraplegia – 98.0 (1), 103.4 (2)
(1) Specialist (N=185) versus (2) more general (N=153) care.

Yarkony et al. 1987; USA
(single centre)
711, Trauma

1973-1980

· Incomplete paraplegia – 78.2
· Complete paraplegia – 83.4
· Incomplete tetraplegia – 107.6
· Complete tetraplegia – 135.3

Woolsey et al. 1985; USA
(single centre)
100, Trauma
Unknown (pre 1985) · Paraplegia – ~105
· Tetraplegia – ~165

Discussion

As seen in Tables 2 and 3, rehabilitation LOS varies widely from country to country. While no investigators have systematically analyzed country-by-country variation it is apparent that the United States has typically shorter rehabilitation LOS compared to other countries reporting data. Most data originated in the United States, bolstered by the development of the United States model systems database, with reports from other countries for the most part limited to a handful of descriptions of single-centre experience.

Within the United States, the trend for progressively shorter rehabilitation LOS has continued to 2009. Across separate reports, authors (Center 2009; Center 2005; M. DeVivo 2007; Eastwood et al. 1999; SA 1999) have indicated reduced LOS from the period between 1973 to 2006. Eastwood et al. (Eastwood et al. 1999) examined the large United States Model systems database of individuals with traumatic SCI (N=3,904) and reported annual mean LOS values from 1990 to 1997. For these years, the highest value was 80.9 days in 1992 and the lowest was 54.3 days in 1996. Mean LOS values for 1990-1992 seemed stable at higher values, with 1994-1997 values lower and 1993 at an intermediate value. DeVivo et al. (2007) has reported on the same dataset over a longer period beginning in 1973 (N=24,333), to extend the trend to a LOS of 45 days in 2006. Morrison (SA 1999) performed a direct comparison of 1991 versus 1995 mean LOS values in the largest SCI rehabilitation in the United States in order to assess the effect of shorter rehabilitation LOS on functional outcomes. These authors confirmed an even more striking difference between these 2 years given an average LOS of 95.8 days in 1991 as compared to 54.2 days in 1995 (p<0.001). Other reports have described reductions over earlier periods, most notably multi-centre investigations associated with the United States Model Systems databases (De Vivo et al. 1991). These same trends are apparent by looking at the public data available from the United States National SCI Statistical Centre (Center 2009; Center 2005). The most recent reports with American data show that LOS continues to average approximately 54.6-57.0 days; data was reported on patients with traumatic SCI from multiple centers between 2007 and 2009 (Whiteneck et al. 2011; Whiteneck et al. 2012; Zanca et al. 2013). One recent German report by Ponfick (Ponfick 2017) showed that rehabilitation LOS between 2013 and 2016 were comparable to American rates (mean=57.7 days).

It is uncertain if the same patterns have been seen in non-Model System centres or in other countries, although it is clear from a single-centre report from Israel analyzing LOS decade by decade that significantly lower LOS was seen beginning in 1996 as compared to earlier time periods (Ronen et al. 2004). Data from this report and also reports from other countries (Australia (Burke et al. 1985; Tooth et al. 2003); Canada (Burns et al. 2017); China (Chan & Chan 2005; Zhenrong et al. 2020); Italy (Pagliacci et al. 2003; G. Scivoletto et al. 2020); Japan (Sumida et al. 2001); Netherlands (Schonherr et al. 1999); Norway (Halvorsen et al. 2019a); Switzerland (Franceschini et al. 2020)) indicate LOS remains significantly longer than reported in United States data.

A low-cost, low intensity, outpatient rehabilitation program is reported by a Columbian group (Lugo et al. 2007) (N=42) where in-patient rehabilitation was shortened to an average of 13.5 days and augmented with 18 month, interdisciplinary out-patient rehabilitation follow-up. This low-cost intervention achieved adequate functional goals, although these were achieved over a longer period due to the lack of accessibility to continuous and intensive therapy. This report might inform payer-directed LOS reduction efforts which may be driven by a focus on costs and may not necessarily circumvent any consequences associated with reductions to LOS by an increased attention to outpatient services.

Also apparent from Table 3 is the relationship of longer LOS associated with higher level of injury and greater severity of injury. Similar patterns were seen in all studies describing rehabilitation LOS for individuals with varying injuries. That is, the greatest mean rehabilitation LOS values were seen for those with complete tetraplegia (especially high level) whereas the shortest mean values occurred for those with incomplete paraplegia (Chan & Chan 2005; DeVivo et al. 1990; Tooth et al. 2003; Whiteneck et al. 2011; Whiteneck et al. 2012) although this relationship of level and injury severity was only a non-significant trend in the data from Israel (Ronen et al. 2004).

Conclusion

There is level 3 evidence (from predominately American studies: DeVivo et al. 1990; Heinemann et al. 1989; SA 1999; Whiteneck et al. 2011; Whiteneck et al. 2012; Woolsey 1985; Yarkony et al. 1987; Yarkony et al. 1990) that rehabilitation LOS has become progressively shorter between 1973 and 2009. For other countries, only investigators from Israel (Ronen et al. 2004) have published data in a single report that is consistent with this trend.

There is level 3 evidence (based on several studies: Chan & Chan 2005; DeVivo et al. 1990; Tooth et al. 2003; Whiteneck et al. 2011; Whiteneck et al. 2012) that those with higher level and more severe injuries have longer rehabilitation LOS.

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