Disparities in Morbidity After Spinal Cord Injury Across Insurance Types in the United States

Intensive support does not improve positive-airway pressure use in spinal cord injury/disease: a randomized clinical trial

STUDY OBJECTIVE

Treatment of sleep-disordered breathing (SDB) with positive airway pressure (PAP) therapy has unique clinical challenges in individuals living with spinal cord injuries and diseases (spinal cord injury [SCI]/D). Interventions focused on increasing PAP use have not been studied in this population. We aimed to evaluate the benefits of a program to increase PAP use among Veterans with SCI/D and SDB.

METHODS

Randomized controlled trial comparing a behavioral Intervention (n = 32) and educational control (n = 31), both including one face-to-face and five telephone sessions over 3 months. The intervention included education about SDB and PAP, goal setting, troubleshooting, and motivational enhancement. The control arm included non-directive sleep education only.

RESULTS

Primary outcomes were objective PAP use (nights ≥4 hours used within 90 days) and sleep quality (Pittsburgh Sleep Quality Index [PSQI] at 3 months). These did not differ between intervention and control (main outcome timepoint; mean difference 3.5 [-9.0, 15.9] nights/week for PAP use; p = .578; -1.1 [-2.8, 0.6] points for PSQI; p = .219). Secondary outcomes included fatigue, depression, function, and quality of life. Only fatigue improved significantly more in the intervention versus the control group (p = .025). Across groups, more PAP use was associated with larger improvements in sleep quality, insomnia, sleepiness, fatigue, and depression at some time points.

CONCLUSIONS

PAP use in Veterans with SCI/D and SDB is low, and a 3-month supportive/behavioral program did not show significant benefit compared to education alone. Overall, more PAP use was associated with improved symptoms suggesting more intensive support, such as in-home assistance, may be required to increase PAP use in these patients.

CLINICAL TRIALS INFORMATION

Title: "Treatment of Sleep Disordered Breathing in Patients with SCI." Registration number: NCT02830074. Website: https://clinicaltrials.gov/study/NCT02830074?cond=Sleep%20Apnea&term=badr&rank=5.

A Framework for Addressing Health Disparities in Adult Neurogenic Lower Urinary Tract Dysfunction-Systematic Review and Neurogenic Bladder Research Group Recommendations

The systematic review and workshop recommendations by the Neurogenic Bladder Research Group offer a comprehensive framework for evaluating health disparities in adult neurogenic lower urinary tract dysfunction (NLUTD). The study acknowledges the multifaceted nature of health, highlighting that medical care, though critical, is not the sole determinant of health outcomes. Social determinants of health significantly influence the disparities seen in NLUTD. This report calls for a shift in focus from traditional urologic care to a broader, more inclusive perspective that accounts for the complex interplay of social, economic, and health care factors in managing NLUTD.

What Is the Pathway to the Best Model of Care for Traumatic Spinal Cord Injury? Evidence-Based Guidance

Introduction

People with traumatic spinal cord injury (tSCI) experience lifelong physical and emotional health impacts, needing specialized care that is complex to navigate. The non-standardized care pathways used by different jurisdictions to address these needs lead to care inequities and poor health outcomes.

Purpose

To develop an evidence-based integrated tSCI Care Pathway, from time of injury to life in the community.

Methods and Analysis

Eighty key partners engaged in planning, providing, and receiving tSCI care (1) identified existing guidelines, pathways, and care models; (2) created the tSCI Care Pathway with key elements or building blocks ("the what"), not specific recommendations ("the how") for each care stage (Acute, Rehabilitation, and Community), with elements highlighting the role of primary care and equity considerations on the pathway; (3) identified regional gaps in the tSCI Pathway and prioritized them for implementation; and (4) developed quality indicators.

Outcomes

The tSCI Pathway was drafted in overarching and detailed formats. For Acute Care, building blocks focused on appropriate assessment, initial management, and transition planning; for Rehabilitation, building blocks focused on access to specialized rehabilitation and assessment and planning of community needs; for Community, building blocks focused on follow-up, mechanisms for re-access, and holistic support for persons and families; and for equity considerations, building blocks focused on those at-risk or requiring complex supports. Team-based primary care and navigation supports were seen as crucial to reduce inequities.

Conclusion

This is the first comprehensive care pathway for tSCI. The Pathway is grounded in person-centred care, integrated care and services, and up-to-date clinical practice guidelines. The tSCI Care Pathway is flexible to regional realities and individual needs to ensure equitable care for all.