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

Epidemiology of Work-Related Traumatic Spinal Cord Injury: An Analysis of Workers' Compensation Claims in Korea, 2011-2019

OBJECTIVE

We aimed to identify the incidence and burden of work-related traumatic spinal cord injury (wrTSCI) in Korea in the 10-year period from 2010 to 2019.

METHODS

We used nationwide workers' compensation insurance data. The study population comprised industrially injured workers with TSCI diagnosis codes. The annual incidence of wrTSCI (number per million workers) was calculated.

RESULTS

The mean annual incidence of wrTSCI was 22.8/1,000,000 (95% confidence interval, 20.5 to 25.0), and the mean total cost per claim was 231.40 million KRW. The incidence of TSCI in the cervical region was the highest (13.1/1,000,000; 95% confidence interval, 11.4 to 14.9), and most cases were in the construction industry (47.3%).

CONCLUSION

These findings can help identify specific at-risk groups and facilitate the development of prevention strategies.

Direct Cost of Illness for Spinal Cord Injury: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Providing a comprehensive review of spinal cord injury cost of illness studies to assist health-service planning.

METHODS

We conducted a systematic review of the literature published from Jan. 1990 to Nov. 2020 via Pubmed, EMBASE, and NHS Economic Evaluation Database. Our primary outcomes were overall direct health care costs of SCI during acute care, inpatient rehabilitation, within the first year post-injury, and in the ensuing years.

RESULTS

Through a 2-phase screening process by independent reviewers, 30 articles out of 6177 identified citations were included. Cost of care varied widely with the mean cost of acute care ranging from $290 to $612,590; inpatient rehabilitation from $19,360 to $443,040; the first year after injury from $32,240 to $1,156,400; and the ensuing years from $4,490 to $251,450. Variations in reported costs were primarily due to neurological level of injury, study location, methodological heterogeneities, cost definitions, study populations, and timeframes. A cervical level of the injury, ASIA grade A and B, concomitant injuries, and in-hospital complications were associated with the greatest incremental effect in cost burden.

CONCLUSION

The economic burden of SCI is generally high and cost figures are broadly higher for developed countries. As studies were only available in few countries, the generalizability of the cost estimates to a regional or global level is only limited to countries with similar economic status and health systems. Further investigations with standardized methodologies are required to fill the knowledge gaps in the healthcare economics of SCI.

Achieving Value in Spine Surgery: 10 Major Cost Contributors

STUDY DESIGN

Narrative Review.

OBJECTIVES

The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

METHODS

We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

RESULTS

We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

CONCLUSIONS

In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

Impact of Patient Counseling and Socioeconomic Factors on Initiation of Rehabilitation Program in Spinal Cord Injury Patients Presenting to a Tertiary Spine Unit in India

Study Design

Prospective case series.

Purpose

This study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program.

Overview of Literature

A rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited.

Methods

A prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison.

Results

A total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation <6 weeks and ≥6 weeks, respectively. In group B, 12 patients (39%; mean MKSS, 13.69) and 19 patients (61%; mean MKSS, 12.10) enrolled for rehabilitation <6 weeks and ≥6 weeks, respectively. The total MKSS and scores for education, income, and occupation did not show a significant difference between the two both groups (p>0.05).

Conclusions

Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program.

Cervical spine clearance when unable to be cleared clinically: a pooled analysis of combined computed tomography and magnetic resonance imaging

BACKGROUND

The role of cervical spine magnetic resonance imaging (MRI) in the evaluation of clinically unevaluable blunt trauma patients has been called into question by several recent studies.

METHODS

A PubMed search was performed for all studies comparing computed tomography and MRI in the assessment of the cervical spine in patients who cannot be evaluated clinically. The radiologic findings and clinical outcomes from each study were collated for analysis.

RESULTS

Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an MRI. There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention.

CONCLUSIONS

MRI identifies additional injuries; however, the vast majority are of minor clinical significance. Routine MRI after a negative computed tomography of the cervical spine is not supported by the current literature.

The role of angiogenic and wound-healing factors after spinal cord injury in mammals

Patients with spinal cord injury (SCI) are permanently paralysed and anaesthetic below the lesion. This morbidity is attributed to the deposition of a dense scar at the injury site, the cellular components of which secrete axon growth inhibitory ligands that prevent severed axons reconnecting with denervated targets. Another complication of SCI is wound cavitation where a fluid filled cyst forms in the peri-lesion neuropil, enlarging over the first few months after injury and causes secondary axonal damage. Wound healing after SCI is accompanied by angiogenesis, which is regulated by angiogenic proteins, produced in response to oxygen deprivation. Necrosis in and about the SCI lesion sites may be suppressed by promoting angiogenesis and the resulting neuropil protection will enhance recovery after SCI. This review addresses the use of angiogenic/wound-healing related proteins including vascular endothelial growth factor, fibroblast growth factor, angiopoietin-1, angiopoietin-2 and transforming growth factor-β to moderate necrosis and axon sparing after SCI, providing a conducive environment for growth essential to functional recovery.

Clearance of the cervical spine in clinically unevaluable trauma patients

STUDY DESIGN

Meta-analytic costeffectiveness analysis.

OBJECTIVE

Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.

SUMMARY OF BACKGROUND DATA

We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.

METHODS

Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.

RESULTS

Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.

CONCLUSION

As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.

Work-related traumatic spinal cord lesions in Chile, a 20-year epidemiological analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To describe the characteristics of patients with work-related traumatic spinal cord injuries (TSCI) in Chile.

SETTING

Hospital del Trabajador in Santiago, Santiago, Chile.

METHODS

Patients suffering from TSCI incurred at the workplace from 1986 to 2005 were identified through records of the Asociación Chilena de Seguridad (ACHS, Chilean Safety Association).

RESULTS

The medical records of 173 patients, 172 men and 1 woman, were analyzed. The yearly average incidence was 7.8 per million workers. Age at TSCI onset was 38.2 ± 12.1 years. The principal external causes for TSCI incurred at the workplace were falls from a height in 86 cases (49.7%) and trauma blows to the vertebral spine in 61 cases (35.3 %). More falls occurred in the field construction, and other traumas occurred as a result of traumatic blows caused by tree trunks and stones in forestry and mining sectors. Mortality in this series was 8.7%, and the worst prognosis was for older patients with complete tetraplegia. The paraplegia:tetraplegia ratio was 3.2:1.

CONCLUSIONS

The characteristics of workplace TSCI are specific to this population. It is important therefore to develop prevention programs for specific work-related TSCI.

The costs and adverse events associated with hospitalization of patients with spinal cord injury in Victoria, Australia

STUDY DESIGN

Analysis of patient-level diagnostic and cost data from an administrative database.

OBJECTIVE

To describe complications and cost differentials for hospitalized patients with traumatic spinal cord injury (T-SCI) and nontraumatic spinal cord injury (NT-SCI).

SUMMARY OF BACKGROUND DATA

Numerous studies have reported costs for T-SCI, but few have involved NT-SCI.

METHODS

All patients with SCI admitted between June 1, 2003 and June 30, 2004 were identified using coding from the International Classification of Diseases and Related Health Problems 10th edition, Australian modification (ICD-10-AM). Analysis of database from 45 major acute care public hospitals included in the Victorian Cost Weights Study hospitals (n = 1605 episodes with a SCI). Complications were identified using the Victorian Department of Human Services C-prefix, assigned to hospital-acquired ICD-10-AM diagnoses.

RESULTS

Most (85.5%) SCI episodes involved NT-SCI. The ratio of acute to chronic admissions was high for T-SCI (1:0.05), but reversed for NT-SCI (1:1.36). Complications were documented in 38% of SCI episodes. T-SCI showed a higher rate of complications (56%) than NT-SCI (35%). SCI admissions with a complication were significantly more costly (mean, $A43,410) compared with those without a complication (mean, $A10,102). Length of stay was extended by an average of 32 days in the presence of a complication.

CONCLUSIONS

SCI entails costly hospital care and high risk of hospital-acquired illness. Some of these complications are preventable. Better understanding of the financial costs of these episodes can assist healthcare providers and funders to weigh the benefits of interventions to reduce the rates of complications in these vulnerable patients.

Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment

PURPOSE

To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

METHOD

Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

RESULTS

There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

CONCLUSIONS

A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.

Rehospitalization following compensable work-related tetraplegia

DESIGN

Descriptive study.

OBJECTIVES

To document the characteristics of rehospitalization following work-related tetraplegia, investigate risk factors for rehospitalization and identify opportunities for rehospitalization prevention.

SETTING

Workers' compensation administrative database with national coverage.

METHODS

The administrative database of a large workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In all, 61 cases were identified where detailed rehospitalization information was available. Medical payment data were extracted, rehospitalization reasons were coded, and rates, costs and length of stay were calculated.

RESULTS

In all, 62% of cases were rehospitalized at some time during the period for which data were available. The average number of days the study group spent rehospitalized per year was 9.2 and the average annual cost was 14,197 US dollars. The most common reasons for rehospitalization were dermatological (23%), orthopedic (18%) and urological (14%). It was found that as many as 74% of the total number of days persons spent rehospitalized, 64% of the monies spent on rehospitalization, and 47% of rehospitalizations could have been prevented.

CONCLUSIONS

Consistent with earlier research, the ability to identify risk factors for rehospitalization was limited. However, the current study does highlight the extent to which rehospitalizations disrupt the lives of people with work-related tetraplegia and that a substantial proportion of rehospitalizations can be avoided.

SPONSORSHIP

The research was supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research National Model SCI Systems (Grant no. H133N00024).

Services provided following compensable work-related tetraplegia

DESIGN

Descriptive study.

OBJECTIVE

To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI).

SETTING

Workers' compensation claims database.

METHODS

The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories.

RESULTS

Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications/supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher.

CONCLUSIONS

Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.