International Comparison of Vocational Rehabilitation for Persons With Spinal Cord Injury:Systems, Practices, and Barriers

Background: Employment rates among people with spinal cord injury or spinal cord disease (SCI/D) show considerable variation across countries. One factor to explain this variation is differences in vocational rehabilitation (VR) systems. International comparative studies on VR however are nonexistent. Objectives: To describe and compare VR systems and practices and barriers for return to work in the rehabilitation of persons with SCI/D in multiple countries. Methods: A survey including clinical case examples was developed and completed by medical and VR experts from SCI/D rehabilitation centers in seven countries between April and August 2017. Results: Location (rehabilitation center vs community), timing (around admission, toward discharge, or after discharge from clinical rehabilitation), and funding (eg, insurance, rehabilitation center, employer, or community) of VR practices differ. Social security services vary greatly. The age and preinjury occupation of the patient influences the content of VR in some countries. Barriers encountered during VR were similar. No participant mentioned lack of interest in VR among team members as a barrier, but all mentioned lack of education of the team on VR as a barrier. Other frequently mentioned barriers were fatigue of the patient (86%), lack of confidence of the patient in his/her ability to work (86%), a gap in the team's knowledge of business/legal aspects (86%), and inadequate transportation/accessibility (86%). Conclusion: VR systems and practices, but not barriers, differ among centers. The variability in VR systems and social security services should be considered when comparing VR study results

Impact of an Online Medical Internet Site on Knowledge and Practice of Health Care Providers: A Mixed Methods Study of the Spinal Cord Injury Rehabilitation Evidence Project

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Modeling the patient journey from injury to community reintegration for persons with acute traumatic spinal cord injury in a Canadian centre.

BACKGROUND: A patient's journey through the health care system is influenced by clinical and system processes across the continuum of care. METHODS: To inform optimized access to care and patient flow for individuals with traumatic spinal cord injury (tSCI), we developed a simulation model that can examine the full impact of therapeutic or systems interventions across the care continuum for patients with traumatic spinal cord injuries. The objective of this paper is to describe the detailed development of this simulation model for a major trauma and a rehabilitation centre in British Columbia (BC), Canada, as part of the Access to Care and Timing (ACT) project and is referred to as the BC ACT Model V1.0. FINDINGS: To demonstrate the utility of the simulation model in clinical and administrative decision-making we present three typical scenarios that illustrate how an investigator can track the indirect impact(s) of medical and administrative interventions, both upstream and downstream along the continuum of care. For example, the model was used to estimate the theoretical impact of a practice that reduced the incidence of pressure ulcers by 70%. This led to a decrease in acute and rehabilitation length of stay of 4 and 2 days, respectively and a decrease in bed utilization of 9% and 3% in acute and rehabilitation. CONCLUSION: The scenario analysis using the BC ACT Model V1.0 demonstrates the flexibility and value of the simulation model as a decision-making tool by providing estimates of the effects of different interventions and allowing them to be objectively compared. Future work will involve developing a generalizable national Canadian ACT Model to examine differences in care delivery and identify the ideal attributes of SCI care delivery

Ordinal logistic regression results for discharge AIS (number of observations = 489).

<p>R-Square = 0.6637,Max-rescaled R-Square = 0.7156.</p><p>Dependent variable: AIS at Discharge (A, B, C, D, E).</p><p>Independent variables: AIS at Admission (A, B, C, D), Neurological Level (High, Medium, Low), Rehabilitation (Yes, No) AIS: American Spinal Injury Association (ASIA) Impairment Scale DF: degrees of freedom.</p><p>The Wald Chi-Square test is used to test the statistical significance of parameters in the logistic regression models.</p

Scenario One: Indirect impact of pressure ulcer reduction during acute care.

<p>Reducing pressure ulcers during acute care has direct impacts on overall complications and length of stay in acute care, but also indirect impacts on rehabilitation complications, length of stay and bed utilization.</p

Scenario Two: Indirect impacts of early surgery.

<p>Providing early surgery to patients with tetraplegia has a direct impact on their neurological recovery and also indirect impact on their life expectancy, quality of life and savings in their rest of life costs.</p

Flow chart of the study design.

<p>Starting with initial information acquisition, followed by process mapping (level 1 and 2), data collection & analyses, model development & validation and “what-if” scenario analyses.</p

Scenario Three: The indirect impact of additional rehabilitation beds.

<p>Adding rehabilitation beds has an impact on the admission to rehabilitation waiting time (alternative level of care days in acute), acute length of stay, bed utilization at the rehabilitation centre and rehabilitation length of stay. ALC: Alternative Level of Care Days; LOS: Length of Stay; Rehab: Rehabilitation.</p

Summary of the variables estimated and the methodology involved in creating the simulation model.

<p>All variables are significant (p-value<0.05). ✓Indicates the independent variable(s) that can estimate the dependent variable (e.g. the dependent variable AIS can be estimated by the independent variables age and energy); MOI: Mechanism of Injury; Neuro Level: Neurological Level of Injury; ISS: Injury Severity Score; GCS: Glasgow Coma Scale; AIS: ASIA Impairment Scale; SCU: Special Care Unit; VGH: Vancouver General Hospital; LOS: Length of Stay; ED: Emergency Department; OR: Operating Room; Rehab: Rehabilitation; FIM: Functional Independence Measure.</p