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The Center for Rehabilitation Outcomes Research (CROR) at Shirley Ryan 小恩雅 was awarded a $4.2 million, five-year grant to explore how different rehabilitation lengths of stay and intensity of rehabilitation affect outcomes and quality of life for people with spinal cord injury in different countries. The project, which began in September 2023, is funded by the National Institute on Disability, Independent Living and Rehabilitation Research, an arm of the U.S. Administration for Community Living.
The study will compare how long people with new spinal cord injuries participate in inpatient rehabilitation – that’s rehabilitation right after discharge from acute care – in five industrialized countries around the world: the United States, the United Kingdom, Australia, Canada and the Netherlands. The researchers will also look at acute care lengths of stay – how long people remain in the hospital right after their injuries.
The countries included are all relatively affluent but have different types of healthcare systems. Except for the U.S., each of the countries involved in the study has a form of universal healthcare. The U.S. health care system consists of a mixture of private insurers and government payors such as Medicare and Medicaid.
“Over the past several decades, U.S. lengths of stay have dropped precipitously,” notes CROR Director Allen Heinemann, PhD, who is principal investigator on the study. “Years ago, someone with tetraplegia might stay in a hospital six to nine months. Now it’s about two months. For people with paraplegia, it’s down to six weeks from four to six months. A lot of advocacy groups fear that patients are being shortchanged.”
Other countries have also reduced their lengths of rehabilitation hospitalization, Heinemann adds, but not as dramatically as the U.S. For example, patients with spinal cord injury in the U.S. spend a median 32 days in the hospital for acute care and inpatient rehabilitation, compared with 83 days in Australia and 114 in China. While it might seem intuitive that patients would benefit from longer stays, that might not always be the case, says British researcher and clinical psychologist Jane Duff, DClinPsych. “Patients with shorter stays could have worse outcomes but very long stays could lead to people being isolated and institutionalized,” says Duff, who is a consultant clinical psychologist and head of the National Spinal Injuries Centre Psychology Team at Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust. “We’re trying to find a sweet spot where people get the most rehab gain from their time in a hospital.”
The CROR research team will collaborate with international researchers including Duff in the United Kingdom to evaluate how health outcomes for patients vary in relation to how long they stay in hospitals for acute treatment and inpatient rehabilitation. The team will look at numerous outcomes including physical, neurological and bladder/bowel function, quality of life, pain levels and sleep quality.
The researchers have several hypotheses about the impact of different lengths of stay and why they vary by country. “Shorter stays are fine if you don’t have complications and you have access to transportation and outpatient services,” says Heinemann. “But longer stays are likely better for patients who don’t have ready access to transportation or outpatient services. For example, Australia has only a few large cities so patients in rural areas would have to travel huge distances for outpatient services. Having a longer stay could be a good thing for them.”
In contrast, the Netherlands is a small country with a dense population and good public transportation so access to outpatient rehabilitation services is much more widespread. That could result in patients staying shorter times in hospitals because they can readily continue their rehabilitation elsewhere, Heinemann says.
The study is comprised of three projects. In the first two years of the study, Heinemann will organize focus groups of discharged patients from different countries as well as clinicians and their care partners. Patients will be asked questions about their satisfaction with their hospital stays and health outcomes. Did they feel like they were hospitalized longer than necessary or conversely, did they feel ready to be discharged after short stays? Care partners will be asked if they feel their loved ones were adequately prepared to go home. The results of the focus groups will be used to prepare surveys that will be administered to several thousand people in each country.
In another part of the study, CROR researcher and project co-director Anne Deutsch, RN, PhD, will analyze large sets of assessment and claims data from the U.S., Canada, Australia, New Zealand and the United Kingdom to identify factors that affect length of stay for people with spinal cord injuries. She will also review de-identified patient health records and data subgroups about injury onset and severity, length of time to discharge, functional outcomes and complications such as pressure ulcers or falls.
Comparing lengths of stays for spinal cord injury patients isn’t as simple as it might sound. “Someone can have a spinal cord injury due to a traumatic event like a car accident or a gunshot wound or a nontraumatic event like a spinal cord tumor,” says Deutsch. “When someone has a more severe injury, they likely will have a longer stay. Longer stays also occur for people with co-morbidities. It’s difficult to understand what length of stay might have been if they had been comparable patients. You can merge lots of data to understand these issues.”
The demographic profiles of people vary significantly between those with traumatic and nontraumatic injuries, she notes. Nontraumatic injuries occur equally among men and women and tend to affect people over the age of 50 whereas traumatic injuries are concentrated among men, many of whom are young. Deutsch has years of experience analyzing assessment and claims data from Medicare, the U.S. healthcare system for older Americans, and has played a role in setting up data collection systems in other countries, including Australia and Canada. “I know these data sets really well,” Deutsch says. “It’s going back to my work several jobs ago. I’m excited to be doing this work and pulling the data together.”
In the third part of the study, CROR Scientist Alex Wong, PhD, OT will review existing scientific literature on lengths of stay around the world to answer the question: Do longer hospital stays result in better outcomes for people with spinal cord injuries? The question is complicated, he notes, because earlier studies have used different definitions of length of stay. Some define it as the amount of time between initial hospitalization and discharge from inpatient rehabilitation. Others focus only on the amount of time patients spend in rehabilitation, excluding their time in an acute-care facility.
Wong already knows that people with higher-level spinal cord injuries, those affecting all four limbs, stay in the hospital for longer periods of time than people with lower-level injuries. But that doesn’t mean they regain more function than those with less severe injuries. In fact, they likely regain less function.
Wong plans to go beyond a standard literature review, which would just summarize the findings of previous studies. He wants to run a quantitative meta-analysis that would statistically combine the results of various studies to provide a more precise answer to the question of whether shorter or longer inpatient stays are more beneficial to people with spinal cord injuries. He also plans to analyze treatment outcomes at the time of discharge and then one year later. Wong hopes to identify moderating factors that affect patient outcomes, including race, income level and type of insurance coverage, among others. “Let’s say our analysis shows people with longer lengths of stay have better outcomes. That might be true only for white people or people with private insurance,” Wong says. “Our U.S. system has the shortest length of stay but we don’t know if we have the best outcomes or not. We will try to answer this question.”