Transcript Age Related Outcomes in Paraplegic and Tetraplegic Patients

Outcomes of Older Adults After SCI:
Examining the Science and the
Mythology of Ageism
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and
Chairman Department of Physical Medicine
and Rehabilitation
Virginia Commonwealth University/Medical
College of Virginia
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Age-Related Outcomes in Individuals
with Paraplegia and Tetraplegia:
Update from the SCI Model Systems
Project
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and Chairman
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University/Medical College of
Virginia
Research Goal
 8 studies examining nearly 20,000 individuals
with traumatic SCI from the NIDRR SCI Model
Systems.
 Goal: Understand the relationship between age at
time of SCI and outcomes.
 Researchers – David Cifu, MD; Mark Huang,
MD; Ron Seel, PhD; Jeff Kreutzer, PhD; William
McKinley, MD; Dave Drake, M.D. and Stephanie
Kolakowsky-Hayner, MA
Research Support
 This research supported by the National Institute
on Disability and Rehabilitation Research, Office
of Special Education and Rehabilitation and
Rehabilitative Services, U.S. Department of
Education Grant #H133N50015
Ageism
 A bias (typically negative) towards an individual
based on their older age.
 The field of Rehabilitation Medicine was founded
to provide coordinated services to young
individuals (war veterans, polio survivors).
 Older individuals have become the largest
receivers of rehabilitation services.
Ageism
 The sub-populations of traumatic neurologic
injury (SCI and TBI) have provided a uniquely
younger group of individuals for rehabilitation
services.
 The significant differences in funding sources (and
perhaps medical and rehabilitation needs) have
resulted in differing approaches to care.
Ageism: Not me!
 What is the prototypical “look” of an older adult
with SCI?
 Do older adults have longer acute care stays? Are
they more expensive?
 Do older adults make slower neurologic and
functional recoveries?
 Are older adults destined to nursing home
placement after rehabilitation?
Overview: Incidence
 SCI incidence in the United States is 30 to 40 per
million, or 7000-10,000 new cases annually.
 While SCI occurs predominantly in individuals
aged 16 to 30 (~ 60%), over the past quarter
century the age at time of SCI has been rising .
 Nearly 20% of new SCI injuries occur in those
over 60 years
Overview: Etiology
 In older patients, the SCI tends to be an
incomplete tetraplegia.
 Incidence of SCI due to falls increases with
age, while SCI due to sports-related injury
decreases.
 Since 1973, the incidence of falls has
increased.
Prior Research: LOS and Charges
 Researchers examining post-SCI care of
older adults have generated conflicting
results.
– Some studies have indicated that older SCI
patients have significantly shorter lengths of
stay (LOS) and fewer charges than younger SCI
patients.
– Others found to no relationship between age
and acute-care LOS or hospital charges.
Prior Research: Complications
and Outcome
 Most researchers have concluded that older
patients have higher mortality and increased
medical complication rates.
 The majority of research showed no relationship
between age and functional independence.
Prior Research:
Outcome and Disposition
 When controlling for degree of incompleteness,
researchers have concluded that older adults have
worse functional outcomes than younger adults.
Almost all of this work has been done looking at
individuals with tetraplegia.
 Studies examining discharge disposition suggest
that older patients are between 3 and 23 times
more likely than younger patients to be discharged
to a nursing home.
Objectives
 To understand the age-related differences between
individuals with paraplegia and tetraplegia.
 To describe the differences in length of stay and
charges for rehabilitation and acute medical care
among different age groups.
 To describe functional levels upon rehabilitation
admission and discharge among different age
groups.
Objectives
 To describe the relationship between age and
changes in functioning, as indicated by ASIA
motor index and FIM scores.
 To compare the specific relationship between age
and likelihood of institutionalization.
Research Studies
 2 investigations examining age-related individuals
with paraplegia; 1 uncontrolled for level and
completeness of injury (all comers) and 1
controlled. [n= 2,169; n=1489]
 2 investigations examining age-related individuals
with tetraplegia; 1 uncontrolled for level and
completeness of injury (all comers) and 1
controlled. [n=2,099; n= 375]
 1 analysis of differences between controlled
tetraplegics and paraplegics.
Research Studies
 1 investigation analyzing the impact of age and
other variables on “length of stay outliers” (>2
SD). [n= 17,132]
 1 investigation analyzing the impact of age and
other variables on “charge outliers” (>2 SD). [n=
13,392]
 1 analysis of overall impact of age on outcomes
after SCI
Study Design:
Unmatched and Matched
 Initially utilized 11, 5-year age increments (18 to
70+), then determined significant “break points”
where differences noted = 18-39, 40-59, 60+
 Controlling for level involved 1:1 matching by
neurologic level of injury and ASIA completeness.
 Demographic (gender, race, education, marital
status, funding source), and clinical (etiology,
level, completeness) data utilized as independent
variables in analyses.
Study Outcome Measures
 Dependent Variables
– Length of stay (LOS) of acute and rehab stay
– Charges of acute & rehab care
– American Spinal Injury Association motor index (AMI)
scores: admit acute, admit rehab, d/c, change, efficiency
– Functional Independence Measure (FIM) scores: admit,
d/c, change, efficiency
– Disposition at discharge
Summary Paraplegia
Measures
Gender
Unmatched
> Female in Older
Matched
Same
Race
Employment
> White in Older
Younger unemployed
Middle employed
Same
Same
Funding Source
Education
Marital Status
Etiology
Older Retired
Medicare funding
Greater in Older
Higher in Older
More Falls and Less
Violence in Older
Medicare funding
Same
Same
Same
Summary Paraplegia
Measures
Unmatched
Matched
Rehab/Total LOS
Greater in Older
Lower in Younger
Rehab Charges
Greater in Older
No Differences
Acute Adm AMI,
Change/Efficiency
Greater in Older on
Admit only
No Differences
Admit FIM
Lower in Older
No Differences
D/C FIM
Lower in Older
Lower in Older
FIM Change
Lower in Older
Lower in Older
FIM Efficiency
Lower in Older
Lower in Older
Disposition
Institutionalization
Greater in Older
No Differences
Summary Tetraplegia
Measures
Unmatched
Matched
Gender
> Female in Older
> Female in Older
Race
> Whites in Older
> AA’s in Middle
Employment
Younger unemployed
Middle employed
Same
Older Retired
Education
Greater in Older
Same
Marital Status
Higher in Older
Same
Etiology
More Falls and Less
Violence in Older
Same
Summary Tetraplegia
Measures
Unmatched
Matched
Rehab/Total LOS
Shorter in Older
No Differences
Rehab/Total Charges
Lower in Older
No Differences
Acute Adm AMI,
Change/Efficiency
Greater in Older on
Admit and D/C only
Lower AMI
change in Older
Admit FIM
No Differences
No Differences
D/C FIM
No Differences
Lower in Older
FIM Change
No Differences
Lower in Older
FIM Efficiency
No Differences
Lower in Older
Disposition
Institutionalization
Greater in Older
Institutionalization
Greater in Older
Matched Paraplegia and Tetraplegia
Measure
Acute LOS
Rehab LOS
Total LOS
Acute Charges
Rehab Charges
Total Charges
Acute AMI
Changes
Rehab AMI
Changes
Total AMI Changes
Paraplegia
Tetraplegia
No Differences
Longer in Older
Longer in Older
No Differences
No Differences
No Differences
No Differences
No Differences
No Differences
No Differences
No Differences
No Differences
No Differences
Lower in Older
No Differences
Lower in Older
No Differences
Lower in Older
Matched Paraplegia and Tetraplegia
Measure
Acute AMI Effic
Paraplegia
Tetraplegia
No Difference
Lower in Older
Rehab AMI Effic
Total AMI Effic
Rehab Adm FIM
DC FIM
No Difference
No Difference
No Difference
Lower in Older
Lower in Older
Lower in Older
No Difference
Lower in Older
FIM Change
FIM Efficiency
Disposition
Lower in Older
Lower in Older
Lower in Older
Lower in Older
No Differences
Higher in Older &
(>90% of all DC to
Middle
Private setting)
(5-10x)
Summary:
Matched Paraplegia and Tetraplegia
 Paraplegia
– Increased lengths of rehabilitation and total hospital
stay
– Lower D/C FIM, FIM change, and FIM efficiency
 Tetraplegia
– Lower ASIA Motor Index changes and efficiency
– Lower D/C FIM, FIM change, and FIM efficiency
– Higher Nursing Home placement
Rehabilitation LOS
80
*
70
60
*
50
Matched
Paraplegia
40
30
Matched
Tetraplegia
20
10
0
Young
Middle
Older
Rehabilitation Charges
$90,000
$80,000
$70,000
$60,000
$50,000
Matched
Paraplegia
$40,000
$30,000
Matched
Tetraplegia
$20,000
$10,000
$0
Young
Middle
Older
FIM Motor Change
40
35
**
30
25
Matched
Paraplegia
20
15
Matched
Tetraplegia
10
5
0
Young
Middle
Older
Institutionalization
*
25%
20%
*
15%
Matched
Paraplegia
10%
Matched
Tetraplegia
5%
0%
Young
Middle
Older
Study Design: Outlier Analyses
 Univariate and multivariate regression analyses
conducted to identify individuals who are either
LOS or charge outliers.
 Goal was to be able to develop a prediction model
so that either interventions could be made to
lessen LOS/charges or innovative treatment
models designed to better meet their needs more
efficiently.
Study Design: Outlier Analyses
 Demographic
–
–
–
–
–
–

age
gender
race
education
marital status
funding source
SCI Clinical
– etiology
– level
– completeness
 Non-SCI Clinical
– associated injuries
– pressure ulcers
– surgical procedures
– medical complications
Results: LOS Outlier Analyses
 Length of stay - Univariate
– Caucasian, Student, Unmarried
– Higher Level of Injury
– Greater ASIA Impairment
– Sports-related Etiology of Injury
– Increased number of Pressure Ulcers
– Increased number of Medical Complications
– Increased number days between injury and rehab admit
Results: LOS Outlier Analyses
 LOS: Multivariate analyses
– Correctly classified 97% of individuals overall, but
only 46% of outliers.
– No one factor predicted more than 3% of variance.
– Age did not play a significant role.
– Factors: (in declining order of strength)
• level of injury, # pressure ulcers, days between
injury and rehabilitation admissions, # medical
complications, increased age, private or
governmental insurance sponsor
Results: Charges
Outlier Analyses
 Length of stay - Univariate
– Increased age
– Asian, Well-Educated, Widowed, Private Funding
– Higher Level of Injury
– Greater ASIA Impairment
– Increased number of Associated Injuries
– Increased number of Pressure Ulcers
– Increased number of Medical Complications
– Increased number of Surgical Procedures
Results: Charges
Outlier Analyses
 LOS: Multivariate analyses
– Correctly classified 92% of individuals overall.
– No one factor predicted more than 7% of variance
– Age did not play a significant role.
– Factors: (in declining order of strength)
• level of injury, ASIA classification, # medical
complications, # pressure ulcers, # associated
injuries, days between injury and rehabilitation
admissions, increased age, private or governmental
insurance sponsor
Predictor Models: Summary
 Age does not play a statistically significant role in
either length of stay or charge outliers for
individuals with paraplegia or tetraplegia.
 Age may play an indirect role (e.g., greater chance
of medical complications or pressure ulcers due to
age-related factors).
 Age alone is not a reason to assume that an
individual will have a longer or more costly
rehabilitation program.
Conclusions
 Aging population in the United States, anticipate
>20% Americans to be 65 years or older by 2030.
 Increasing incidence of older adults with SCI.
 Older adults have specialized needs following
SCI.
 Ageism bias against older adults with SCI due to
perceived higher medical acuity, higher costs,
longer LOS, and poorer outcomes.
Conclusions
 Research data suggests:
– Older adults with paraplegia do have higher LOS (but
not higher costs), tetraplegics do not.
– Older adults with tetraplegia make slower neurologic
recovery, paraplegics do not.
– Older adults with paraplegia or tetraplegia make slower
functional recovery.
– Older adults with tetraplegia have higher NHP rates,
paraplegics do not.
– Age alone does not account for longer LOS or higher
cost after SCI.
References
 Cifu DX, Kreutzer JS, Seel RT, McKinley WO: Lengths of stay,
hospitalization charges, and outcomes for an age and injury matched
tetraplegia sample: A multi-center, prospective investigation. Arch Phys
Med Rehabil 1999;80:733-40.
 Cifu DX, Kreutzer JS, Seel RT, Marwitz J, McKinley WO, Wisor D: Age,
outcome, and rehabilitation costs after tetraplegia spinal cord injury.
NeuroRehabilitation 1999;12(3):169-176.
 Cifu DX, Huang ME, Kolakowsky-Hayner SA, Seel RT: Age, outcome,
and rehabilitation costs after paraplegia caused by traumatic injury of
the thoracic spinal cord, conus medullaris, and cauda equina. J
Neurotrauma 1999:16(9);805-15.
 Burnett, DM, Kolakowsky-Hayner SA, Gourley EV, Cifu DX: Spinal cord
injury 'outliers': an analysis of etiology, outcomes and length of stay. J
Neurotrauma 2000;17(9):765-772
References
 Hess DW, Kolakowsky-Hayner SA, Cifu DX, Huang ME: A comparative
study of outcomes and expenses following tetraplegia and paraplegia. J
Spinal Cord Med 2000;23(4):228-233.
 Burnett, DM, Cifu DX, Kolakowsky-Hayner SA, Kreutzer, JS:
Predicting 'Charge Outliers' Following Spinal Cord Injury: A Multi-Center
Analysis of Demographics, Injury Characteristics, Outcomes, and
Hospital Charges. Arch Phys Med Rehabil 2001;82:114-9.
 Seel RT, Huang ME Cifu DX, Kolakowsky-Hayner SA, McKinley WO :
Age-related differences in stays, hospitalization costs, and outcomes
for an injury-matched paraplegia sample. J Spinal Cord Med 2001 (in
Press).
 McKinley WO, Cifu DX, Seel R, Huang ME, Kreutzer JS, Drake D: Agerelated outcomes in tetraplegic and paraplegic patients: A summary
paper. J Spinal Cord Med (submitted).
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