Presentation on theme: "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."— Presentation transcript:
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
Do you have to document your ASIA level to get a discount?
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 4 8 studies examining nearly 20,000 individuals with traumatic SCI from the NIDRR SCI Model Systems. 4 Goal: Understand the relationship between age at time of SCI and outcomes. 4 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 4 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 4 A bias (typically negative) towards an individual based on their older age. 4 The field of Rehabilitation Medicine was founded to provide coordinated services to young individuals (war veterans, polio survivors). 4 Older individuals have become the largest receivers of rehabilitation services.
Ageism 4 The sub-populations of traumatic neurologic injury (SCI and TBI) have provided a uniquely younger group of individuals for rehabilitation services. 4 The significant differences in funding sources (and perhaps medical and rehabilitation needs) have resulted in differing approaches to care.
Ageism: Not me! 4 What is the prototypical “look” of an older adult with SCI? 4 Do older adults have longer acute care stays? Are they more expensive? 4 Do older adults make slower neurologic and functional recoveries? 4 Are older adults destined to nursing home placement after rehabilitation?
Overview: Incidence 4 SCI incidence in the United States is 30 to 40 per million, or ,000 new cases annually. 4 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. 4 Nearly 20% of new SCI injuries occur in those over 60 years
Overview: Etiology 4 In older patients, the SCI tends to be an incomplete tetraplegia. 4 Incidence of SCI due to falls increases with age, while SCI due to sports-related injury decreases. 4 Since 1973, the incidence of falls has increased.
Prior Research: LOS and Charges 4 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 4 Most researchers have concluded that older patients have higher mortality and increased medical complication rates. 4 The majority of research showed no relationship between age and functional independence.
Prior Research: Outcome and Disposition 4 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. 4 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 4 To understand the age-related differences between individuals with paraplegia and tetraplegia. 4 To describe the differences in length of stay and charges for rehabilitation and acute medical care among different age groups. 4 To describe functional levels upon rehabilitation admission and discharge among different age groups.
Objectives 4 To describe the relationship between age and changes in functioning, as indicated by ASIA motor index and FIM scores. 4 To compare the specific relationship between age and likelihood of institutionalization.
Research Studies 4 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] 4 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] 4 1 analysis of differences between controlled tetraplegics and paraplegics.
Research Studies 4 1 investigation analyzing the impact of age and other variables on “length of stay outliers” (>2 SD). [n= 17,132] 4 1 investigation analyzing the impact of age and other variables on “charge outliers” (>2 SD). [n= 13,392] 4 1 analysis of overall impact of age on outcomes after SCI
Study Design: Unmatched and Matched 4 Initially utilized 11, 5-year age increments (18 to 70+), then determined significant “break points” where differences noted = 18-39, 40-59, Controlling for level involved 1:1 matching by neurologic level of injury and ASIA completeness. 4 Demographic (gender, race, education, marital status, funding source), and clinical (etiology, level, completeness) data utilized as independent variables in analyses.
Study Outcome Measures 4 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 MeasuresUnmatchedMatched Gender> Female in OlderSame Race> White in OlderSame EmploymentYounger unemployed Middle employed Same Older Retired Funding SourceMedicare funding EducationGreater in OlderSame Marital StatusHigher in OlderSame EtiologyMore Falls and Less Violence in Older Same
Summary Paraplegia No DifferencesInstitutionalization Greater in Older Disposition Lower in Older FIM Efficiency Lower in Older FIM Change Lower in Older D/C FIM No DifferencesLower in OlderAdmit FIM No DifferencesGreater in Older on Admit only Acute Adm AMI, Change/Efficiency No DifferencesGreater in OlderRehab Charges Lower in YoungerGreater in OlderRehab/Total LOS MatchedUnmatchedMeasures
Summary Tetraplegia SameMore Falls and Less Violence in Older Etiology SameHigher in OlderMarital Status SameGreater in OlderEducation Older Retired SameYounger unemployed Middle employed Employment > AA’s in Middle> Whites in OlderRace > Female in Older Gender MatchedUnmatchedMeasures
Summary Tetraplegia Institutionalization Greater in Older Disposition Lower in OlderNo DifferencesFIM Efficiency Lower in OlderNo DifferencesFIM Change Lower in OlderNo DifferencesD/C FIM No Differences Admit FIM Lower AMI change in Older Greater in Older on Admit and D/C only Acute Adm AMI, Change/Efficiency No DifferencesLower in Older Rehab/Total Charges No DifferencesShorter in OlderRehab/Total LOS MatchedUnmatchedMeasures
Matched Paraplegia and Tetraplegia Measure ParaplegiaTetraplegia Acute LOSNo Differences Rehab LOSLonger in OlderNo Differences Total LOSLonger in OlderNo Differences Acute ChargesNo Differences Rehab ChargesNo Differences Total ChargesNo Differences Acute AMI Changes No DifferencesLower in Older Rehab AMI Changes No DifferencesLower in Older Total AMI ChangesNo DifferencesLower in Older
Matched Paraplegia and Tetraplegia Measure ParaplegiaTetraplegia Acute AMI EfficNo DifferenceLower in Older Rehab AMI EfficNo DifferenceLower in Older Total AMI EfficNo DifferenceLower in Older Rehab Adm FIMNo Difference DC FIMLower in Older FIM ChangeLower in Older FIM EfficiencyLower in Older DispositionNo Differences (>90% of all DC to Private setting) Higher in Older & Middle (5-10x)
Summary: Matched Paraplegia and Tetraplegia 4 Paraplegia –Increased lengths of rehabilitation and total hospital stay –Lower D/C FIM, FIM change, and FIM efficiency 4 Tetraplegia –Lower ASIA Motor Index changes and efficiency –Lower D/C FIM, FIM change, and FIM efficiency –Higher Nursing Home placement
Rehabilitation LOS * *
FIM Motor Change **
Institutionalization * *
Study Design: Outlier Analyses 4 Univariate and multivariate regression analyses conducted to identify individuals who are either LOS or charge outliers. 4 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.
Results: LOS Outlier Analyses 4 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 4 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 4 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 4 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 4 Age does not play a statistically significant role in either length of stay or charge outliers for individuals with paraplegia or tetraplegia. 4 Age may play an indirect role (e.g., greater chance of medical complications or pressure ulcers due to age-related factors). 4 Age alone is not a reason to assume that an individual will have a longer or more costly rehabilitation program.
Conclusions 4 Aging population in the United States, anticipate >20% Americans to be 65 years or older by Increasing incidence of older adults with SCI. 4 Older adults have specialized needs following SCI. 4 Ageism bias against older adults with SCI due to perceived higher medical acuity, higher costs, longer LOS, and poorer outcomes.
Conclusions 4 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 4 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: 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): 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); 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):
References 4 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): 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: 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). 4 McKinley WO, Cifu DX, Seel R, Huang ME, Kreutzer JS, Drake D: Age-related outcomes in tetraplegic and paraplegic patients: A summary paper. J Spinal Cord Med (submitted).