title: Defining the Pathway to Definitive Care and Surgical Decompression after Traumatic Spinal Cord Injury: Results of a Canadian Population-Based Cohort Study.
abstract: Early access to specialized care after acute traumatic spinal cord injury (SCI) is associated with improved outcomes. However, many SCI patients do not receive timely access to such care. To characterize and quantify patients' pathway to definitive care and surgery post SCI, and to identify factors that may delay expeditious care, a population based cohort study was performed in Ontario. Using provincial administrative health data, adult patients with acute traumatic SCI who underwent surgery between 2002 and 2011 were identified using SCI specific ICD-10 codes. The relationship between predictor variables and a) time to arrival at the site of definitive care and b) time to surgery was statistically evaluated. Of 1,111 patients meeting eligibility criteria, mean times to arrival at the site of definitive care and to surgery were 8.1 ± 25.5 and 49.4 ± 65.0 hours respectively, with 53.3% of patients having surgery prior to 24 hours. While most patients (88.4%) reached the site of definitive care within 6 hours, only 34.2% reached surgery within 12 hours of arrival. Older age (IRR = 1.01; 95% CI: 1.01, 1.02), increased number of stops at intermediate health care centers (IRR = 7.70; 95% CI: 7.54, 7.86), higher comorbidity index (IRR = 1.43; 95% CI: 1.14, 1.72) and fall related SCI etiology (IRR = 1.16; 95% CI: 1.02, 1.29) were associated with increased time to arrival at definitive care. For surgery, increased age (OR = 1.02; 95% CI: 1.01, 1.03) and stops at intermediate health centers (OR = 2.48; 95% CI: 1.35, 4.56) were associated with a greater odds of undergoing late surgery (>24hrs). These results can inform policy decisions and facilitate creation of a streamlined path to specialized care for patients with acute SCI.
authors.affiliation: 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Jefferson R
authors.initials: JR
authors.lastname: Wilson
authors.affiliation: 2 Institute of Clinical Evaluative Sciences, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Jennifer
authors.initials: J
authors.lastname: Voth
authors.affiliation: 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Anoushka
authors.initials: A
authors.lastname: Singh
authors.affiliation: 3 Rehabilitation Studies Unit, University of Sydney , Sydney, Australia .
authors.forename: James
authors.initials: J
authors.lastname: Middleton
authors.affiliation: 2 Institute of Clinical Evaluative Sciences, University of Toronto , Toronto, Ontario, Canada .|4 Department of Physical Therapy, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Susan B
authors.initials: SB
authors.lastname: Jaglal
authors.affiliation: 4 Department of Physical Therapy, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Singh
authors.affiliation: 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Todd G
authors.initials: TG
authors.lastname: Mainprize
authors.affiliation: 5 Division of Orthopedic Surgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Albert
authors.initials: A
authors.lastname: Yee
authors.affiliation: 1 Division of Neurosurgery and Spinal Program, University of Toronto , Toronto, Ontario, Canada .
authors.forename: Michael G
authors.initials: MG
authors.lastname: Fehlings
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003422:Critical Care / Q000706:statistics & numerical data*; D016208:Databases, Factual / Q000706:statistics & numerical data; D019299:Decompression, Surgical / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012042:Registries / Q000706:statistics & numerical data*; D013119:Spinal Cord Injuries / Q000601:surgery*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D013997:Time Factors
keywords: access to care; population cohort study; spinal cord injury; surgical decompression; time to treatment