Sara J.T. Guilcher

Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada

Study design:Cohort study.Objectives:To provide recent estimates of the incidence of traumatic spinal cord injury (SCI) in adults living in Ontario.Setting:Ontario, Canada.Methods:The study included all men and women aged 18 years and older living in Ontario. The two primary data sources used for this study were the census data provided by Statistics Canada and the hospital Discharge Abstract Database (DAD) provided by the Canadian Institute for Health Information. Incidence was estimated for the fiscal years 2003/04–2006/07, and examined by age, gender, mechanism and seasonality of injury, the level of injury, the presence of comorbidity and in-hospital mortality.Results:The incident cases had a mean age of 51.3 years (s.d. 20.1). The majority of the cases was male (74.1%) and had a cervical SCI caused by falls (49.5%). The age-adjusted incidence rate was stable over the 4-year study period, from 24.2 per million (95% CI: 21.2–27.6) in 2003 to 23.1 per million (95% CI: 20.2–26.3) in 2006.Conclusion:Despite worldwide trends that have indicated motor vehicle collisions (MVCs) as the leading cause of injury, falls emerged as the leading cause of traumatic SCI in this study. This finding, and the fact that the number of fall-induced injuries increased steadily with age, may indicate that there is growing concern for the consequences of falls in the elderly. Further work is needed to understand this trend in age and gender and the causes of falls to develop effective fall prevention strategies.

Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study

Study Design:Retrospective cohort design.Objectives:To compare socio-demographic, impairment characteristics and utilization (physician and emergency department (ED) visits) for non-traumatic (NTSCI) and traumatic (TSCI) spinal cord injury 1 year post inpatient rehabilitation.Setting:Ontario, Canada.Methods:Inpatient stays (2003–2006) were identified from the National Rehabilitation Registry System. Exclusions were: in-hospital mortality; discharge after 31 March 2006; death within 1 year after discharge. Multivariate logistic regression analyses were used to determine factors predicting high utilization.Results:NTSCI cases (n=1002) were greater than TSCI (n=560). NTSCIs were older (mean=61.6, s.d.=15.8) with more co-morbidities, paraplegic (39.5%) and female (P<0.001). NTSCI had higher FIM admission and discharge scores but lower change scores. Mean number of physician visits for NTSCI and TSCI were 31.2 (median=24) and 29.7 (median=22), with no significant differences in mean specialist visits (NTSCI 16.5: TSCI 17.0). Factors predicting 30 or more physician visits included age 60 years or above (OR=1.5; 95% CI=1.2–1.9), urban living (OR=1.59; 95% CI=1.12–2.22) and lowest quartile (18–88) discharge FIM (OR=1.8; 95% CI=1.4–2.3). Charlson score of 3 or more (OR=2.1; 95% CI=1.3–3.2), urban living (OR=1.92; 95% CI=1.3–2.86) and lowest quartile discharge FIM (OR=1.5; 95% CI=1.2–2.0) were associated with 20 or more specialist visits. Factors for high ED use were: rurality (OR=1.5; 95% CI=1.1–2.1), low income (OR=1.4; 95% CI=1.1–1.9) and low (18–88) discharge FIM (OR=1.7; 95% CI=1.3–2.2).Conclusion:Both demonstrated significant health care utilization requiring attention to health care needs; particularly for those living in rural settings, with low income and/or low functional ability.

Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.

Study design:This is a cohort study with 1-year follow-up.Objectives:The aim of this study was to examine 1-year rehospitalization rates following spinal cord injury (SCI) onset and health system factors affecting rehospitalization.Methods:All persons who had an acute care hospitalization for traumatic SCI in Ontario between 1 April 2003 and 31 March 2006 were identified according to International Classification of Diseases, Tenth Revision codes and followed for 1 year following acute care discharge through record linkage of administrative databases. Index cases with an SCI admission the year before 2003 as well as persons who died within 1 year after the index hospitalization were excluded from the analysis. Factors associated with 1-year rehospitalization were assessed using multivariate logistic regression analyses and included age, sex, rurality, length of stay, comorbidity, level of injury, discharge disposition, in-hospital complication, physician visits and specialist visits measure and etiology of injury.Results:A total of 559 individuals met the inclusion criteria and 27.5% (n=154) were rehospitalized 1 year after initial acute care discharge. Factors significantly associated with 1-year rehospitalization were length of stay, rural residence, 50+ outpatient physician visits and 50+ specialists visits following the index admission. The main causes of rehospitalization were musculoskeletal, respiratory, gastrointestinal and urological disorders.Conclusion:This study presents recent data on rehospitalization and yet rehospitalization rates continue to remain high. Our findings have significant implications for healthcare policy and planning in Ontario, Canada with respect to the management of SCI to achieve optimal health outcomes, in particular in rural areas.

Physician utilization among adults with traumatic spinal cord injury in Ontario: a population-based study.

Study design:Retrospective cohort study.Objectives:To describe the physician utilization patterns (family physicians (FP), specialist and emergency department (ED) visits) of adults with traumatic spinal cord injury (SCI) 1 year after the initial injury.Setting:Ontario, Canada.Methods:A total of 559 individuals with a traumatic SCI were identified. Five administrative databases were linked to examine health-care utilization in acute care, inpatient rehabilitation, chronic care rehabilitation, outpatient physician visits and ED visits. Factors predicting frequent physician, specialist and ED use were identified.Results:The mean number of physician visits for traumatic SCI patients during the first year after their injury onset was 31.7 (median 26). FPs had the greatest number of visits (mean 11.6, median 7) followed by physiatrists (mean 6.1, median 2). Factors predicting 50 or more physician visits included age 70 or above (OR=3.6, 95% CI=2.0–6.5), direct discharge to chronic care (OR=3.6, 95% CI=1.0–13.1) and in-hospital complication (OR=2.34, 95% CI=1.3–4.3). Age 70 or less (OR=0.19, 95% CI=0.0–0.9) and direct discharge to chronic care were associated with 50 or more specialist visits. Only rurality predicted two or more visits to the ED.Conclusions:Individuals with traumatic SCI show significant physician utilization, especially among their FPs and physiatrists. Although the factors predicting higher physician and specialist utilization may reflect individuals with the most severe impairment, comorbid conditions or lack of social support, the model for higher ED visits may point to limited accessibility to/availability of primary care services for SCI patients in rural regions.

Determinants of research use in clinical decision making among physical therapists providing services post-stroke: a cross-sectional study

BackgroundDespite evidence of the benefits of research use in post-acute stroke rehabilitation where compliance with clinical practice guidelines has been associated with functional recovery and patient satisfaction, the rate of reliance on the research literature in clinical decision making among physical therapists is low. More research examining factors that motivate physical therapists to consider research findings in neurological practice is needed to inform efforts to intervene. The objective of this study was to identify practitioner, organizational, and research characteristics associated with research use among physical therapists providing services post-stroke.MethodsA cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada was conducted. The survey questionnaire contained items to evaluate practitioner and organizational characteristics and perceptions of research considered to influence evidence-based practice (EBP), as well as the frequency of using research evidence in clinical decision making in a typical month. Ordinal regression was used to identify factors associated with research use.ResultsThe percentage of respondents reporting research use in clinical decision making 0 to 1, 2 to 5, or 6+ times in a typical month was 33.8%, 52.9%, and 13.3%, respectively (n = 263). Academic preparation in the principles of EBP, research participation, service as a clinical instructor, self-efficacy to implement EBP, a positive attitude towards research, perceived organizational support of research use, and Internet access to bibliographic databases at work were each associated with research use and placed in the final regression model. In the final model (n = 244), academic preparation in EBP, EBP self-efficacy, agreement that research findings are useful, and research participation each remained significantly associated with research use after adjusting for the effects of the other variables in the model.ConclusionsA third of therapists rarely use research evidence in clinical decision making. Education in the principles of EBP, EBP self-efficacy, a positive attitude towards research, and involvement in research at work may promote research use in neurological physical therapy practice. Future research is needed to confirm these findings and to determine the type of research participation that may promote research use.

Factors Influencing Information Seeking by Physical Therapists Providing Stroke Management

Background: Searching and reading the research literature are essential activities for enhancing the use of research and optimizing the quality of physical therapist practice. Objectives: The objectives of this study were to identify practitioner, organization, and research characteristics that are associated with searching or reading the research literature among physical therapists involved in stroke management. Design: A cross-sectional study design was used. Methods: A survey questionnaire was mailed to 1,155 physical therapists in neurological practice in Ontario, Canada. Therapists who treated people with stroke were eligible to participate. Results: Of the 334 eligible respondents, 270 (80.8%) completed a questionnaire. Among participants with complete data, 37.7% of 265 participants conducted online literature searches and 73.3% of 266 participants read the research literature 2 or more times in a typical month. The following factors were associated with conducting online literature searches 2 or more times in a typical month: participation in research, self-efficacy for implementing evidence-based practice (EBP), being male, perceived facility support of research use, and Internet access to bibliographic databases at work. The following factors were associated with reading the literature 2 or more times in a typical month: participation in research, EBP self-efficacy, membership in a professional organization, perceived facility support of research use, and positive perceptions about the usefulness of the research literature and the relevance of walking interventions evaluated in the stroke rehabilitation research literature. A positive association between searching and reading was observed (odds ratio=16.5, 95% confidence interval=5.8–47.1). Limitations: The cross-sectional design limited inferences of causality. Conclusion: Despite a low frequency of searching, the majority of the participating therapists acquired and read the research literature on a monthly basis. Online searching and reading are closely linked behaviors. Modifiable practitioner characteristics, including self-efficacy for implementing EBP and participation in research, appear to be key determinants of EBP.

Identifying mechanisms for facilitating knowledge to action strategies targeting the built environment

BackgroundIn recent years, obesity-related diseases have been on the rise globally resulting in major challenges for health systems and society as a whole. Emerging research in population health suggests that interventions targeting the built environment may help reduce the burden of obesity and type 2 diabetes. However, translation of the evidence on the built environment into effective policy and planning changes requires engagement and collaboration between multiple sectors and government agencies for designing neighborhoods that are more conducive to healthy and active living. In this study, we identified knowledge gaps and other barriers to evidence-based decision-making and policy development related to the built environment; as well as the infrastructure, processes, and mechanisms needed to drive policy changes in this area.MethodsWe conducted a qualitative thematic analysis of data collected through consultations with a broad group of stakeholders (N = 42) from Southern Ontario, Canada, within various sectors (public health, urban planning, and transportation) and levels of government (federal, provincial, and municipalities). Relevant themes were classified based on the specific phase of the knowledge-to-action cycle (research, translation, and implementation) in which they were most closely aligned.ResultsWe identified 5 themes including: 1) the need for policy-informed and actionable research (e.g. health economic analyses and policy evaluations); 2) impactful messaging that targets all relevant sectors to create the political will necessary to drive policy change; 3) common measures and tools to increase capacity for monitoring and surveillance of built environment changes; (4) intersectoral collaboration and alignment within and between levels of government to enable collective actions and provide mechanisms for sharing of resources and expertise, (5) aligning public and private sector priorities to generate public demand and support for community action; and, (6) solution-focused implementation of research that will be tailored to meet the needs of policymakers and planners. Additional research priorities and key policy and planning actions were also noted.ConclusionOur research highlights the necessity of involving stakeholders in identifying inter-sectoral solutions to develop and translate actionable research on the built environment into effective policy and planning initiatives.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care

Purpose: To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI). Method: This was a case study design with ‘Ontario’ as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified. Results: Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of ‘fighting’. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies. Conclusions: Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level. Implications for Rehabilitation Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

An Online Community of Practice to Support Evidence-Based Physiotherapy Practice in Manual Therapy

Introduction: The purpose of this study was to explore how a community of practice promoted the creation and sharing of new knowledge in evidence‐based manual therapy using Wengers constructs of mutual engagement, joint enterprise, and shared repertoire as a theoretical framework. Methods: We used a qualitative approach to analyze the discussion board contributions of the 19 physiotherapists who participated in the 10‐week online continuing education course in evidence‐based practice (EBP) in manual therapy. The course was founded on community of practice, constructivism, social, and situated learning principles. Results: The 1436 postings on 9 active discussion boards revealed that the community of practice was a social learning environment that supported strong participation and mutual engagement. Design features such as consistent facilitation, weekly guiding questions, and collaborative assignments promoted the creation and sharing of knowledge. Participants applied research evidence to the contexts in which they worked through reflective comparison of what they were reading to its applicability in their everyday practice. Participants’ shared goals contributed to the common ground established in developing collective knowledge about different study designs, how to answer research questions, and the difficulties of conducting sound research. Discussion: An online longitudinal community of practice utilized as a continuing education approach to deliver an online course based on constructivist and social learning principles allowed geographically dispersed physiotherapists to be mutually engaged in a joint enterprise in evidence‐based manual therapy. Advantages included opportunity for reflection, modeling, and collaboration. Future studies should examine the impact of participation on clinical practice.

Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury

Study design:Retrospective cohort with linkage of administrative data sets.Objectives:To describe the patterns (for example, number of visits by year post-injury) and characteristics of the emergency department (ED) visits (for example, acuity level, timing of visits, reasons for visits) made by persons with traumatic spinal cord injury (TSCI) over a 6-year period following injury.Settings:Ontario, Canada.Methods:Rates of ED utilization and reasons for ED visits were calculated between the fiscal years 2003–2009. Reasons for visits were categorized by acuity level: potentially preventable visits were defined as visits related to ambulatory sensitive conditions; low acuity and high acuity visits were defined by the Canadian Triage and Acuity Scale.Results:The total number of ED visits for the 6-year period is 4403 (n=1217). Of these visits, 752 (17%) were classified as potentially preventable, 1443 (33%) as low acuity and 2208 (50%) as high acuity. The majority of patients, regardless of acuity level, did not see a primary care practitioner on the day of the ED visit and most visits occurred during the weekday (Mon–Fri 0700–1659 hours). ED use was highest in the first year but remained high over the subsequent years. For potentially preventable visits, the majority of visits were related to urinary tract infections (n=385 visits, 51.2%), followed by pneumonia (n=91, 12.1%).Conclusion:Given the high rates of ED use for low acuity and potentially preventable conditions, these results suggest that the ED is being used as an inappropriate substitute for primary care for individuals with TSCI 50% of the time.