Study design, materials and methods
This a prospective multicenter observational study of patients with SCI evaluating patient reported outcomes over a one year follow up period. Patients with traumatic SCI, who were >18 years of age, English speaking, and able to complete computer based assessments were included in the study and any patients with congenital or neurodegenerative disorders were excluded. After the initial enrollment, questionnaires were administered every three months to assess hospitalization and ER visit events as well as causes for each. Primary outcomes assessed were the rates of urologic related hospitalizations over one year. Multivariable logistic regression model was then used to evaluated factors associated with risk of hospitalization or ER visit.
Results
Of 1479 participants enrolled across the US from 1/1/ 2016 to 6/30/2017, 1260 had one year follow up data.The average age of the group was 45 (IQR: 34-54)years and 39.6% (585/1479) were female. Majority of the patients had an injury at T1 or below and 56.1% (806/1436) were complete injuries and median time from injury was 11 years (IQR: 5-22). Thirty three percent of the patients (422/1260) reported at least one hospitalization or ER visit and 11.0% (142/1260) had 2 or more hospitalizations during one year of follow up. Urologic reasons were cited as the reason for seeking care in 50% (211/422), majority were due to infections (185/422). Patients with an indwelling catheter were most likely to have had a hospital or ER admission (31%), followed by patients with previous bladder surgery (21%), performing intermittent catheterization (19%), and patients who spontaneously voided as primary method of bladder emptying (10%) (p<0.001)(Figure 1). On multivariable analysis accounting for gender, co-morbidities, education, and injury characteristics self-reported SF-12 physical disability scores (OR=0.98, CI:0.96-0.996, p=0.014), diminished hand function (OR=1.83, CI:1.05-3.19, p=0.033), and unemployment (OR=1.64, CI:1.13-2.37, p=0.009) were associated with hospitalization or ER visit for urologic indication (Table 1). Also, patients with indwelling catheter, performing CIC, or those who had previous reconstructive bladder surgery, had respectively 3.34 (CI:1.68-6.67, p=0.001), 2.56 (CI:1.36-4.84, p=0.004), and 2.57 (CI:1.20-5.52, p=0.015) greater odds of hospitalization/ER visit for urologic indications as compared to those voiding.
Interpretation of results
The all cause hospitalization rates was 33% over 1 year in this prospectively followed SCI cohort and is unchanged from those in the 1990(1). The most common reasons for admission were urologic complications and many are due to infections. This is likely multifactorial however lack of proper urologic care in population may be playing a major role. Cameron et al demonstrated previously that only about 1/3 of SCI patients saw a urologist during a 2 year period and only half had any upper tract surveillance (2). SCI patients with indwelling catheters, either suprapubic or urethral, had the highest incidence of hospitalization/ER visits and bladder management type was an independently associated with increased odds of hospitalization/ER visit. On multivariable analysis self-reported physical disability scores and diminished hand function, unemployment were associated with hospitalization or ER visit for urologic indication.