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. 2026 Jul 9;26:1356. doi: 10.1186/s12913-026-14614-y

Role of specialized care in reducing unplanned readmissions after incomplete traumatic spinal cord injury: a population based observational study

Naama Rotem-Kohavi 1, Jijie Xu 1, Zeina Waheed 1, Nader Fallah 1, Michael Bond 2,3, Jason M Sutherland 2, Tamir Ailon 3, Raphaële Charest-Morin 3, Charlotte Dandurand 3, Nicolas Dea 3, Nathan Evaniew 4, Charles G Fisher 3, Scott Paquette 3, John Street 3, Andrea Townson 5,6,7, Viet Vu 5,6, Rhonda Willms 5,6,7, Mei Chong 8, Vanessa K Noonan 1, Brian K Kwon 3,7,✉, Marcel F Dvorak 3
PMCID: PMC13637134  PMID: 42420965

Abstract

Background

Specialized acute and rehabilitation care for traumatic spinal cord injury aims to improve outcomes. This study assessed whether receiving specialized acute and rehabilitation care for incomplete traumatic spinal cord injury was associated with a lower risk of having one or more readmissions within one year post-discharge, compared with receiving care in partially specialized or non-specialized settings.

Methods

Administrative healthcare datasets from British Columbia were linked with the Rick Hansen Spinal Cord Injury Registry to identify individuals who sustained an incomplete traumatic spinal cord injury between 2001 and 2017. The association between the setting of care and the risk of unplanned readmissions was measured and the causes of those unplanned readmissions were described.

Results

A total of 1,733 patients were included. After adjusting for group differences, receiving non-specialized acute care (with or without non-specialized rehabilitation, N = 810) was statistically significantly associated with higher odds of one-year unplanned readmissions compared with receiving specialized care (including both acute and rehabilitation care, N = 421) (OR = 2.06; p < 0.01). The odds of one-year unplanned readmissions were also higher among individuals who received partial specialized care (either only specialized acute care (OR = 1.59, p = 0.05, N = 411), or only specialized rehabilitation care (OR = 2.54, p = 0.02, N = 38)) compared with those who received both specialized acute and rehabilitation care. There were 536 unplanned readmissions identified during the 17-year study period. The most common cause of unplanned readmissions among patients who received specialized care was urinary tract infection, while the most common cause among patients who received non-specialized care was injury/complications of surgery (e.g. femur fractures, complications with internal orthopedic prosthetic devices, implants or grafts).

Conclusions

These findings emphasize the benefits of both acute and rehabilitation specialized care in reducing unplanned readmissions and provide information on the causes of readmissions following incomplete traumatic spinal cord injury.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-14614-y.

Keywords: Specialized care, Traumatic spinal cord injury, Readmissions, Population data, Acute care, Rehabilitation care, Rehospitalization, Complications, Urinary tract, Surgery

Introduction

Traumatic spinal cord injury (SCI) is a complex event that requires timely, comprehensive, multidisciplinary care. Specialized centers for treating SCI have been established to improve care, outcomes and recovery [1–3]. Parent et al. recommended the following criteria to describe specialized acute care: location within or nearby a Level 1 trauma center, spinal surgery team with 24 hours on-call coverage, rapid 24 hours access to an MRI and operating room, a multidisciplinary team, and easy referral to a SCI rehabilitation center [1]. Furthermore, specialized hospitals should have the processes in place to monitor the number and outcomes of individuals with traumatic SCI treated at the center annually to identify changing patterns in the outcomes and complications [4].

There is some evidence that specialized care can improve outcomes following traumatic SCI by providing access to specialized and more holistic personnel and technology [5–8]. In addition, specialized rehabilitation care plays an important role in educating patients in preparation for discharge to the community which has been shown to reduce secondary health conditions [9]. While specialized centers offer specific expertise and SCI focused care, they have some disadvantages such as higher costs [10] and being predominantly located in urban areas, making them less accessible for individuals residing in rural or remote areas. These considerations are especially relevant in the context of a healthcare system such as in British Columbia (BC; Canada) which provides publicly funded hospital care and physician services. It operates within fixed budgets and is required to manage and balance health priorities at the provincial level [11]. Ultimately, the disadvantages of specialized centers should be weighed against the advantages to ensure that the healthcare system and triage guidelines are adequately addressing the patient’s needs, overall healthcare goals and cost-effectiveness [12].

Previous research has demonstrated that in BC there is a clear distinction in triage to a specialized vs. non-specialized care of individuals with complete traumatic SCI (i.e., no motor or sensory function below neurological level of injury, and no sacral sparing [13]) and those with incomplete traumatic SCI (i.e., some motor or sensory function retained below neurological level of injury) [14, 15]. The majority of individuals with complete SCI are admitted either directly or indirectly to a specialized acute care center. However, individuals with incomplete injuries are admitted to both specialized and non-specialized acute care centers, likely due to the diversity of clinical presentations, complexity of the injury, and geographical distribution of patients [14]. Moreover, it was shown that among these individuals with incomplete injuries who were admitted to a specialized acute care center, mortality rates within the first year after injury were lower compared with those admitted to non-specialized centers.

Unplanned readmissions in the first year following discharge from care for traumatic SCI represent a poor outcome [16, 17], are associated with lower quality of life [18] and can be stressful for the patient and their families [5, 19]. Individuals with traumatic SCI have a 2.6- to 2.9-fold higher risk of readmissions compared to the general population [20, 21]. These readmissions represent avoidable high costs accruing to the healthcare system [5, 16, 22, 23]. A better understanding of the factors impacting readmissions following discharge can inform targeted interventions to improve both care and outcomes following traumatic SCI [6].

The objective of this study was to examine outcomes associated with receiving specialized care following acute traumatic SCI. Specifically, we compared the risk of having unplanned readmissions at one-year post-discharge between individuals with traumatic SCI who received care for their injury at a specialized center and individuals who received limited specialized care or non-specialized care using population data from BC. Based on previous studies [16, 24–26], we hypothesized that patients with traumatic SCI exposed to specialized care centers – encompassing both inpatient specialized acute care and specialized rehabilitation care – would exhibit fewer unplanned readmissions compared with those who received limited (i.e., only specialized acute care or only specialized rehabilitation care) or no specialized care. The secondary objective was to identify causes for readmissions following discharge in order to guide opportunities for interventions to avoid unnecessary readmissions [6].

Methods

This study was based on analysis of a retrospective cohort of individuals from population-based linked administrative healthcare datasets from Population Data BC, a data resource which facilitates research access to comprehensive collections of healthcare, health services and population health data. These datasets include longitudinal, de-identified health data from the BC population of approximately 5 million residents. Ethics approval was obtained from the university and hospital ethics review boards (H22-02696). The study cohort creation has been described elsewhere [14] and a description of the data sources, cohort creation methods, variables and validation strategies have been previously published [27].

Patient sample

Individuals aged 18 or older who were treated for an acute traumatic SCI in BC between 2001 and 2017 were identified from hospital discharge summary data using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) codes [28]. Traumatic SCI was defined as any new injury of the spinal cord causing either a motor and/or sensory deficit as a result of an acute external force of any magnitude [14]. Individuals with an incomplete traumatic cervical, thoracic or lumbar injury were included.

Exclusion criteria included patients without an index admission for a traumatic SCI, injuries of the conus and cauda equina (see Appendix for codes used for exclusion), those who died during initial care, those who received initial acute care out of province, and those with Injury Severity Score (ISS) below 9 (considered minor injuries) [29]. Iatrogenic injuries resulting from surgical procedures were not included. Patients with sensorimotor complete injuries [i.e. American Spinal Injury Association Impairment Scale (AIS) A] were not included in the analysis because the majority were admitted to the specialized acute care center (526 of 563, 93%).

Data sources

For this study we used linked healthcare data on individuals with traumatic SCI facilitated through Population Data BC that included data from the following sources:

  1. The Canadian Institute for Health Information Discharge Abstract Database (Hospital Separations, DAD) [28].

  2. BC Provincial Vital Statistics Agency (Deaths) [30].

  3. BC Trauma Registry [31].

  4. Vertebase/QISpine [32].

  5. Medical Services Plan (MSP) Payment Information File [33].

  6. MSP Consolidation File (MSP Registration and Premium Billing) [34].

  7. Rick Hansen SCI Registry (RHSCIR) on participants who were treated for their injury within BC [35, 36].

Interventions – type of SCI care

Individuals were categorized based on whether they were treated in a specialized or in a non-specialized center for their injury as per the criteria suggested by Parent et al. [1]. Eleven hospitals were considered to be non-specialized acute care centers while one acute hospital was categorized as a specialized acute care center accredited using the SCI Acute Standards [4, 37]. In BC, one rehabilitation center provides specialized in-patient rehabilitation care accredited using the SCI Rehabilitation Standards [26, 37], while all other non-specialized in-patient rehabilitation care services were provided through non-specialized rehabilitation centers or within the non-specialized acute care center.

For this study cohort, in-patient rehabilitation care provided through a non-specialized acute care center was not reliably coded in the hospital discharge data. Therefore, all individuals who received non-specialized acute care were grouped together in the non-specialized group without distinction between individuals who received rehabilitation and those who did not. To investigate the effect of receiving specialized care throughout all, partial or no phase of care, on the risk for having unplanned readmissions we divided our cohort into six groups (see Table 1).

Table 1.

Comparison groups

Care Type Category Description Group Label
All Specialized Care 1. Specialized Acute and Specialized Rehabilitation A + R+
Partial Specialized Care

2. Specialized Acute (no rehabilitation)

3. Specialized Acute and Non-specialized Rehabilitation

4. Non-specialized Acute and Specialized Rehabilitation

5. Non-specialized Acute and both types of Rehabilitation (Specialized and Non-specialized)

A + R-

Excluded due to insufficient sample size*

A-R+

Excluded due to insufficient sample size*
No Specialized Care 6. Non-specialized Acute with/without Non-specialized Rehabilitation A-R-
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* For details see results section

Variables

Data on time from injury to first admission, as well as data on spine surgeries were derived using MSP data within the linked cohort. The AIS grade as per the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI [38]) was not available for the cohort. AIS grades classify SCI severity from A (complete injury, with no sensory or motor function preserved below the level of injury) to E (normal sensory and motor function), with grades B-D representing increasing preservation of sensory and motor function below the level of injury. The variables included were age, sex, prior hospital admissions, Charlson Comorbidity Index (CCI), rurality, socio economic status (SES), ISS, concurrent traumatic brain injury (TBI), total length of stay (LOS), and spine surgery. These variables were selected based on previous literature [16, 17] and clinical experience (see Table 2 for full list of variables).

Table 2.

List of variables used

Category Variable
Demographics and Patient Characteristics Age at injury
Sex
Rural vs. urban residence at the time of injury
Charlson Comorbidity Index (CCI) [39]
Socio Economic Status (SES) (measured using quintile of annual income per person equivalent at the time of admission [40])
Number of prior unplanned admissions within one-year pre-injury (0,1,2+)
Injury-related Variables Neurological level of injury (cervical, thoracic, lumbar)
Paraplegia vs. tetraplegia
Mechanism of injury
Injury Severity Score (ISS)
Traumatic Brain Injury (TBI) (yes/no)
Arrival method (directly admitted vs. transferred to acute care center)
Time from injury to first admission (< 24 h, 25–72 h, > 72 h)
Care-related Variables Spine surgery (yes/no)
Length of Stay (LOS) in days
Final discharge destination (discharged home/ discharged to a home setting with support services, signed out, transferred to a long-term care facility, transferred to other (palliative care/hospice, addiction treatment center)).
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Primary outcome

The primary outcome was the occurrence of unplanned readmissions (having no readmissions vs. having one or more readmissions). Any unplanned all-cause readmission to an acute care center within one-year from the in-patient discharge (i.e., discharged from either the acute or rehabilitation center) were included. Elective or day surgery related admissions were excluded. Admissions with a Z-code ICD-10-CA diagnosis code (Z00-Z999) were not considered as unplanned readmissions but rather as part of aftercare or routine care, required during recovery from SCI and were excluded as per Moore et al. [16]. The cause of unplanned readmissions was determined using hospital discharge summary’s most responsible diagnosis categorized using ICD-10-CA codes [24].

Statistical analysis

For categorical variables, counts or proportions were reported. Continuous variables were presented as means with standard deviations (SDs). Skewed continuous variables and ordinal variables were presented by medians with interquartile ranges (IQRs). Parametric tests were used for data with normal distributions, while nonparametric tests including chi-square and Kruskal-Wallis’s test were applied to data that did not follow a normal distribution. For causes of unplanned readmissions we reported the distribution of primary causes of readmissions (unadjusted) across the groups for descriptive purposes only. Formal statistical comparison of cause distribution was not conducted. To measure associations between the type of care and risk of unplanned readmissions within one-year post-discharge, unadjusted and multivariable logistic regression were used.

In the multivariable model, in addition to the intervention (i.e. type of care), covariates were selected based on prior literature and clinical relevance. Bivariate associations with a significance of less than 5% were additionally considered to inform model specificity and avoid overfitting. The following covariates were included in the model: age at injury, sex, CCI, injury level, ISS, time from injury to first traumatic SCI admission, discharge destination, direct/indirect admission (through transfer) to the acute care center, TBI, number of previous unplanned readmissions within one-year pre-injury date, spine surgery (yes/no) and LOS.

Results of the multivariable model were reported as Odds Ratios (ORs) with 95% Confidence Intervals (CIs). Model performance was assessed using the area under the curve (AUC) and Hosmer-Lemeshow test. For the multivariable model, p-values less than 5% were considered statistically significant. Statistical analyses were conducted using SAS software (version 9.4, SAS Institute Inc.). For post hoc analyses, a Bonferroni correction was applied to adjust for multiple comparisons.

Results

The cohort comprised 1,740 individuals (see Fig. 1). Less than 10 individuals belonged to the Specialized Acute with Non-specialized Rehabilitation group and to the Non-specialized Acute Care with both types of Rehabilitation (Specialized and Non-specialized) group and were excluded from further analysis.

Fig. 1.

Fig. 1

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Study cohort identification. 1733 patients with acute traumatic spinal cord injury (SCI) who received care for their injury in British Columbia between 2001 and 2017 were included in the final cohort. Injury Severity Score (ISS); American Spinal Injury Association Impairment Scale (AIS)

The final comparison groups included Specialized Acute and Specialized Rehabilitation (n = 432), which from this point is referred to as “A + R+”, Specialized Acute (no rehabilitation) (n = 445) which is referred to as “A + R-”, Non-specialized Acute and Specialized Rehabilitation (n = 40) referred to as “A-R+”, and Non-specialized Acute with or without Rehabilitation (Non-specialized) (n = 816) referred to as “A-R-”.

A descriptive analysis of the baseline characteristics for the four groups is summarized in Table 3. There were significant age differences between the groups (A + R+ (48, SD = 17), A + R- (51, SD = 19), A-R+ (54, SD = 16), A-R- (56, SD = 19) (p < 0.01)). This was due to the significantly younger age of individuals from the A + R+ and A + R- groups compared with individuals in the A-R- group, (see Appendix for post hoc comparisons with Bonferroni adjustment for multiple comparisons). The percentage of spine surgeries was significantly higher among individuals in the A + R+ group compared with the other groups and significantly higher for the A-R+ group compared with the A-R- group (80.3% (A + R+), 52.1% (A + R-), 60.0% (A-R+), 38.4% (A-R-) p < 0.01, also in the Appendix). The number of patients with a TBI was significantly different among the groups (19.0% (A + R+), 16.9% (A + R-), > 12.5% (A-R+), 12.9% (A-R-) p = 0.02). ISS also differed among the groups (p < 0.01), and this was due to higher ISS for the A + R+ compared with the A-R- group (22.2, SD = 8.7 and 15.3, SD = 7.4; p < 0.001) and compared to the A + R- group (18.2, SD = 8.0; p < 0.001). In addition, ISS was significantly higher among individuals in the A-R+ group compared with the A-R- group (p < 0.01) and was approaching significance compared to the A + R- group (p = 0.026 with Bonferroni adjustment; also see Appendix). Individuals from the A + R+ group also had the lowest rates of direct admission compared to the rest of the groups (33.8% (A + R+), 37.5% (A + R-), 87.5% (A-R+), 94.2% (A-R-), p < 0.01). Neither SES at the time of admission nor rurality were significantly different between the groups (p > 0.05).

Table 3.

Descriptive Analysis Comparing care group in British Columbia, 2001–2017

Variable A + R+
(N = 432)		 A + R-
(N = 445)		 A-R+
(N = 40)		 A-R-
(N = 816)		 P-value
Age: mean (SD) 48 (17) 51 (19) 54 (16) 56 (19) < 0.01
Sex: female (%) 97 (22.4%) 103 (23.1%) 8 (20.0%) 225 (27.6%) 0.12
Charlson Comorbidity Index: mean (SD) 0.3 (0.8) 0.4 (1.0) 0.5 (0.9) 0.4 (0.9) 0.14
Injury Severity Score: mean (SD) 22.2 (8.7) 18.2 (8.0) 21.9 (9.7) 15.3 (7.4) < 0.01
Time from injury to first admission (%): < 0.01
 <=24 h 314 (72.7%) 281 (63.1%) 25 (62.5%) 575 (70.5%)
 25–72 h 51 (11.8%) 104 (23.4%) 8 (20.0%) 129 (15.8%)
 > 72 h 67 (15.5%) 60 (13.5%) 7 (17.5%) 112 (13.7%)
Direct admission (%) 146 (33.8%) 167 (37.5%) 35 (87.5%) 769 (94.2%) < 0.01
Spine surgery: yes (%) 347 (80.3%) 232 (52.1%) 24 (60.0%) 313 (38.4%) < 0.01
TBI: yes (%) 82 (19.0%) 75 (16.9%) < 5 105 (12.9%) 0.02
Injury level (%): 0.10
 Cervical 304 (70.7%) 294 (66.7%) 29 (72.5%) 637 (78.8%)
 Thoracic 64 (14.9%) 58 (13.2%) 8 (20.0%) 84 (10.4%)
 Lumbar 53 (12.3%) 57 (12.9%) < 5 87 (10.8%)
 Missing 9 (2.1%) 32 (7.3%) < 5 < 5
LOS total: mean (SD) 130 (81) 38 (57) 168 (93) 32 (46) < 0.01
Median (Q1-Q3) 111 (70–169) 15 (6–43) 146 (93–227) 12 (5–42)
QAIPPE – SES (%): 0.65
 Missing 13 (3.0%) 16 (3.6%) < 5 16 (2.0%)
 1 89 (20.6%) 120 (27.0%) 8 (20.0%) 185 (22.7%)
 2 86 (19.9%) 83 (18.7%) 6 (15.0%) 165 (20.2%)
 3 78 (18.1%) 85 (19.1%) 10 (25.0%) 162 (19.9%)
 4 85 (19.7%) 67 (15.1%) 7 (17.5%) 146 (17.9%)
 5 81 (18.8%) 74 (16.6%) 8 (20.0%) 142 (17.4%)
Number of prior unplanned admissions: < 0.01
 0 396 (91.7%) 385 (86.5%) 37 (92.5%) 681 (83.5%)
 1 27 (6.3%) 37 (8.3%) < 5 92 (11.3%)
 >=2 9 (2.1%) 23 (5.2%) < 5 43 (5.3%)
Discharge destination (%): < 0.01
 Discharged home/ Discharged to a home setting with support services 395 (91.4%) 350 (78.6%) 31(77.5%) 715 (87.6%)
 Signed out < 5 9 (2.0%) < 5 17 (2.1%)
 Transferred to a long-term care facility 29 (6.7%) 65 (14.6%) 6 (15.0%) 61 (7.5%)
 Transferred to other (palliative care/hospice, addiction treatment center) 6 (1.4%) 21 (4.7%) < 5 23 (2.8%)
Rurality (%): 0.73
 Missing - - - 6
 Rural 78 (18.1%) 75 (16.9%) 8 (20.0%) 157 (19.4%)
 Urban 354 (81.9%) 368 (83.1%) 32 (80.0%) 653 (80.6%)
One-year unplanned readmissions: 1/+ (%) 72 (16.7%) 76 (17.1%) 14 (35.0%) 153 (18.8%) 0.03
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Specialized Acute and Specialized Rehabilitation (“A + R+”), Specialized Acute (no rehabilitation) (“A + R-”), Non-Specialized Acute and Specialized Rehabilitation (“A-R+”), Non-specialized Acute with or without Rehabilitation (Non-Specialized) (“A-R-”), Length of Stay (LOS), Traumatic Brain Injury (TBI). QAIPPE (Quintile of Annual Income Per Person), calculated using the average income per person for each dissemination area. 20% of dissemination areas with the lowest incomes have a QAIPPE of “1”, while 20% of the dissemination areas with the highest incomes are given a QAIPPE of “5”. Socio Economic Status (SES), Standard Deviation (SD). Discharged to a home setting with support services (senior’s lodge, attendant care, home care, meals on wheels, homemaking, supportive housing). Transferred to a long-term care facility (personal care homes, auxiliary care, nursing homes, extended care, homes for the aged, senior’s home, Department of Veterans Affairs homes). Transferred to another facility providing inpatient hospital care (including other acute, sub-acute, psychiatric, rehabilitation, cancer center/agency, pediatric hospital). Transferred to other (palliative care/hospice, addiction treatment center)

The descriptive unadjusted analysis revealed a significant difference in the number of unplanned readmissions between the groups (16.7% (A + R+), 17.1% (A + R-), 35.0% (A-R+), 18.8% (A-R-), p = 0.03) (see Table 3). Post hoc analysis revealed that this was due to a significant difference in the percentage of individuals who had at least one unplanned readmission in both the A + R+ and the A + R- groups compared to the A-R+ group (see Appendix).

We identified a total of 536 unplanned readmissions to an acute hospital in the first-year post-discharge across all the groups with a total of 130 readmissions for the A + R+ group (24.3% of readmissions), 131 readmissions for the A + R- group (24.4% of readmissions), 252 readmissions for the A-R- group (47.0% of readmissions) and 23 for the A-R+ group (4.3% of readmissions). As shown in Fig. 2, the distribution of primary causes of readmissions varied among the groups. In the A + R+ group the most frequent cause was genitourinary conditions (25% of readmissions), followed by injuries or procedural complications (i.e. fracture of the femur and neck fractures or postoperative procedural complications related to grafts and implants (20%)). For the A + R-, A-R + and the A-R- groups, the most frequent cause was injuries/procedural complications (32%, 22% and 16% respectively). For the A-R+ group, an equally common cause of readmissions was attributed to symptoms such as pain. For the A + R- and A-R- groups, the second most common cause was mental and behavioral conditions, mostly related to alcohol or multiple drugs and psychoactive drug use (13% and 14%, respectively). For the A-R + group, the second most common cause was related to genitourinary system conditions (17%).

Fig. 2.

Fig. 2

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Causes of one-year unplanned readmissions in individuals with incomplete traumatic spinal cord injury. A stacked column graph illustration of the percentages of the primary causes of readmission per center. The primary cause of the unplanned readmissions was identified using diagnosis code, ICD-10 codes (primary reason). A total of 536 unplanned readmissions were identified across all groups with 130 readmissions for the A + R, 131 for the A + R-, 23 for the A-R+ group and 252 for the A-R- group. Specialized Acute and Specialized Rehabilitation (“A + R+”), Specialized Acute (no rehabilitation) (“A + R-”), Non-specialized Acute and Specialized Rehabilitation (“A-R+”), Non-specialized Acute with or without rehabilitation (Non-Specialized) (“A-R-”). ICD − 10 International Classification of Diseases, Tenth Revision

Results from multivariable logistic regression analysis are summarized in Table 4. Fifty-three individuals had missing data (6 individuals were missing ISS, 41 had missing injury level, and 6 were missing LOS) and were excluded from the model. The logistic regression model included 1680 individuals. The type of care was significantly associated with one-year unplanned readmissions post-discharge. There was a significant increase in the odds of unplanned readmissions in individuals in the A-R+ (OR = 2.54, 95%CI 1.15–5.62, p = 0.02) and A-R- (OR = 2.06, 95%CI 1.27–3.35, p < 0.01) groups and approaching significant increase in the A + R- group (OR = 1.59, 95%CI 1.00-2.53, p = 0.05) compared to individuals in the A + R+ group. Factors associated with a higher risk of readmissions were older age at injury (OR = 1.01, 95%CI 1.00-1.02, p = 0.01), CCI (per point) (OR = 1.19, 95%CI 1.05–1.36, p = 0.01) and longer total LOS (OR = 1.01, 95%CI 1.00-1.01, p < 0.01). Prior unplanned admissions were also associated with increased OR for unplanned readmissions following their traumatic SCI (p < 0.01). Discharge destination and injury level were not significant factors in the model (see Appendix).

Table 4.

Adjusted associations between types of care and one-year unplanned readmissions among 1680 individuals with traumatic spinal cord injury

Parameter P-value Odds Ratio 95% CI
Intercept < 0.01 0.02 0.01–0.04
Age at injury 0.01 1.01 1.00-1.02
Sex (Male) 0.23 1.21 0.89–1.66
Injury Severity Score (per point) 0.47 1.01 0.99–1.02
Charlson Comorbidity Index (per point) 0.01 1.19 1.05–1.36
Time from injury to admission ≤  24 h (reference) -
Time from injury to admission 24 h < t≤ 72 h 0.07 1.39 0.97–1.98
Time from injury to admission > 72 h* 0.21 1.27 0.87–1.87
Traumatic Brain Injury (Yes) 0.08 1.39 0.96–2.02
Transferred from another hospital 0.13 1.34 0.92–1.96
Number of unplanned prior admissions – 0 (reference) -
Number of unplanned prior admissions – 1 < 0.01 2.05 1.37–3.06
Number of unplanned prior admissions – ≥2 < 0.01 3.99 2.36–6.75
A + R+ (reference) -
A-R+ 0.02 2.54 1.15–5.62
A-R- < 0.01 2.06 1.27–3.35
A + R- 0.05 1.59 1.00-2.53
Spine surgery (No) 0.23 1.20 0.90–1.60
Total LOS < 0.01 1.01 1.00-1.01
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Odds Ratios less than 1 indicate decreased odds of unplanned readmissions association with a given variable. Length of Stay (LOS). Traumatic Brain Injury (TBI). Area under the curve (AUC). A + R+ (Specialized Acute and Rehabilitation) (reference), n = 421; A-R+ (Non-specialized Acute and Specialized Rehabilitation), n = 38; A-R- (Non-specialized Acute and Non-specialized Rehabilitation), n = 810; A + R- (Specialized Acute (no rehab)), n = 411. AUC = 0.73. Hosmer and Lemeshow (HL) goodness of fit p = 0.17

Discussion

In this observational population-based study in BC, we examined whether receiving care at a specialized center following an acute traumatic incomplete SCI was associated with a lower risk for unplanned readmissions. The results confirmed that individuals with traumatic SCI who received specialized care including both acute and rehab care had the lowest likelihood of unplanned all-cause readmissions.

Studies have reported inconsistent findings when investigating the association between center specialization and unplanned readmissions for other types of injuries [16, 24, 41]. Patients receiving specialized care following a burn injury had a 25% lower risk for being readmitted to a hospital in the 5 years following discharge compared to those admitted to a non-specialized care [24]. However, another study examining acute care following traumatic injury (30 days following discharge) showed no effect [16]. These differences may be attributed to the inherent different impact of these acute pathologies on patient’s health (traumatic SCI vs. burns and general trauma) as well as the differences in the care needed during the acute and rehabilitation phase. Furthermore, other factors such as familial dynamics, home environment, and community related factors may affect the care received once discharged from hospital and influence outcomes over time [42].

The triage of individuals to the differing care pathways was not random. We noted significant differences between the groups in demographics as well as in injury related factors. Individuals in the A + R+ group were typically younger and had the highest rates of spine surgeries, which is likely a reflection of a more complex patient population and of those that require surgical stabilization or decompression. Moreover, referral bias within our cohort may have led to a higher number of unplanned readmissions in the A + R+ group, which could have reduced the apparent differences in the unadjusted, descriptive analyses when compared with the A-R- and the A + R- groups.

The proportion of individuals with one or more all cause unplanned readmissions, compared with those with none, was highest in the A-R+ group. This result could be partly attributed to the high level of injury severity of this group compared to the A + R- and A-R- groups. While individuals admitted to a specialized acute care center benefited from streamlined access to a specialized rehabilitation center, those admitted to non-specialized acute care were more likely to receive non-specialized rehabilitation or not be referred to rehabilitation at all. This may be due to a more complex process requiring special healthcare approvals and arrangements. We suspect that at the acute stage, there was lack of recognition that individuals in the A-R+ group required specialized care, and this need was only acknowledged later. However, the “delayed onset” of specialized care (i.e., specialized rehabilitation) did not lead to improvement in their readmission outcomes. This suggests that the A-R+ group could have benefited most from receiving specialized care throughout the care journey.

Similar to other studies, the results from the current study demonstrate that individual-related factors such as older age [43–46], comorbidities [16, 46], and prior injury hospital admissions [16, 47] as well as healthcare related factors such as surgery and total LOS pose a risk for avoidable healthcare utilization and complications [16, 24, 48]. As LOS and spine surgery may partially lie on the pathway between care type and readmission, the estimates should be interpreted as adjusted (conditioned) associations rather than total causal effects. Several studies in traumatic SCI and other health conditions (e.g. burns) reported that discharge destination was associated with a risk for readmissions [16, 17, 24, 49] but in the current study this association was not observed. Variations in study design may explain this difference.

While there was considerable variability in our cohort regarding the rates of individuals who had at least one readmission between the different study groups, the average rate was 18.2% which could be considered lower compared with other reports, where readmission rates following trauma ranged between 19% and 57% [6, 16, 24, 41, 47, 50–52]. A direct comparison of rates between our results and these studies was not possible due to differences in selection criteria, health providers and funding systems across countries [5]. The lower average rate of unplanned readmissions in our cohort was likely due to the exclusion of individuals with a complete traumatic SCI.

In our study, the primary cause for unplanned readmissions for the A + R+ group and the second most common cause in the A-R+ group was related to genitourinary conditions similar to what has been previously reported [5, 6, 43]. Neurogenic bladder is a known secondary complication following SCI, and the related pathophysiological changes increase the risk for urinary tract infections and other genitourinary complications [53]. Interestingly, genitourinary conditions were less common in the A-R- and A + R- whereas fractures of the femur and neck fractures, as well as complications with grafts and implants were the most common causes in those two groups as well as in the A-R+ group. Cardenas et al. showed that genitourinary conditions and respiratory complications were the leading causes for readmissions whereas injury related complications were less common [54]. It was reported that genitourinary system conditions were more prevalent among individuals with AIS A-C injuries compared to AIS D. As mentioned previously, our administrative dataset did not have information on the AIS grades, but a high percentage of less severe injuries in these groups could explain this difference. Moreover, causes of readmission in our cohort were described to provide clinical context, however, no formal comparative model was conducted, and thus these findings are exploratory and should be considered hypothesis-generating.

A substantial proportion of readmissions were associated with mental health conditions. However, the current analysis did not account for depressive symptoms, and therefore our interpretation of this result is limited. Nonetheless, this result suggests the significance of mental health conditions in readmissions, emphasizing the need for further investigation, particularly regarding the role of pre-existing and new depressive symptoms and their effect on post-discharge outcomes [5, 6].

The main strength of this study was using comprehensive population-level data spanning 17 years, allowing us to investigate the effect of specialized care incorporating both acute and rehabilitation care compared to partial or non-specialized care. Our study, however, does have limitations. The administrative dataset lacked detailed information on the AIS grades, limiting our ability to account for injury severity, which could have impacted our results. In the multivariable model we adjusted for multiple complementary indicators of injury severity including ISS, neurological level, TBI and spine surgery. To preserve information and maintain statistical power, ISS was modeled as a continuous variable. Nevertheless, residual confounding by unmeasured aspects of injury severity cannot be ruled out. In addition, it is important to note that the A-R+ group was relatively small compared to the other groups, which may contribute to less stable estimates. Results related to this group should be interpreted with caution. Moreover, in BC, specialized SCI care is provided in one acute care center and one rehabilitation center, whereas non-specialized care is provided across the province. This centralized approach fosters the development and maintenance of specialized expertise, like the BC provincial healthcare model for treating other complex conditions such as cancer and paediatric conditions. While this centralization is inherent to the BC healthcare system, there could be site-specific factors unrelated to the type of care, such as site-specific care protocols or practices, we could not control for in the analysis. Some of the differences observed in the outcomes could potentially be attributed to these factors, which is a limitation of our study. However, we have controlled for many injury-related, demographic and care related factors, to minimize the site-specific effects.

Also, in the current dataset, we could not distinguish within the non-specialized group between those who received non-specialized rehabilitation services and those who received no rehabilitation and therefore we grouped them together. The absence of this additional comparative group may have introduced bias against our hypothesis, which could have potentially diminished the impact of our findings. The absence of functional measures and the amount of physical therapy which were linked to readmission risk [6, 17] is another limitation. Future studies should incorporate these measures as well as other healthcare utilization factors such as emergency room visits and community healthcare visits.

While this study included available administrative data up to 2017, the structure and delivery of care of specialized acute and rehabilitation care for traumatic SCI and the referral structure have remained stable over the years, which supports the continued validity of our results. However, future studies should examine more recent data to confirm our findings. Moreover, future studies should also account for calendar year effects in the model to reduce temporal biases related to changes in care practices.

In conclusion, using 17 years of administrative data from the BC population we found that individuals with incomplete traumatic SCI who received non-specialized care or partial specialized care had an increased risk for unplanned readmissions in the year following discharge compared to individuals who received specialized care for both the acute and rehabilitative phases. These results emphasize the potential benefits of early specialized care, including both acute and rehabilitation specialized care, in enhancing post discharge outcomes. Additionally, genitourinary complications and external injuries were the most prevalent causes for readmission, and preventative measures should be considered to reduce complications in both specialized and non-specialized care setting.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (24.9KB, docx)

Acknowledgements

We thank the following individuals for their contributions to the acquisition and preparation of data for this study: Jerome Buenaventura, Melody Chen, Susan Jaglal, Shawna Cronin, and Suzanne Humphreys. We thank Allan Aludino, Leilani Reichl and the Spine Research Team for their assistance in data provisioning and support. We thank Lori Korchinski, Jenn McMillan, Jaimini Thakore, Recep Gezer, and the rest of the Trauma Services BC team for their assistance in data provisioning and support. We thank Andrea Fung, Tim Choi, Victoria Farkas, Kady Toure Yeo, Ambrose Fong and the rest of the Population Data BC team for their assistance in data provisioning and support. Lastly, we acknowledge the visionary SCI leadership of Marcel Dvorak who initiated this work with Population Data BC but sadly passed away in May 2025.

Abbreviations

AIS

American Spinal Injury Association (ASIA) Impairment Scale

AUC

Area Under the Curve

BC

British Columbia

CA

Canada

CCI

Charlson Comorbidity Index

CI

Confidence Interval

ICD

International Statistical Classification of Diseases and Related Health Problems

ISNCSCI

International Standards for Neurological Classification of Spinal Cord Injury

ISS

Injury Severity Score

IQR

Interquartile Range

LOS

Length of Stay

OR

Odds Ratio

QAIPPE

Quintile of Annual Income Per Person

RHSCIR

Rick Hansen Spinal Cord Injury Registry

ROC

Receiver Operating Characteristic

SCI

Spinal Cord Injury

SD

Standard Deviation

SES

Socio-Economic Status

TBI

Traumatic Brain Injury

Author contributions

Naama Rotem-Kohavi: Conceptualization, Methodology, Writing – Original Draft, Review and Editing, Visualization, Project Administration. Jijie (Jason) Xu: Software, Formal Analysis, Data Curation, Writing – Original Draft, Review and Editing. Nader Fallah: Conceptualization, Methodology, Analysis supervision, Writing – Original Draft, Review and Editing. Vanessa K. Noonan: Conceptualization, Methodology, Writing – Original Draft, Review and Editing, Supervision. Zeina Waheed, Michael Bond, Jason M. Sutherland, Tamir Ailon, Raphaële Charest-Morin, Charlotte Dandurand, Nicolas Dea, Nathan Evaniew, Charles G. Fisher, Scott Paquette, John Street, Andrea Townson, Viet Vu, Rhonda Willms, Mei Chong: Writing – Review and Editing. Marcel F. Dvorak and Brian K. Kwon: Conceptualization, Writing – Review and Editing, Supervision.

Funding

This work was supported by funding from the Praxis Spinal Cord Institute (Praxis), the Canadian Government, and the Government of British Columbia. MFD was the Cordula & Günter Paetzold Chair of Clinical Spinal Cord Injury Research at ICORD, University of British Columbia. BKK is the Canada Research Chair in Spinal Cord Injury and Dvorak Chair in Spine Trauma at UBC. JMS received funding for statistical services from Praxis through CHSPR for a work not related to this project. NRK, JX, NF, ZW and VKN are employed by Praxis.

Data availability

The data that support the findings of this study was obtained upon request from Population Data BC. Data use agreements prohibit sharing. Access to data provided by the Data Stewards is subject to approval but can be requested for research projects through the Data Stewards or their designated service providers. The following data sets were used in this study: (Consolidation file (includes demographics, registry, and census geodata), Hospital Separations, Medical Services Plan (MSP), Vital Events and Statistics - Deaths, RHSCIR, BCTR, Vertebase/QISpine). You can find further information regarding these data sets by visiting the PopData project webpage at: (https://my.popdata.bc.ca/project_listings/15-119/collection_approval_dates). Inferences, opinions, and conclusions drawn in this publication are those of the authors, and do not reflect the opinions or policies of the Data Stewards.

Declarations

Ethics approval and consent to participate

Ethics approval was obtained from the university and hospital ethics review boards (H22-02696). As this study used retrospective administrative data from population datasets (Population Data BC), the need for consent to participate was waived by the University of British Columbia Review Board (IRB). The study was carried out according to the Declaration of Helsinki.

Consent for publication

N/A.

Competing interests

Other disclosers: CGF is receiving royalties from Medtronic and is consulting to Medtronic. CGF declares that Medtronic, AO Spine, Depuy Synthes paid to Institution Fellowship Funding. MFD was receiving royalties from Medtronic. The royalties were not related to this current work.

Footnotes

^In memory of Marcel F. Dvorak.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1 (24.9KB, docx)

Data Availability Statement

The data that support the findings of this study was obtained upon request from Population Data BC. Data use agreements prohibit sharing. Access to data provided by the Data Stewards is subject to approval but can be requested for research projects through the Data Stewards or their designated service providers. The following data sets were used in this study: (Consolidation file (includes demographics, registry, and census geodata), Hospital Separations, Medical Services Plan (MSP), Vital Events and Statistics - Deaths, RHSCIR, BCTR, Vertebase/QISpine). You can find further information regarding these data sets by visiting the PopData project webpage at: (https://my.popdata.bc.ca/project_listings/15-119/collection_approval_dates). Inferences, opinions, and conclusions drawn in this publication are those of the authors, and do not reflect the opinions or policies of the Data Stewards.

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