Table 2.

Summary of the studies on costs of veterans with spinal cord injury/disease (SCI/D) according to this systematic review

Reference	Participants	Costing data	Original costs for SCI/D	Current costs for SCI/D	Notes	Results
23	Veterans with SCI/D who underwent inpatient rehabilitation (number of cases is not available)	Direct VA inpatient rehabilitation budgetary costs	(Mean costs per year in 2000 USD): Per diem costs for SCI/D: 1998: $765 1999: $830 2000: $829 Average: $808 Overall costs for SCI/D: 1998: $263,374,200 1999: $295,264,200 2000: $248,113,897 Mean: $268,917,432 Inpatient rehabilitation categories: SCI: $268,917,432 Rehab: $200,057,995 Blind rehab: $111,694,191	(Mean costs per year in 2016 USD): Per diem costs for SCI/D: 1998: $1,360 1999: $1,475 2000: $1,473 Average: $1,436 Overall costs for SCI/D: 1998: $468,112,783 1999: $524,793,037 2000: $440,989,614 Mean: $477,965,144 Inpatient rehabilitation categories: SCI: $477,965,144 Rehab: $207,660,199 Blind rehab: $115,938,570	The Health Economics Resource Center (HERC) Average Cost Database is based on allocated budgets and, hence, it may not precisely reflect the true costs of production services. Also, the cost data included spending with facility and physician but not the cost of capital financing or malpractice.	The mean per diem costs of inpatient rehabilitation of veterans with SCI/D was estimated in $808 in 2000 USD (or $1,436 in 2016 USD). The inpatient rehabilitation of veterans with SCI/D was the most expensive among the categories of inpatient rehabilitation in the study.
24	Veterans with SCI/D aged 65 to 79 years (n=5,401); and Veterans with SCI/D aged 80 or older (n=993)	Direct VA inpatient and outpatient costs	(Mean costs per case in 2000 USD): Aged 65 to 79 years: Total costs: $31,306 Costs without long-term care: $25,193* Aged 80 years or older: Total costs: $31,714 Costs without long-term care: $22,290 * Top 3 most costly chronic conditions after SCI: Aged 65 to 79 years: Renal failure: $20,967 Lung cancer: $17,145 All dementias: $16,795 Aged 80 years or older: Renal failure: $ $19,302 Lung cancer: $15,252 All dementias: $ $17,056	(Mean costs per case in 2016 USD): Aged 65 to 79 years: Total costs: $55,642 Costs without long-term care: $44,777 * Aged 80 years or older: Total costs: $56,367 Costs without long-term care: $39,618 * Top 3 most costly chronic conditions after SCI: Aged 65 to 79 years: Renal failure: $37,266 Lung cancer: $30,473 All dementias: $29,850 Aged 80 years or older: Renal failure: $34,307 Lung cancer: $27,108 All dementias: $30,315	The proportion of users of long-term care varied as follows: Aged 65 to 79 years: SCI (15.6%), renal failure (11.6%), lung cancer (16%), and all dementias (19.4%) Aged 80 years or older: (SCI 20.4%), renal failure (15.5%), lung cancer (19.5%), and all dementias (22.8%)	The total costs to care for elderly veterans with SCI/D did not significantly differ between the age-related groups. However, the oldest veterans with SCI/D had significantly lower health care costs after excluding the long-term care costs when compared with SCI/D veterans who aged 65 to 79 years. The most expensive chronic condition among elderly veterans was SCI/D followed by renal failure, lung cancer and all dementias.
25	19,234 veterans with SCI/D	Direct VA inpatient and outpatient costs identified using Quality Enhancement Research Initiative (QUERI) system	(Mean costs per case in 2000 USD): Inpatient medical/surgical services: $5,690 Other inpatient services: $15,115 Outpatient: $3,512 Pharmacy: $2,777 Overall costs: $27,094 Top 3 most common QUERI conditions: Psychiatric diseases ($9,704), diabetes ($7,709), and substance abuse ($9,489) Top 3 most costly QUERI conditions after SCI: Chronic heart failure ($14,959); stroke ($14,679); colorectal cancer ($14,422)	(Mean costs per case in 2016 USD): Inpatient medical/surgical services: $10,113 Other inpatient services: $26,865 Outpatient: $6,242 Pharmacy: $4,936 Overall costs: $48,156 Top 3 most common QUERI conditions: Psychiatric diseases ($17,248), diabetes ($13,702), and substance abuse ($16,865) Top 3 most costly QUERI conditions after SCI: Chronic heart failure ($26,588); stroke ($26,090); colorectal cancer ($25,633)	The top 3 most common QUERI conditions were psychiatric disorders (23.3%), diabetes (18.5%), and substance abuse (13.5%). The least common QUERI conditions were colorectal cancer, SCI, and HIV/AIDS, accounting for less than 1% of QUERI patients. Of note, the QUERI groups are not mutually exclusive since patients may have multiple conditions.	The inpatient care costs represented 76.8% of the total direct health care costs for veterans with SCI/D, whereas outpatient costs (13%) and outpatient pharmacy (10.2%) had less impact on their total direct health care costs. The costs to care for veterans with SCI/D were the highest among the QUERI chronic conditions in the study, even though it represents less than 1% of them.
26	98 working-age veterans with SCI/D (aged 18 to 64 years); and 93 college-educated civilians of working age with SCI/D (aged 18 to 64 years)	Costs of the assistive technology (AT) devices self-reported by civilians and veterans with SCI/D. The VA costs reported by the veterans were also verified using the National Prosthetic Patient Database (NPPD).	(Costs in 1998-2002 USD) Mean cost per device per person across all categories was $2,032 for veterans vs. $2,155 for civilians. Mean cost per Manual Mobility and Independent Living (MMIL) device was $859 for veterans vs. $859 Mean cost per Powered Mobility and Independent Living (PMIL) device was $ 9,472 for veterans vs. $ 7,947 for civilians. Mean cost per prosthetics & orthotics device was $ 178 for veterans vs. $47*	Costing data could not be properly converted to 2016 USD due to the lack of original data by year. Using the extremes of all original costs in 1998 USD and all original costs in 2002 USD, the mean cost per device per person across all device categories could vary from $3,298 to $3,892 in 2016 USD among veterans, and from $3,498 to $4,127 in 2016 USD among civilians.	SCI/D veterans were significantly older, more likely to be male, non-white than the SCI/D civilians. While both groups had similar degree of disability, the proportion of paraplegics was greater among civilians (57%) when comparted to veterans (47%). Of note, the veterans usually underreported the AT costs in comparison with the NPPD information	Self-reported costing data were underestimated among veterans with SCI/D when compared with NPPD data. The two most frequently owned assistive technology device categories were also the most expensive (i.e. MMIL devices and PMIL devices). The mean costs of the Prosthetics & Orthotics devices were significantly higher for the veterans than for the civilians.
27	675 veterans with SCI for at least 2 years who use wheelchair as a primary means of mobility.	Direct VA inpatient and outpatient costs	(Mean costs per case in 2005 USD): Cervical complete SCI: $28,334 incomplete SCI: $22,134 Thoracic complete SCI: $20,925 incomplete SCI: $16,792 Lumbar complete SCI: $23,158 incomplete SCI: $17,561 Overall: $21,450 Inpatient costs (n=233): $30,866 Outpatient costs: $10,795	(Mean costs per case in 2016 USD): Cervical complete SCI: $40,644 incomplete SCI: $31,751 Thoracic complete SCI: $30,017 incomplete SCI: $24,088 Lumbar complete SCI: $33,220 incomplete SCI: $25,191 Overall costs: $30,770 Inpatient costs: $44,277 Outpatient costs: $15,485	Proportion of inpatient costs (by service): nursing (53.1%); pharmacy (6.5%); surgery (5.7%); laboratory (2%); Radiology (3.8%); other costs (28.9%) Proportion of outpatient costs (by service): SCI clinic (25.8%); Prosthetic (17.9%); VA-paid home care (15.5%); SCI home (3.6%); laboratory (3.3%); Radiology (3%); contract nursing homes (2.6%); dental (2.2%); phone/ancillary medicine (1.9%); primary care (1.5%); other costs (22.9%)	The total inpatient care costs ($7,191,725 in 2005 USD) were close to the total outpatient costs ($7,286,719 in 2005 USD). The overall costs to care for veterans with chronic SCI were higher for cervical complete SCI and lower for thoracic incomplete SCI. Among the inpatient costs, nursing services (53.1%) were the most expensive followed by other costs (28.9%), pharmacy (6.5%) and surgery (5.7%). Among the outpatient costs, SCI clinic services (25.8%) were the most expensive followed by prosthetic services (17.9%) and VA-paid home care (15.5%).
28	5,518 veterans with paraplegia after SCI/D; and 4,521 veterans with tetraplegia after SCI/D included in the Veterans Equitable Resource Allocation (VERA) system	Direct VA inpatient and outpatient costs	(Median costs per case in USD in different years) Paraplegia: 1998: $18,894 1999: $21,553 2000: $22,408 2001: $19,661 2002: $19,838 Tetraplegia: 1998: $20,237 1999: $24,917 2000: $24,967 2001: $26,018 2002: $21,762	(Median costs per case in 2016 USD) Paraplegia: 1998: $36,182 1999: $39,878 2000: $39,827 2001: $33,408 2002: $32,196 Tetraplegia: 1998: $38,754 1999: $46,102 2000: $44,376 2001: $44,210 2002: $35,318	Based on the available data, the overall median costs per case were estimated in $22,402 (in 2002 USD) or $36,357 (in 2016 USD) for paraplegics, and $25,799 (in 2002 USD) or $41,869 (in 2016 USD) for tetraplegics	The median costs for VERA complex class of veterans with paraplegia were estimated in $22,402 USD (2002) or $36,357 USD (2016). The median costs for VERA complex class of veterans with tetraplegia were estimated in $25,799 USD (2002) or $41,869 USD (2016).
29	2,008 veterans with SCI/D during their last 24 months of life	Direct VA medical and surgical costs based on Medicare, other inpatient costs (e.g. home care, long-term hospital care) and outpatient costs based on national costs per diem.	(Mean costs per case in 2016 USD) Overall costs: Final year: $61,900 Previous year: $24,900 Overall costs: $86,800 Traumatic SCI: $98,400 Non-traumatic: $97,600 Paraplegia: $100,400 Tetraplegia: $95,700 Major conditions: Nephritis: $120,200 Septicemia: $99,500 Other: $97,300 COPD: $93,100 Blood vessel disease: $91,700 Pneumonia: $90,400 Diabetes: $84,400 Hernia: $80,900 Heart disease: $79,800 Stroke: $73,200 Cancer: $71,300	(Mean costs per case in 2001 USD) Overall costs: Final year: $105,181 Previous year: $42,310 Overall costs: $147,491 Traumatic SCI: $167,202 Non-traumatic: $165,842 Paraplegia: $170,600 Tetraplegia: $162,614 Major conditions: Nephritis: $204,244 Septicemia: $169,071 Other: $165,333 COPD: $158,196 Blood vessel disease: $155,817 Pneumonia: $153,608 Diabetes: $143,413 Hernia: $137,466 Heart disease: $135,596 Stroke: $124,382 Cancer: $121,153	The most common “major causes of death” and their 2-year costs (in 2016 USD) were: cancer (20.9%; $49 million), influenza/ pneumonia (15.1%; $44.9 million), heart disease (13.5%; 35.4 million), septicemia (5.9%; $19.3 million), stroke (5.1%; $12.3 million), COPD (4.5%; $13.8 million), diabetes (5.3%; $14.7 million), nephritis (4%; $15.8 million), hernia (2.8%; $7.4 million), blood vessel disorders (1.4%; 4.2 million), and other causes (21.5%; $68.8 million)	The costs of caring for SCI/D veterans near their end of life (24 month) are substantially higher than the costs of caring for VA veterans without SCI/D. Most the costs of caring for veterans with SCI/D near their end of life incur in the final year (71.3%), that significantly escalate in the last 6 months before death. Although nephritis was the top major condition with the highest costs for the end of life among veterans with SCI/D, the most expensive major condition for the VA to care for veterans with SCI/D in their near end of life was cancer, followed by influenza/ pneumonia, and heart disease.
30	Veterans with SCI/D and pressure ulcer (n=1,220); and veterans with SCI/D without pressure ulcer (n=9,757)	Direct VA expenditures for patient care either provided at VA facilities or provided in non-VA facilities but paid for by VA.	(Mean annual costs in 2008 USD) SCI/D veterans with pressure ulcer: Outpatient costs: $19,844 Pharmacy costs: $2,394 Inpatient costs: $91,341 Total costs: $100,935 SCI/D veterans without pressure ulcer: Outpatient costs: $11,829 Pharmacy costs: $1,613 Inpatient costs: $13,754 Total costs: $27,195	(Mean annual costs in 2016 USD) SCI/D veterans with pressure ulcer: Outpatient costs: $20,598 Pharmacy costs: $3,050 Inpatient costs: $116,373 Total costs: $128,596 SCI/D veterans without pressure ulcer: Outpatient costs: $15,071 Pharmacy costs: $2,055 Inpatient costs: $17,523 Total costs: $35,564	Both groups were statistically similar with regards to their age, sex distribution, ethnic subgroups, and most of the co-morbidities; however, veterans with pressure ulcer were more likely to have a traumatic SCI, diabetes mellitus, prior hospitalization, and higher mean household income.	SCI/D veterans with pressure ulcers were more costly and had longer length of hospital stay than SCI/D veterans without ulcers. After adjustments, the total annual costs per patient were $73,021 USD (or $75,796 in 2016 USD) higher among veterans with pressure ulcer and their annual hospital admissions were about 52 days longer than SCI/D veterans without ulcer.
31	8,645 veterans with traumatic SCI; and 2,795 veterans with non-traumatic SCI/D	Direct VA expenditures for patient care either provided at VA facilities or provided in non-VA facilities but paid for by VA.	(Mean costs per year in 2008 USD) Traumatic SCI: Outpatient costs: $16,655 Pharmacy costs: $1,938 Inpatient costs: $30,513 Total costs: $49,106 Non-traumatic SCI/D: Outpatient costs: $15,860 Pharmacy costs: $2,030 Inpatient costs: $27,581 Total costs: $45,470	(Mean costs per year in 2016 USD) Traumatic SCI: Outpatient costs: $21,219 Pharmacy costs: $2,469 Inpatient costs: $38,875 Total costs: $62,563 Non-traumatic SCI/D: Outpatient costs: $20,206 Pharmacy costs: $2,586 Inpatient costs: $35,139 Total costs: $57,931	The group of veterans with traumatic SCI were significantly younger and predominantly white men with less co-morbidities, more pressure ulcers, and greater median household income than their counterparts with non-traumatic SCI/D.	Veterans with non-traumatic SCI/D had greater overall outpatient utilization; however, there were no significant differences between the group of veterans with traumatic SCI and the group of veterans with non-traumatic SCI/D with regards to their total health care costs.
32	76 veterans with SCI/D received traditional care; and 20 veterans with SCI/D received teleconsultation for wound care	Direct inpatient and outpatient costs from the VA Decision Support System (DSS) for the VA Centers in Ohio	(Median costs during 30 months in 2007 USD) Outpatient encounters: Teleconsultation: $3,956* Traditional care: $474 Inpatient admissions: Teleconsultation: $139,473 Traditional care: $70,666	(Median costs during 30 months in 2016 USD) Outpatient encounters: Teleconsultation: $5,227 * Traditional care: $626 Inpatient admissions: Teleconsultation: $184,270 Traditional care: $93,363	This retrospective economic analysis used a convenience sample	There were no significant differences in inpatient cost between the two strategies. However, teleconsultation group had a significantly higher median cost per outpatient encounter than the traditional care group.
33	Standard of care versus telehealth care for treatment of pressure ulcers after SCI using low-, medium- and high-cost technology (Base estimate for the model: 20,000 veterans with SCI)	Direct costs primarily gathered from US Department of VA administrative records.	(Medium costs per year in 2007 USD) Prevention care: Standard of care (with homecare): $23,673 Standard of care (without homecare): $9,242 High-cost tech: $21,349 Medium-cost technology: $8,066 Treatment: Standard of care (with homecare): $11,234 Standard of care (without homecare): $8,408 Low-cost tech: $6,325	(Medium costs in 2016 USD) Prevention care: Standard of care (with homecare): $31,276 Standard of care (without homecare): $12,210 High-cost tech: $28,206 Medium-cost technology: $10,657 Treatment: Standard of care (with homecare): $14,842 Standard of care (without homecare): $11,109 Low-cost tech: $8,356	Low-cost technology: digital cameras and e-mail. Medium-cost technology: interactive videoconferencing machine plus station-to-station (hub and spoke) teleconferencing. High-cost technology: interactive videoconferencing machine that was installed in the patient’s home.	Telehealth care was less expensive than standard care when patients and facilities used low-cost technology (e.g. digital cameras and e-mail). Telehealth care using low- and medium-cost technology may reduce the costs of prevention and treatment of SCI-related pressure ulcers.
34	5,233,994 veterans with SCI and/or other chronic diseases received care within the VA system in the Fiscal Year 2010.	The overall cost of VA care for each patient was estimated by aggregating costs for inpatient care, outpatient care, prescription drugs, and contract care from several sources.	(Mean costs per year in 2016 USD) Triad of diabetes, hypertension, SCI: $77,546 among veterans younger than 65 years old; and $65,905 among veterans aged 65 years or older	(Mean costs per year in 2010 USD) Triad of diabetes, hypertension, SCI: $92,586 among veterans younger than 65 years old; and $78,687 among veterans aged 65 years or older	The authors did not report the cost for each condition separately.	Among younger veterans, the triad “chronic heart failure, chronic renal failure, chronic obstructive pulmonary disease” was the most expensive for the year 2010; the triad “diabetes, hypertension, SCI” was the fourth most expense. Among older veterans, the triad “diabetes, hypertension, SCI” was the most expensive for the year 2010.

SCI: spinal cord injury; SCI/D: spinal cord injury or disease; COPD: chronic obstructive pulmonary disease; AIDS: Acquired Immunodeficiency Syndrome; * indicates statistically significant differences