Original research| Volume 100, ISSUE 5, P938-944, May 2019

Concentration of Costs Among High Utilizers of Health Care Services Over the First 10 Years After Spinal Cord Injury Rehabilitation: A Population-based Study

Published:November 23, 2018DOI:



      The purpose of this study was to (1) categorize individuals into high, medium, and low utilizers of health care services over a 10-year period after the onset of spinal cord injury (SCI) and (2) identify the pattern of causes of hospitalizations and the characteristics associated with high utilization.


      Retrospective analysis of self-report assessment linked to administrative data.


      Data were collected from participants living in and utilizing hospitals in the state of South Carolina.


      Adult participants with traumatic SCI were identified through a state SCI Surveillance System Registry, a population-based system capturing all incident cases treated in nonfederal facilities. Among 963 participants who completed self-report assessments, we matched those with a minimum of 10 years of administrative records for a final sample of 303 participants (N=303).


      Not applicable.

      Main Outcome Measures

      Costs related to health care utilization for emergency department visits and hospitalizations, as measured operationally by hospital charges at full and established rates; causes of hospitalizations


      Over two-thirds of the total $49.4 million in charges for hospitalization over the 10-year timeframe (69%) occurred among 16.5% of the cohort (high utilizers), whereas those in the low utilizer group comprised 53% of the cohort with only 3.5% of the charges. The primary diagnoses were septicemia (50%), other urinary tract disorder (48%), mechanical complication of device, implant, or graft (48%), and chronic ulcer of skin (40%). Primary diagnoses were frequently accompanied by secondary diagnoses, indicating the co-occurrence of multiple secondary health conditions. High utilizers were more likely to be male, minority, have a severe SCI, have reported frequent pressure ulcers and have income of less than $35,000 per year.


      The high cost of chronic health care utilization over a 10-year timeframe was concentrated in a relatively small portion of the SCI population who have survived more than a decade after SCI onset.


      List of abbreviations:

      BRFSS (Behavioral Risk Factor Surveillance System), CDC (Centers for Disease Control and Prevention), ED (emergency department), HCU (health care utilization), ICD-9-CM (International Classification of Diseases-9th Revision-Clinical Modification), SCI (spinal cord injury), SHC (secondary health condition)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Guilcher S.J.
        • Munce S.E.
        • Couris C.M.
        • et al.
        Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2010; 48: 45-50
        • DeJong G.
        • Tian W.
        • Hsieh C.H.
        • et al.
        Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation.
        Arch Phys Med Rehabil. 2013; 94: S87-S97
        • Skelton F.
        • Hoffman J.M.
        • Reyes M.
        • Burns S.P.
        Examining health-care utilization in the first year following spinal cord injury.
        J Spinal Cord Med. 2015; 38: 690-695
        • Pretz C.R.
        • Graham J.E.
        • Middleton A.
        • Karmarkar A.M.
        • Ottenbacher K.J.
        Longitudinal investigation of rehospitalization patterns in spinal cord injury and traumatic brain injury among medicare beneficiaries.
        Arch Phys Med Rehabil. 2017; 98: 997-1003
        • Dryden D.M.
        • Saunders L.D.
        • Rowe B.H.
        • et al.
        Utilization of health services following spinal cord injury: a 6-year follow-up study.
        Spinal Cord. 2004; 42: 513-525
        • Cardenas D.
        • Hoffman J.
        • Kirshblum S.
        • McKinley W.
        Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis.
        Arch Phys Med Rehabil. 2004; 85: 1757-1763
        • Krause J.S.
        • Saunders L.L.
        Risk of hospitalizations after spinal cord injury: relationship with biographical, injury, educational, and behavioral factors.
        Spinal Cord. 2009; 47: 692-697
        • Krause J.S.
        • Cao Y.
        • Bozard J.L.
        Changes in hospitalization, physician visits, and self-reported fitness after spinal cord injury: a cross-sequential analysis of age, years since injury, and age at injury onset.
        Arch Phys Med Rehabil. 2013; 94: 32-37
        • Noonan V.K.
        • Fallah N.
        • Park S.E.
        • et al.
        Health care utilization in persons with traumatic spinal cord injury: the importance of multimorbidity and the impact on patient outcomes.
        Top Spinal Cord Inj Rehabil. 2014; 20: 289-301
        • Mahmoudi E.
        • Meade M.A.
        • Forchheimer M.B.
        • Fyffe D.C.
        • Krause J.S.
        • Tate D.
        Longitudinal analysis of hospitalization after spinal cord injury: variation based on race and ethnicity.
        Arch Phys Med Rehabil. 2014; 95: 2158-2166
        • Krause J.S.
        • Terza J.V.
        • Cao Y.
        • Clark J.M.
        Emergency room visits and hospitalizations among participants with spinal cord injury.
        NeuroRehabilitation. 2015; 36: 313-321
        • National Spinal Cord Injury Statistical Center
        Spinal cord injury model systems 2017 annual report – public version.
        University of Alabama, Birmingham, AL2017
        • Charlifue S.
        • Lammertse D.
        • Adkins R.
        Aging with spinal cord injury: changes in selected health indices and life satisfaction.
        Arch Phys Med Rehabil. 2004; 85: 1848-1853
        • Pagliacci M.C.
        • Franceschini M.
        • Di Clemente B.
        • Agosti M.
        • Spizzichino L.
        • GISEM
        A multicentre follow-up of clinical aspects of traumatic spinal cord injury.
        Spinal Cord. 2007; 45: 404-410
        • Savic G.
        • Short D.J.
        • Weitzenkamp D.
        • Charlifue S.
        • Gardner B.P.
        Hospital readmissions in people with chronic spinal cord injury.
        Spinal Cord. 2000; 38: 371-377
        • Guilcher S.J.
        • Craven B.C.
        • Calzavara A.
        • McColl M.A.
        • Jaglal S.B.
        Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury?.
        Spinal Cord. 2013; 51: 202-208
        • Stillman M.D.
        • Frost K.L.
        • Smalley C.
        • Bertocci G.
        • Williams S.
        Health care utilization and barriers experienced by individuals with spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 1114-1126
        • National Spinal Cord Injury Statistical Center
        Spinal cord injury model systems 2009 annual report – public version.
        University of Alabama, Birmingham, AL2009
        • Hammond F.M.
        • Horn S.D.
        • Smout R.J.
        • et al.
        Acute rehospitalizations during inpatient rehabilitation for spinal cord injury.
        Arch Phys Med Rehabil. 2013; 94: S98-S105
        • Dorsett P.
        • Geraghty T.
        Health-related outcomes of people with spinal cord injury - a 10 year longitudinal study.
        Spinal Cord. 2008; 46: 386-391
        • Meyers A.R.
        • Branch L.G.
        • Cupples L.A.
        • Lederman R.I.
        • Feltin M.
        • Master R.J.
        Predictors of medical care utilization by independently living adults with spinal cord injuries.
        Arch Phys Med Rehabil. 1989; 70: 471-476
        • January A.M.
        • Zebracki K.
        • Czworniak A.
        • Chlan K.M.
        • Vogel L.C.
        Predictive factors of hospitalization in adults with pediatric-onset SCI: a longitudinal analysis.
        Spinal Cord. 2015; 53: 314-319
        • Eastwood E.
        • Hagglund K.
        • Ragnarsson K.
        • Gordon W.
        • Marino R.
        Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury.
        Arch Phys Med Rehabil. 1999; 80: 1457-1463
        • Krause J.S.
        • Zhai Y.
        • Saunders L.L.
        • Carter R.E.
        Risk of mortality after spinal cord injury: an 8-year prospective study.
        Arch Phys Med Rehabil. 2009; 90: 1708-1715
        • Krause J.S.
        • Saunders L.L.
        Health, secondary conditions, and life expectancy after spinal cord injury.
        Arch Phys Med Rehabil. 2011; 92: 1770-1775
        • Cao Y.
        • Krause J.S.
        • Dipiro N.
        Risk factors for mortality after spinal cord injury in the USA.
        Spinal Cord. 2013; 51: 413-418
        • Butler J.
        • Langlois J.A.
        Central nervous system injury surveillance: annual data submission standards-2000.
        US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA2001
        • Saunders L.L.
        • Murday D.
        • Corley B.
        • Cao Y.
        • Krause J.S.
        A comparison of rates of hospitalization and emergency department visits using self-report and South Carolina administrative billing data among a population-based cohort with spinal cord injury.
        Arch Phys Med Rehabil. 2016; 97: 1481-1486
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Cao Y.
        • Chen Y.
        • DeVivo M.
        Lifetime direct costs after spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2011; 16: 10-16