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Page 6 of 11 Merritt et al. Neuroimmunol Neuroinflammation 2019;6:9 I http://dx.doi.org/10.20517/2347-8659.2019.15
[29]
the society . Despite its importance, discrepancies of who should receive rehabilitation continue to exist.
A study investigating rehabilitation rates in patients with TSCI examined patients with private insurance,
government insurance (Medicare/Medicaid), and the uninsured. Patients with private insurance were
referred to rehabilitation services 84.6% of the time, while government and the uninsured were referred
rehabilitation 55.5% and 55.2% of the time, respectively, despite both populations having similar injury
severities. This study also found that patients with government insurance had an average LOS of 12 days
longer than both privatized insurance and those who remain uninsured. However, the explanations are
[28]
varied. Claridge et al. hypothesizes that uninsured patients are simply rejected from most rehabilitation
facilities and are inevitably sent home, while privately insured patients are transferred to rehabilitation
facilities as soon as possible. Patients with government insurance are kept in the hospital while case
[28]
management explores potential options, explaining their increased LOS . Although not surprising, these
results give rise for concern. Increased time between injury and rehabilitation has been associated with
decreased long-term quality of life and a decreased ability to live independently; thus, raising the long-term
cost of care for these individuals. Rehabilitation teaches patients to prevent secondary health complications,
[23]
maximizing function and work towards long term healthy lifestyles .

Long-term complications of a traumatic spinal cord injury
In the years following a TSCI, patients face a risk of several severe co-morbidities. Most fatal complications
are due to urinary tract infections (UTIs), sepsis due to pneumonia, and pressure ulcers (in those with
T1-S5 injuries) [30,31] . A medium-sized cohort study found that 47.6% of TSCI participants were treated
[32]
for a UTI, 33.8% were treated for pneumonias, 27.5% for depression, and 19.7% for a decubitus ulcers .
Characterized as a “never event”, almost one third of all pressure ulcers are seen in paralyzed patients. The
estimated cost for treating a stage IV pressure ulcer (an ulcer that extends into the underlying bone and
[33]
muscle ) is approximately $124,000-$129,000 per instance [34,35] . Sepsis, the second most expensive of the
above listed comorbidities in TSCI patients, was found to cost around $27,000 per stay in the intensive care
unit (ICU). When broken down to the cost by day, the cost of sepsis in the ICU per day in the United States
[36]
was just over $4,500 . As suggested in the data from the medium sized cohort, TSCI paralysis is a risk
factor for increased UTI rates [32,37] . The most common of the comorbidities and the least expensive, it cost
[37]
around $8,300 per hospital treatment .

Post-injury re-hospitalization rates
Patients within the first year following a TSCI are at a significant risk for re-hospitalization. One study
estimates a re-hospitalization rate between 36%-45% in the first year post-injury, decreasing to a 30% re-
[38]
hospitalization risk in subsequent post-injury years . The authors of a 2015 study investigating emergency
room visits (ERV) and emergency re-hospitalizations (ERH) in chronic TSCI patients found that 37%
of participants had at least 1 ERV in the last year, with half of those visits progressing to an ERH . The
[39]
[40]
average hospital LOS for these patients was found to be 21 days . An additional study found that the
only modifiable risk factor for a TSCI patient ERH is lower functional independence following initial
[41]
rehabilitation . Lack of independence is an important issue for uninsured TSCI patients, who encompass
[11]
12% of the TSCI population . As stated previously, most uninsured TSCI patients forego rehabilitation,
[42]
causing decreased functional independence and a subsequent increased risk of medical emergencies .
TSCI patients re-admitted to a hospital post-injury experience a wide range of costs that are dependent on
their co-morbidities. A 2018 study followed a cohort of TSCI patients over a decade while analyzing their
use of health care services over that period. This study found that a combined $49.4 million was spent on
health care services over this 10-year span for all 303 participants. Interestingly, two-thirds of those costs
were utilized by only 16.5% of the study population (termed High Utilizers), with each individual charging
$51,860 per year. High Utilizers had an ERH 2.6 times per year with an average LOS of 9.6 days, often
being treated for multiple co-morbidities. High Utilizers were commonly male, of a racial minority, of low