Trends in Life Expectancy and Causes of Death Following Spinal Cord Injury. Michael J. DeVivo, Dr.P.H.

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1 Trends in Life Expectancy and Causes of Death Following Spinal Cord Injury Michael J. DeVivo, Dr.P.H.

2 Disclosure of PI-RRTC Grant James S. Krause, PhD, Holly Wise, PhD; PT, and Emily Johnson, MHA have disclosed a research grant with the National Institute of Disability and Rehabilitation Research The contents of this presentation were developed with support from an educational grant from the Department of Education, NIDRR grant number H133B However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.

3 Accreditation The Medical University of South Carolina is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Medical University of South Carolina designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. In accordance with the ACCME Essentials &Standards, anyone involved in planning or presenting this educational activity will be required to disclose any relevant financial relationships with commercial interests in the healthcare industry. This information is listed below. Speakers who incorporate information about off-label or investigational use of drugs or devices will be asked to disclose that information at the beginning of their presentation. The Center for Professional Development is an approved provider of the continuing nursing education by the South Carolina Nurses Association an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation

4 Disclosure of Presenter Dr. Michael DeVivo, DrPH does not have any financial disclosures.

5 History Until world war II, spinal cord injury was a condition with a very poor prognosis People generally died within a year or two, typically due to infections, renal or respiratory failure During the war, the British pioneered new treatment methods based on specialized centers of care

6 History Discovery of penicillin and sulfa drugs Treatment results improved dramatically Similar specialized centers were developed within the VA system in the US based on the British experience

7 Spinal Cord Injury Model System Program These successes in Britain and the VA led the US federal government to begin an experimental program of spinal cord injury model systems for the general public

8 Spinal Cord Injury Model System Program Model systems are centers of excellence required to offer a program of coordinated multidisciplinary care from the scene of the accident through acute care, rehabilitation, discharge to the community, and long-term follow-up

9 Spinal Cord Injury Model System Program Funds are awarded by NIDRR through a competitive process based on proposed individual and collaborative research as well as the program of care provided to patients

10 Spinal Cord Injury Model System Program 1970 NIDRR funds 1 st model system in Phoenix, AZ additional model systems funded st federally funded data center 1976 formal data collection commenced (10 centers) Retrospectively back to 1973 and prospectively since 1976

11 Spinal Cord Injury Model Systems Database Original Purpose Store information on patients treated at SCIMS located throughout the United States Evaluate the efficacy of the Model SCI Systems of Care

12 SCIMS Database Current Objectives Examine longitudinal course of SCI Evaluate trends over time Etiology, demographics, injury characteristics, health services delivery, treatment outcomes Establish rehabilitation outcomes standards Facilitate other research Generate research hypotheses Identify study subjects Database linkage

13 Eligibility Criteria SCI of traumatic etiology Complete inpatient rehabilitation at a model system Admitted to SCIMS within one year of injury Reside in SCIMS catchment area U.S. citizen or permanent resident Signed informed consent

14 Spinal Cord Injury Model Systems 1973 present (28 centers) Seattle, WA Ann Arbor, MI Detroit, MI Rochester, NY Bost on, MA San Jose, CA Downey, CA Milwaukee, WI Chicago, IL Englewood, CO Pittsburgh, PA Philadelphia, PA Columbia, MO Charlottesville, VA Louisville, KY Phoenix, AZ Houston, TX Birmingham, AL Cleveland, OH Atlanta, GA Mt Sinai, NY New York, NY West Orange, NJ Washington, DC Richmond, VA Currently funded centers (n=14) Form II follow-up centers (n=5) Previously funded centers (n=9) New Orleans, LA Miami, FL

15 Life Expectancy Research Rapid progress in life expectancy after SCI from 1940 through 1980 No change in life expectancy after SCI for year 1 survivors in past 30 years General population life expectancy is increasing Gap between SCI and general population is increasing

16 Cause of Death Research Most recent model system cause of death study was concluded in 1992 New data desperately needed

17 Objectives Review life expectancy statistics and risk factors for mortality Determine leading causes of death Compare leading causes of death with those of the general population

18 Objectives Determine trends in age-adjusted cause-specific mortality rates Calculate life expectancy gains from eliminating leading causes of death Assess reasons for lack of progress in life expectancy

19 Study Population 45,489 patients with traumatic SCI Injured between 1936 and 2009 Treated at a model system since ,577 deaths

20 Statistical Analysis Logistic regression on person-years 566,557 person years of follow up Probability of survival each year Life expectancy

21 Statistical Analysis Overall frequency and percentage for each cause of death 1997 Age-sex-race-cause-specific mortality rates from the general population Cause-specific SMR, 95% CI Competing risk analysis

22 Statistical Analysis Deaths from each cause and years of exposure stratified by decade Age-specific rates for each cause of death in each time period were calculated Age-adjusted rates were based on the 2000 US standard million population

23 Risk Factor Current Age Age OR 95% CI

24 Risk Factor Current Age Age OR 95% CI

25 Risk Factor Current Age Age OR 95% CI

26 Risk Factor Demographics Factor OR 95% CI Male Hispanic/Asian 1.00 White African American Native American Age at injury

27 Risk Factor Etiology of Injury Etiology OR 95% CI Sports 1.00 Motor vehicle Fall Violence Other

28 Risk Factor Level of Injury ASIA ABC ASIA D Level OR 95% CI OR 95% CI C8 - S C5 - C C1 - C

29 Risk Factor ASIA Impairment Scale ASIA OR 95% CI A B C D E 1.00

30 Risk Factor Year Post-Injury Year OR 95% CI

31 Risk Factor Ventilator Dependent Ventilator OR 95% CI Independent 1.00 Dependent Year Year Year

32 Risk Factor Health Indicators Indicator OR 95% CI Fair Health Poor Health Worse Health Hospitalization Grade 3/4 Sore

33 Risk Factor CHART Scale OR 95% CI Physical < Mobility < Occupation < Social < Economic <

34 First Year Relative Odds of Death OR

35 Relative Odds of Death After First Year OR

36 Life Expectancy (Year 1 Survivors) Age No SCI AIS D Para C5-8 C1-4 Vent

37 Leading Cause of Death (%) Cause Primary Secondary Total 1. Respiratory External causes Infective Ischemic heart Cancer

38 Leading Cause of Death (%) Cause Primary Secondary Total 6. Other heart Digestive system Cerebrovascular PE Urinary system

39 Septicemia Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

40 Pulmonary Embolus Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

41 Pneumonia Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

42 Ischemic Heart Disease Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

43 Other Heart Disease Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

44 Stroke Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

45 Urinary System Disease Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

46 Digestive System Disease Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

47 Endocrine/Nutrition/Metabolic Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

48 Unintentional Injuries Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

49 Suicide Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

50 Homicide Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

51 Cancer Group SMR 95% CI Ventilator C1-4 ABC C5-8 ABC T1-S5 ABC AIS D Overall

52 Age-adjusted Mortality Rates Ischemic Other Time Period Cancer Heart Heart ,996 1,921 1, ,417 2,765 1, ,533 3,347 2, ,842 3,158 4, ,410 4,718 4,274

53 Age-adjusted Mortality Rates Time Period Stroke Arteries Urinary , , , ,019

54 Age-adjusted Mortality Rates Time Period Ill-defined Pulmonary Embolus Digestive , , ,303 2,591 2,066

55 Age-adjusted Mortality Rates Time Period Respiratory Infective Blood ,713 2, ,684 2, ,316 2, ,594 2, ,917 2,

56 Age-adjusted Mortality Rates Time Period Endocrine Musculoskeletal Nervous

57 Age-adjusted Mortality Rates Time Period Accident Suicide Homicide , ,

58 Age-adjusted Mortality Rates Time Period Mental Unknown , , , , ,185

59 Years of Life Expectancy Gained Age 25, White, Male, AIS A, Motor Vehicle Crash, 24-Hour Survivors Prevented Cause C1-4 C5-7 C8-S5 Pneumonia Septicemia Unintentional Injuries Suicide

60 Years of Life Expectancy Gained Age 25, White, Male, AIS A, Motor Vehicle Crash, 24-Hour Survivors Prevented Cause C1-4 C5-7 C8-S5 Ischemic Heart Disease Pulmonary Embolus Urinary System Disease

61 Limitations 6.5% unknown cause of death Not population based Accuracy of death certificates SSDI 92% sensitive Mortality rates and SMR s based on primary cause of death Other confounding factors may affect results of trend analyses

62 Conclusions Life expectancy remains significantly below normal No progress for year 1 survivors in last 30 years

63 Conclusions Leading causes of death are pneumonia, external causes, septicemia, and heart disease

64 Conclusions Mortality rates are declining for cancer, heart disease, stroke, arterial diseases, pulmonary embolus, urinary diseases, digestive diseases, and suicide

65 Conclusions Mortality rates are increasing for endocrine, metabolic and nutritional diseases, accidents, nervous system diseases, musculoskeletal disorders, and mental disorders

66 Conclusion No change in infective disease mortality rate Slight improvement in mortality due to respiratory causes only since 2005

67 Acknowledgement National Institute on Disability and Rehabilitation Research Paralyzed Veterans of America South Carolina Spinal Cord Injury Research Fund

68 Web Site

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