The Value of Recovery After Spinal Cord Injury: Long-Term Healthcare Costs in Relation to Home Time in a Population-Based Cohort.

Abstract

Traumatic spinal cord injury (SCI) is associated with substantial long-term healthcare utilization. While prior studies have quantified costs, few have contextualized expenditures in relation to patient-centered recovery and healthcare value. To characterize five-year longitudinal healthcare cost following traumatic SCI, estimate phenotype-specific cost trajectories, and evaluate healthcare value by integrating costs with days alive and at home (DAH). Population-based retrospective cohort study using linked administrative health data from Ontario, Canada. Adults (≥18 years) presenting to trauma centers with acute traumatic SCI between 2009 and 2023 (n=614). Total direct healthcare costs over five years; DAH within two years (DAH-2y); change in Functional Independence Measure (FIM) motor score during inpatient rehabilitation. Multi-sector healthcare costs were ascertained from provincial single-payer records using validated person-level costing algorithms. Longitudinal costs were modeled using generalized estimating equations with a gamma distribution and log link. Five-year phenotype-specific population-averaged costs were estimated via marginal standardization. Healthcare value was assessed by integrating two-year costs with DAH-2y using cost-per-DAH metrics and modeling of the association between DAH and total costs using multivariable gamma regression. Associations between FIM motor improvement and costs were also evaluated. Healthcare spending was heavily front-loaded, with median total costs of CA$78,572 in the first 30 days following SCI and declining to < $10,000 annually after year 1. Median five-year cumulative costs were $204,924 (interquartile range [IQR] $112,357-$367,952). Adjusted five-year population-averaged costs varied substantially by phenotype, ranging from $440,383 for complete cervical injuries to $191,273 for incomplete lumbar injuries. Cost differentials by injury completeness were most pronounced within the first two years and attenuated thereafter. Median DAH-2y was 603 days (IQR 229-664). Greater DAH-2y was independently associated with lower two-year costs (10% reduction per 100 additional days; cost-ratio 0.90, 95% CI 0.87-0.92; p<0.001). Among patients with DAH>0, median spending intensity was $268 per DAH (IQR $155-$515) and varying by phenotype ($577 per DAH for complete cervical vs $228 for incomplete cervical injuries). Greater improvement in FIM motor score was independently associated with lower one-year costs (0.86% reduction per point; p<0.001). Long-term healthcare expenditures after traumatic SCI vary substantially by injury phenotype and are concentrated early after injury. Integrating costs with DAH and functional recovery reframes resource use through a value-based lens relative to patient-centered outcomes.