Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Johnson, Christopher

Committee Co-Chair (if applicable)

Karimi, Seyed

Committee Member

Karimi, Seyed

Committee Member

Ugiliweneza, Beatrice

Committee Member

Lorenz, Douglas

Author's Keywords

spinal cord; paraplegia; rehabilitation length


Background: Spinal Cord Injury (SCI) is associated with functional and physical limitations as well as psychological challenges. Rehabilitation care is crucial to SCI individuals’ overall health. It is recommended that individuals with SCI receive an intensive and early rehabilitation care to improve their health and avoid medical complications. Hospitals and rehabilitation facilities use length of stay (LOS) as a proxy to quantify rehabilitation care and a measure for quality of care. Objectives: This dissertation has three aims: 1) to identify factors associated with rehabilitation LOS in paraplegia populations, 2) to examine trends of inpatients rehabilitation LOS in SCI paraplegia between 1988 and 2016 in the United States, 3) to evaluate the association between rehabilitation LOS and health outcomes in SCI paraplegia after one-year of inpatient rehabilitation discharge from 2000 to 2015 in the United States.

Methods: The first manuscript used a systematic review of the existing literature to identify the factors associated with rehabilitation LOS in paraplegia. The review included only peer-reviewed articles from the United States between 1980 to 2022. The search was conducted in three databases: PubMed, Embase, and CINAHL. The second manuscript used the National Spinal Cord Injury Statistic Center (NSCISC) database to examine the trends of rehabilitation LOS in SCI paraplegia between 1988 and 2016. The multivariable linear regression was used for statistical analysis with interaction term model between Functional Independence Measurement (FIM) score and years (1988-2016). The Donabedian model for quality of care was used to construct the manuscript and the selected variables. The third manuscript used the same database (NSCISC) that was used for the second manuscript. The International Classification of Function, Disability and Health (ICF) framework was applied to examine the association between the rehabilitation LOS and the health outcomes of individuals with SCI paraplegia after oneyear of inpatient rehabilitation discharge. Seven health outcomes were examined in this manuscript including FIM scores, satisfaction of life scale (SWLF), rehospitalization, and four Craig Handicap Assessment and Reporting (CHART) scores (physical independence, mobility, occupation and social integration scores). Multivariable logistic, linear and quantile regressions were used for statistical analysis. In the second and third manuscripts, the sociodemographic disparities were evaluated. Results: In manuscript 1, the systematic review identified 13 articles for final review. The results yielded 6 factors associated with rehabilitation LOS: age, gender, type of etiology, severity of injury, surgical intervention and body weight. Of the 6 factors, only age and severity of injury had significant effect on rehabilitation LOS, while the rest did

not show significant results. In manuscript 2, the finding of linear regression showed that rehabilitation LOS decreased by 1.4% on average each year from 1988 to 2016. Shorter rehabilitation was associated with younger age, being employed, having incomplete paraplegia, and having higher FIM scores. In manuscript 3, the first year of postdischarge outcomes became worse or did not improve from 2000 to 2015. Of the 7 health outcomes included in the study, FIM scores, physical independence scores, and rehospitalization rates showed significantly negative results over years. Moreover, old, unemployed, and with complete paraplegia had lower FIM score, higher rehospitalization rate, lower SWLF scores, and higher degree of handicap in physical independence, mobility, occupation, and social integration handicap. In addition, higher degree of handicap of physical independence, mobility, and occupation, lower FIM scores, lower SWLF and higher rate of rehospitalization were associated with longer rehabilitation LOS. Conclusion: The dissertation’s manuscripts found that age and severity of injury were the most factors affecting rehabilitation LOS. Also, rehabilitation LOS continued to decline over years with variation among sociodemographic factors. Patients who were young, employed with incomplete paraplegia and with higher FIM had shorter rehabilitation LOS. The health outcomes after inpatient rehabilitation discharge were worse or did not improve over years. Shorter rehabilitation was associated with better health outcomes in physical independence and mobility scores, FIM score, SWLF, and rehospitalization rates.