Influence of administrative factors on the effectiveness of health care delivery to victims with acute spine and spinal cord injuries: regional retrospective study as a base for improving national clinical guidelines

Objective. To identify key organizational factors that determine the effectiveness of the system for delivering medical care to victims with acute spinal cord injury in the setting of large constituent entity of the Russian Federation, and to develop appropriate proposals for improving the national clinical guidelines.

Material and Methods. The study included data on 2,283 patients with acute spinal cord injury who were treated within the framework of three successively existed organizational models of the health care delivery system: I – decentralized unprofiled (306 patients); II – decentralized profiled (454 patients); and III – centralized profiled (1523 patients). Using the methods of nonparametric statistics, the medical and statistical indicators were compared in patients examined when evaluating the results of treatment: 44, 75 and 148 patients from each organizational model, respectively (p > 0.05).

Results. The effectiveness of the treatment of victims with acute spinal cord injury depends on the interaction of organizational factors that determine the structure and operation of the health care system at the level of the federation subject as a whole (centralization factor) and at the level of the relevant hospital (profiling factor). Specialized departments/centers for emergency spine surgery housed by multidisciplinary emergency hospitals – level I trauma centers (profiling factor) operate to maximum effect only when a centralized model of health care is organized in the subject of the federation (centralization factor).

Conclusion. Within the framework of national clinical guidelines for the treatment of patients with acute spinal cord injury, the principles of their routing and the requirements to be met by the involved hospitals should be clearly regulated.

1. Lipa SA, Sturgeon DJ, Blucher JA, Harris MB, Schoenfeld AJ. Do Medicare Accountable Care Organizations reduce disparities after spinal fracture? J Surg Res. 2020;246:123–130. DOI: 10.1016/j.jss.2019.09.003.

2. Shank CD, Walters BC, Hadley MN. Current topics in the management of acute traumatic spinal cord injury. Neurocrit Care. 2019;30:261–271. DOI: 10.1007/s12028-018-0537-5.

3. Федонников А.С., Андриянова Е.А., Баратов А.В. Перспективные направления развития медико-социальной помощи при травматических повреждениях позвоночника // Здоровье и образование в XXI веке. 2016. Т. 18. № 2. С. 413–417. [Fedonnikov AS, Andriyanova EA, Baratov AV. Medical and social care in traumatic spine injuries. Zh Nauchn Statei Zdor Obraz XXI Veke. 2016;18(2):413–417. In Russian].

4. Pouramin P, Li CS, Busse JW, Sprague S, Devereaux PJ, Jagnoor J, Ivers R, Bhandari M. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study. Lancet Glob Health. 2020;8:E711–E720. DOI: 10.1016/S2214-109X(20)30067-X.

5. Шульга А.Е., Зарецков В.В., Островский В.В., Арсениевич В.Б., Смолькин А.А., Норкин И.А. К вопросу о причинах развития вторичных посттравматических деформаций грудного и поясничного отделов позвоночника // Cаратовский научно-медицинский журнал. 2015. Т. 11. № 4. С. 570–575. [Shulga AE, Zaretskov VV, Ostrovsky VV, Arsenievich VB, Smolkin AA, Norkin IA. Towards the causes of secondary post-traumatic deformations of thoracic and lumbar spine. Saratov Journal of Medical Scientific Research. 2015;11(4):570–575. In Russian].

6. Об утверждении порядка и сроков разработки клинических рекомендаций, их пересмотра, типовой формы клинических рекомендаций и требований к их структуре, составу и научной обоснованности включаемой в клинические рекомендации информации: приказ Минздрава России от 28.02.2019 № 103н. Зарегистрирован в Минюсте России 08.05.2019 № 54588 // Российская газета. 2019. 8 мая. URL: https://rg.ru/2019/05/16/minzdrav-prikaz-103n-site-dok.html (дата обращения: 08.06.2020). [On approval of the procedure and terms for the development of clinical guidelines, and their revision, the model format of clinical guidelines and requirements to their structure, contents and scientific validity of the information included in the clinical guidelines: Order of the Ministry of Health of Russia dated February 28, 2019 No. 103n: Ministry of Justice of Russia Registration No. 54588 (08 May 2019). Ross Gazeta. 2019 May 8. URL: https://rg.ru/2019/05/16/minzdrav-prikaz-103n-site-dok.html (Accessed: 08 Jun 2020). In Russian].

7. Черепанов Е.А. Русская версия опросника Освестри: культурная адаптация и валидность // Хирургия позвоночника. 2009. № 3. С. 93–98. [Cherepanov EA. Russian version of the Oswestry Disability Index: cross-cultural adaptation and validity. Hir. Pozvonoc. 2009;(3):93–98. In Russian]. DOI: 10.14531/ss2009.3.93-98.

8. Дулаев А.К, Мануковский В.А., Кутянов Д.И., Булахтин Ю.Ю., Брижань С.Л., Желнов П.В. Совершенствование организации оказания неотложной специализированной хирургической помощи пациентам с травматическими и нетравматическими поражениями позвоночника в условиях мегаполиса // Вестник хирургии им. И.И. Грекова. 2017. Т. 176. № 4. С. 39–43. [Dulaev AK, Manukovskiy VA, Kutyanov DI, Bulakhtin YuYu, Brizhan’ SL, Zhelnov PV. Development of management of emergency surgical care for patients with acute traumatic and nontraumatic spinal pathologies in conditions of megapolis. Vestn Khir Im II Grek. 2017;176(4):39–43. In Russian]. DOI: 10.24884/0042-4625-2017-176-4-39-43.

9. Дулаев А.К., Мануковский В.А., Кутянов Д.И., Искровский С.В., Брижань С.Л., Желнов П.В., Дулаева Н.М. Эффективность централизованной системы оказания специализированной медицинской помощи при острой позвоночно-спинномозговой травме в современном мегаполисе // Хирургия позвоночника. 2019. Т. 16. № 1. С. 8–15. [Dulaev AK, Manukovskiy VA, Kutyanov DI, Iskrovskiy SV, Brizhan SL, Zhelnov PV, Dulaeva NM. The efficiency of the centralized system for delivery of specialized medical care to victims with acute spinal cord injury in a modern metropolis. Hir. Pozvonoc. 2019;16(1):8–15. In Russian]. DOI: 10.14531/ss2019.1.8-15.

10. Щербук Ю.А., Дулаев А.К., Багненко С.Ф., Дулаева Н.М., Аликов З.Ю. Научно-практическое обоснование целесообразности создания отделений (центров) неотложной хирургии позвоночника в мегаполисах // Скорая медицинская помощь. 2011. Т. 12. № 1. С. 45–51. [Shcherbuk YuA, Bagnenko SF, Dulaev AK, Dulaeva NM, Alikov ZYu. Scientifically and practical substantiation of expediency of creation of branches (centers) of urgent surgery of the backbone in megacities. Skor Med Pomoshch. 2011;12(1):45–51. In Russian].

11. Щедренок В.В., Яковенко И.В., Орлов С.В., Симонова И.А., Красношлык П.В., Могучая О.В. Результаты экспертизы качества медицинской помощи при сочетанной позвоночно-спинномозговой травме // Травматология и ортопедия России. 2010. № 1. С. 102–105. [Shchedrenok VV, Yakovenko IV, Orlov SV, Simonova IA, Krasnoshlyk PV, Moguchaya OV. The results of examination of medical care quality for associated vertebro-spinal-cord injury. Travmatol Ortop Ross. 2010;(1):102–105. In Russian]. DOI: 10.21823/2311-2905-2010-0-1-102-105.

12. Maharaj MM, Hogan JA, Phan K, Mobbs RJ. The role of specialist units to provide focused care and complication avoidance following traumatic spinal cord injury: a systematic review. Eur Spine J. 2016;25:1813–1820. DOI: 10.1007/s00586-016-4545-x.

13. Parent S, Barchi S, LeBreton M, Casha S, Fehlings MG. The impact of specialized centers of care for spinal cord injury on length of stay, complications, and mortality: a systematic review of the literature. J Neurotrauma. 2011;28:1363–1370. DOI: 10.1089/neu.2009.1151.

14. Harrop JS, Rymarczuk GN, Vaccaro AR, Steinmetz MP, Tetreault LA, Fehlings MG. Controversies in spinal trauma and evolution of care. Neurosurgery. 2017;80(3S):S23–S32. DOI: 10.1093/neuros/nyw076.

15. Holland CM, Mazur MD, Bisson EF, Schmidt MH, Dailey AT. Trends in patient care for traumatic spinal injuries in the United States: a national inpatient sample study of the correlations with patient outcomes from 2001 to 2012. Spine. 2017;42:1923–1929. DOI: 10.1097/BRS.0000000000002246.