Munce et al. 2009
Canada
Downs & Black = 9
Case series
N=559

Population: 559 adult (136 female) patients with SCI, at least one year after discharge from acute care.  62 lumbar, 126 thoracic, 350 cervical, 21 other.
Treatment: No treatment.
Purpose:   To examine physician utilization from various Ontario health databases for the years 2003-2006.
Outcome measures:  Information about physician utilization, including family physician, specialist and emergency department visits was analyzed. The Charlson Index (measure of comorbidity) and The Rurality Index of Ontario (RIO) (high scores indicates more rural communities) were reviewed.

1. Overall, women had a higher number of physicians visits, and men had a higher number of visits to their physiatrist.
2. Older age (70+) (OR=3.64), direct discharge to chronic care (OR=3.62) and an in-hospital complications (OR=2.34) were associated with 50 or more physician visits per year.
3. Younger age (OR=0.19) and direct discharge to chronic care (OR=11.52) were associated with 50 or more specialist visits per year.
4. RIO results predicted two or more visits to the ED (OR=2.16)

Goetz et al. 2005
USA
Downs & Black = 13
Pre-post
N=4432

Population: 4432 subjects (4302 male, 130 female); age: 47-69 yrs;
Treatment: Implementation of neurogenic bowel Clinical Practice Guideline. Adherence measured before implementation (T1), after publication (before targeting dissemination and implementation) (T2) and after dissemination and implementation strategies (T3).
Outcome measures: Adherence to CPG recommendations, effect of targeted implementation strategy

1. Overall adherence to recommendations did not change between T1 and T2
2. Statistically significant increase in adherence for 3 of 6 recommendations from T2 to T3 (p<0.001)
3. Publication alone did not alter adherence, targeted implementation play increased adherence for 3 of 6 recommendations.

Beatty et al. 2003
USA
Downs & Black = 14
Observational (Survey)
N=800
(169 SCI)

Population: 800 adults (≥18 years; 69% female) with either arthritis (357), SCI(169), MS(164), or CP  (110)
Treatment: No treatment.
Purpose:  To survey patterns of need for, and access to specific health care services by persons with disabilities or chronic conditions and the relationship between access and factors identified as predictors of access.
Outcome measures: 80 item self-report questionnaire inquiring about perceived need for, and access to five specific health care services [ primary care physician (PCP); specialist care (SC); physical rehabilitation (PR); assistive equipment (AE); and prescription medications(PM)] & health plan type [fee for service (FFS); or managed care organization (MCO)],

1. Overall need for health services varied; 62.7% reported a need for PCP, 57.4% for SC, 39.1% for PR, 69.2% for AE, & 94.1% for PM
2. Need Vs. actual receipt of services: Only 67% of needed PCP was received; 75.3% of SC; 40.9% of PR; 69.2% of AE; and 93.1% of PM.
3. Factors affecting access:  Health plan type; Condition; Health status; Severity; Coverage; Income; Age
4. No differences were found across gender and region of residence)

Collins et al. 2005
USA
Downs & Black = 13
Observational (Survey)
N=853

Population: 853 veterans with SCI
Treatment: No treatment.
Purpose:  to assess patient satisfaction with the annual comprehensive preventative health evaluation (CPHE)
Outcome measures: 21 survey questionnaires about the satisfaction with CPHE content, whether needs were met, what respondents valued about the examination and health concerns they would like to see addressed. Answers were dichotomized for analysis purposes.

1. 76% of survey respondents had completed the CPHE within the previous year.
2. Satisfaction with the CPHE was 81%.
3. Completion of CPHE was related to other health care utilization and having health needs met.

van Loo et al. 2009
Netherlands
Observational (Survey)
Downs & Black = 12
N = 453

Population: Mean age = 47.7; Male = 65.1%; Complete tetraplegia = 19.9%, Incomplete tetraplegia = 14.4%, Complete paraplegia = 46.3%, Incomplete paraplegia = 19.4%
Treatment: No treatment.
Purpose of the study:   To determine the care received for secondary condition and extra care needs, and to determine if the secondary conditions were preventable.
Outcome measures: Questionnaire inquiring about frequency of SCI-related contacts with professional caregivers during previous 12 months, secondary conditions and which conditions were perceived as most important, what kind of care they received, and how the condition could have been prevented.

1. 77% had SCI-related contact with their general physician, 57% with a physiatrist, 65% with another specialist.
2. 72% indicated need for additional care due to secondary conditions.
3. For most important secondary conditions, 47% received care, and extra care in 41.3%.
4. Patients preferred to receive follow-up care from specialists rather than community care.

Francisco et al. 1995
USA
Downs & Black = 11
Observational (Survey)
N=104

Population: 54 US physiatrists and 50 US Physical Medicine and Rehabilitation (PM&R) residents (12 in 1st year, 19 in 2nd year, and 19 in 3rd year)
Treatment: No treatment.
Purpose: to determine physiatrists’ and PM&R residents’ opinions on the competency, qualification and desire to provide primary care for the disabled.
Outcome measures: 4 page, 11- item questionnaire seeking information about: level of training/experience, certification, type of practice/internship; if they agree/disagree with statements regarding primary care provision by physiatrists using a six-point scale (1=strongly disagree to 6 strongly agree; reasons why/why not to provide primary care, by choosing from a given list; and if they agreed, to choose the group of disabled patients that should receive the primary care by physiatrists.

1. Although 53% believe physiatrists are competent to provide primary care, only 40% were willing to assume the role
2. Only 38% believe that the PM&R residency programs adequately trains physiatrists in primary care for the disabled
3. Conditions for which most respondents believed that primary care should be provided by a physiatrist are SCI (60%), and head injury (51%).

Donnelly et al. 2007
Canada, US, & UK
Downs & Black = 10
Observational (Survey)
N=373

Population: 373 individuals with SCI (315 male, 56 female); 127 Canadian [aged 55.9 (±10.7) years; 32.1(±8.4) years of SCI]; 162 British [aged 62 (±7.7) years; 39.2 (±5.5) years of SCI]; 84 Americans [aged 56.7(±8.9) years; 35.3 (±6.5) years of SCI]
Treatment: No treatment.
Purpose:  1) To describe utilization, accessibility and satisfaction with primary and preventative health care services by individuals with long term SCI,
2) To compare results across three countries; Canada, US, and UK.
Outcome  measures: 46-item measure [compilation of Health Care Questionnaire (HCQ) and Patient Satisfaction with Health Care Provider Scale (PSHCPS)]surveying utilization, access and satisfaction with primary and preventative health care services

1. 93% had a family doctor (FD), 63% had a spinal injury specialist (SIS), 56% had both, 36% had only a FD, 6% had only a SIS, and 1% had no doctor at all. Canadians most likely to received care from FD and Americans from specialists.
2. The highest utilization of FD was for pain (86%, p<0.05) and fatigue (84%, p<0.05); The highest Utilization of SIS was for routine rehab follow-up (91%, p<0.05)
3. FD were more accessible than SIS in all areas, with the exception of physical accessibility of office and equipment.
4. Satisfaction was rated as 74% for FD and 76% for SIS; there were no significant differences in accessibility or satisfaction across countries.

Warms 1987
USA
Downs & Black = 9
Observational (Survey)
N=59

Population: 59 adult (53 males; 5 females) patients with SCI, at least two years post-injury. Age range 21-60. 29 cervical injury; 24 thoracic injury; 6 lumbar or sacral injury.
Treatment: No treatment.
Purpose: To survey the source and content of health care received by individuals with spinal cord injury and to describe what healthcare services are desired.
Outcome measures: A self-reported survey assessing: source of health care, content of care, and healthcare services desired, but not obtained.

1. 54.2% reported consulting a rehabilitation medicine physician; 44% consulted a family physician.

Cox et al. 2000
Australia
Downs & Black = 9
Observational (Survey)
N=54

Population: 54 subjects (42 male, 12 female); age: 19-79 yrs; Injury: tetraplegia (n=30) or paraplegia (n=24).
Treatment: No treatment
Purpose: To assess areas of need
Outcome measures: overall need for specialist multidisciplinary outreach service, most significant barriers to meeting needs, preferred service delivery options; rated on a 5-point scale

1. 25% indicated high or very-high need for specialist outreach services; 2% saw no need.
2. Barriers: limited local expert knowledge (81%), inadequate funding (56%), complicated process/service fragmentation (31%).
3. Preferred service delivery: telephone advice (79%), home visiting (43%).

Bockeneck 1997
USA
Downs & Black = 8
Observational (Survey)
N=144

Population: 144 SCI outpatients (no demographic information stated).
Treatment: No treatment.
Purpose:  To survey whether primary care needs of outpatient population with SCI were being met.
Outcome measures: A self-reported survey assessing the ability of the local community to provide primary care services, and to determine whether additional services were needed in the area of primary care at a rehabilitation facility.

1. 50% of SCI outpatients considered their rehabilitation physician is their primary care physician.
2. Of the SCI patients who had another physician treating general medical problems, 48% were treated by a general practitioner.
3. 96% of SCI patients reported that their physician’s office was accessible.
4. 90% of SCI patients reported that they had no difficulty receiving medical care in the community.
5.  51% of SCI patients reported that they would be interested in obtaining all general medical care at one rehabilitation facility.

Glickman et al. 1996
England
Downs & Black = 6
Observational (Survey)
N=139

Population: 139 General Practitioners (GPs) with SCI patients
Treatment: No treatment.
Purpose:  to examine the workload and common problems facing primary care teams in SCI management.
Outcome measures: Mailed survey inquiring about annual number of consultations with the patient regarding any of gastrointestinal, urological and dermatological problems, and the magnitude of pain and spasticity

1. Average annual consultation rate with: GP in surgery = 4.03 (range = 0 – 52); GP home visit = 4.57 (range = 2 – 26); Other team member in surgery = 0.56 range = 0 – 6); Other team member home visit = 50.94 (range = 0 – 730).
2. 53.9% of the GPs offered services to change urethral catheters; 15.8% were able to change suprapubic catheters; and 29.5% offered psychological or social counselling.