Healthcare system factors determining rehab LOS

Author: Dominik Zbogar | Reviewer: Giorgio Scivoletto | Published: 30 April 2025 | Updated: ~

Early surgery is associated with a small decrease in acute care LOS. However, there is no association between early surgery and rehabilitation LOS. More research is needed to support the finding as the 2 studies on this topic had very imprecise estimates.

Research has shown that SCI patients without effective rehabilitation in the six months following injury had a significantly longer length of stay in rehabilitation (as well as a notably lower percent increase in motor recovery from admission to discharge). Additionally, it has been shown that early rehabilitation is effective in accelerating and promoting improvement in activities of daily living.

Sometimes, individuals remain in the rehabilitation setting after their rehabilitation goals have been met and even when they are deemed ready for discharge. For example, family deliberations, procurement of supported care or services, provision of required equipment, need for residential care, a lack of accessible housing or a requirement for home modifications can all result in an extended stay in rehabilitation. Architectural barriers in heritage buildings and neighbourhoods in old European cities can be a significant barrier to discharge that the North American reader may not have considered.

When patients have access to specialized centres of care there is a decrease in mortality and LOS. However, relatively few specialized SCI rehabilitation centers exist globally and they are generally concentrated in high-income countries. Examples include the acute care centres and rehabilitation units that are part of the Spinal Cord ­Injury Model Systems in USA and the Rick Hansen Spinal Cord Injury Registry in Canada. The global lack of specialist rehabilitation skills in low-income countries can result in inadequate initial management of SCI cases at the receiving hospital and a rapid development of secondary complications, ultimately contributing to a longer length of hospital stay and potentially poorer functional outcomes or even death.

LOS can be influenced by the healthcare models. In one study from 2005 comparing USA, Canada and Italy, it was found that LOS in USA was influenced by third party payer requirements for discharge where patients are discharged as soon as they achieve a minimally acceptable level of mobility. In contrast, for Italy and Canada, length of stay in rehabilitation was based primarily on patients achieving the highest level of independence feasible. Today, 20 years later, while the health care systems in many countries are intended to allow continued rehabilitation (inpatient or outpatient) until patients reach a mobility plateau or maximal mobility independence, there is tremendous financial pressure to discharge patients as quickly as possible.

While there is much variability even within HICs and low- and middle-income countries (LMICs), the health care infrastructure in HICs supports a more structured and systematic approach to SCI rehabilitation with clear protocols for early intervention, which can reduce LOS. In many LMICs, the infrastructure might be less developed, leading to inefficiencies in care delivery. Additionally, insurance coverage and health policies in HICs often allow for longer recovery times in rehabilitation settings, while in LMICs, financial constraints might force earlier discharge.

HICs tend to have better resources in terms of advanced medical equipment, trained personnel, and ongoing support services post-discharge, which can facilitate quicker rehabilitation and shorter hospital stays. In LMICs, economic conditions can directly impact LOS as lack of funding and constraints in resources mean that rehabilitation might be slower or less effective due to a lack of necessary equipment, like robotic rehabilitation devices, trained staff, and lack of systems for post-discharge care, including home care services, community support, and outpatient rehabilitation, which could reduce the need for prolonged inpatient stays. Environmental factors like access to transportation for follow-up care or the availability of accessible living environments also play a role.