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

BACKGROUND: 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. PURPOSE: 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). STUDY DESIGN/SETTING: Population-based retrospective cohort study using linked administrative health data from Ontario, Canada. PATIENT SAMPLE: Adults (≥18 years) presenting to trauma centers with acute traumatic SCI between 2009 and 2023 (n=614). OUTCOME MEASURES: Total direct healthcare costs over five years; DAH within two years (DAH-2y); change in Functional Independence Measure (FIM) motor score during inpatient rehabilitation. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.