Abstract
BACKGROUND: Spinal cord injuries (SCIs) resulting from gunshot wounds (GSWs) and motor vehicle accidents (MVAs) differ in mechanism, injury severity, and care pathways. Insurance coverage may further influence access to inpatient rehabilitation (IPR) and post-acute services, thereby affecting recovery trajectories. In the United States, MVA-related SCIs are frequently covered by no-fault auto insurance with broad benefits, whereas GSW-related SCIs are more commonly covered by Medicaid, which may limit rehabilitation duration and intensity. The objective of this study was to assess the association between insurance status and post-rehabilitation outcomes in patients with SCI due to GSWs compared with MVAs. METHODS: This Institutional Review Board (IRB)-approved retrospective cohort study included 40 patients with traumatic SCI treated at a single IPR center, including 20 GSW-related and 20 MVA-related SCIs, all with at least 1 year of follow-up. Demographic characteristics, insurance type, injury severity, and social determinants of health were collected, including Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Primary outcomes included IPR length of stay (LOS), inpatient complications, and healthcare utilization [emergency department (ED) visits and hospital readmissions] within 1 year of discharge. Between-group comparisons were performed using independent t-tests. RESULTS: GSW patients were significantly younger than MVA patients (mean age 27.45 vs. 46.00 years, P<0.001) and were more frequently insured by Medicaid (85% vs. 45%, P=0.004). In contrast, auto insurance coverage was present in 50% of MVA patients and 0% of GSW patients (P<0.001). Neighborhood disadvantages were similar between groups (ADI 88.45 vs. 83.30, P=0.14; SVI 0.77 vs. 0.68, P=0.14). GSW patients had more severe neurologic injury, with lower mean American Spinal Injury Association (ASIA) scores (1.90 vs. 2.74, P=0.01), lower rates of surgical intervention (45% vs. 85%, P=0.004), and shorter IPR stays (32 vs. 46 days, P=0.004). GSW patients experienced more inpatient complications (6.35 vs. 4.80 per patient, P=0.03) and greater post-discharge healthcare utilization, including higher ED visits (1.60 vs. 0.50, P=0.01) and hospital readmissions (1.25 vs. 0.25, P=0.04) within 1 year. CONCLUSIONS: Insurance disparities influence orthopedic surgical decision-making, IPR length, and complication burden in SCI patients. Patients with GSW-related SCIs, despite being younger, experienced more severe injuries, lower surgical intervention rates, and higher post-discharge healthcare utilization. These findings highlight the need for equitable access to spine surgery, rehabilitation, and follow-up care to optimize outcomes across trauma mechanisms.