Saskatchewan Specialized Seating Program Fiscal Accountability
R. C. TERVO, MD*, A. C. POWALINSKY**,B. SCHULTZ-HURLBURT*** AND 1. LESZCZYNSKI, MD****Saskatoon, Saskatchewan
Standard wheelchairs are often inadequate to meet the seating needs of multiply handicapped patients. In response to their needs, Saskatchewan developed its own Specialized Seating Program to provide wheelchair-using patients with Specialized Seating Devices (SSDs). SSDs are designed to provide optimal patient positioning, to control abnormal tone and movement, to prevent or delay medical problems, to maximize patient stimulation and to promote ease of care for primary and secondary caregivers.
Physically handicapping conditions are often accompanied by major deformities. Standard wheelchairs are designed for patients with normal posture, but for patients unable to maintain a normal posture independently, standard wheelchairs are inadequate1-4. Without adequate body support while seated, a physically handicapped individual's deformities progress5. Depending on the underlying condition, many wheelchair-using patients encounter a wide range of problems caused by uncontrolled motor activity, progressive deformities, insufficient mobility or exhaustion from attempts to be mobile. Recently, SSDs have been devised to prevent or delay some of these problems and to improve the quality of life of the wheelchair-user. As a form of preventive medicine, SSDs provide spinal support, improved comfort and posture and protection for the seated patient. Upright posture encourages full use of one's visual fields, while comfort enhances sitting tolerance. Improved seating helps the patient develop head and trunk control, increase upper-limb function and acquire skills fundamental to better communication and wheelchair-based mobility. Such capabilities enable the patient to engage in social, recreational, educational and, ultimately, vocational activities. SSDs constitute a dynamic and beneficial treatment regime1.
Following successful field trials with the Winnipeg Modular seating system and Memphis Foam-in-Place seating systems, Saskatchewan started its own governmentfunded Specialized Seating program. Since inception of the program in July 1980 until June 1983, $109,011.01 has been spent on the acquisition of 129 SSDs and maintenance of SSDs for 164 patients, while an estimated $24,988.90 was spent by Saskatchewan Aids to Independent Living (SAIL) for 35 SSDs during a field test in cooperation with wheelchairs supplied from Winnipeg, Manitoba and Memphis. Overall, the average cost was $817.07 per patient during the three-year period.
Patients and Methods
The records of all Saskatchewan patients who had received SSDs during the Winnipeg and Memphis field tests and from the period July 1980 to June 1983 were studied. Information abstracted from the records included: diagnosis and age of each patient, cost of acquisition and maintenance for each SSD and the names and contributions of each funding agency. Excluded were 15 cases whose records were incomplete with regard to diagnosis.
Of the 164 patients included in the study, 104 patients had cerebral palsy; their ages ranged from 0.59 to 62.53 years (mean + standard deviation = 15.94 + 15.40 years). Twenty-two individuals had muscular dystrophy; their ages ranged from 3.86 to 20.97 years (mean + standard deviation = 17.84 + 18.04 years). Eight patients with spinal cord lesions were reviewed, whose ages ranged from 0.97 to 40.80 years (mean + standard deviation = 26.00 + 30.64 years). The remaining 30 persons were grouped as a miscellaneous category. They ranged in age from 1.10 years to 64.48 years (mean + standard deviation = 23.06 + 21.81 years).
Table 1 shows the cost of the Saskatchewan Specialized Seating Program from July 1980 to June 1983. SAIL contributed the largest sum of money, 56.81 percent of all funds. Valley View Centre, an institutional setting providing level III and IV care for the mentally retarded and funded by a small hospital budget, contributed 16.11 percent of the total program cost.
The expense of supplying and repairing SSDs differed among diagnostic groups, with cerebral palsy patients utilizing 61.53 percent of total dollars spent, followed by the miscellaneous group with 18.56 percent of total dollars. The cost of supplying and maintaining SSDs for muscular dystrophy patients accounted for 15.08 percent of the total program cost, while SSDs and repairs for spinal cord injured totaled 5.02 percent of the program cost.
As information regarding the cost of SSDs obtained during the Winnipeg and Memphis field test trials was unavailable, an estimate of these costs was made, using the average cost of an SSD supplied by the Saskatchewan Specialized Seating Program (Table 3 ).
Table 2 indicates that an estimated $24,988.90 was spent on new SSDs during the Winnipeg and Memphis field test periods. The funds for the field test SSDs were supplied by SAIL.
Table 3 shows the ratio of the cost of repairs made to SSDs to the cost of supplying a new SSD for each diagnostic category. Cost estimates for the Winnipeg and Memphis field test trial SSDs were included in the calculations. The muscular dystrophy group showed the highest repair-to-new-SSD cost ratio, reflecting the relatively large number of adjustments to accommodate progressive deformity and weakness. The miscellaneous category had the lowest repair-to-new-SSD cost ratio because the majority of the patients in the miscellaneous group live at Valley View Centre which undertakes most of its SSD repairs.
The average cost to supply and maintain a SSD for each patient was $817.07. Over the long term the cost must be compared to the costs incurred by the added difficulties of meeting a patient's medical, educational and social needs resulting from inadequate seating. Many major medical problems can be delayed or avoided with the use of an SSD. These complications represent enormous costs to the disabled individual and the health care system. The patient faces the burden of reduced pulmonary capacity, dependence on others, inconvenience in daily life and undeveloped potential. Costs to the health care system include extensive surgery, numerous hospitalizations and, possibly, the price of institutionalization of the severely disabled individual.
SSDs are essential in the management of the physically disabled by primary and secondary caretakers in such activities as feeding, transportation and general care. Because of the convenience of handling SSDs, caretakers of wheelchair-using patients are relieved of some of the stress of tending a physically disabled person. Associated cost-saving to the health care system results if seating technology can enable a patient to live independently or at home, rather than in an institution.
In addition to medical and patient management considerations, regular follow-up assessments of patients fitted with SSDs suggest many advantages that cannot easily be objectively evaluated. Such benefits include patient comfort and security, increased sitting tolerance, stimulation provided by upright positioning (especially maximal use of visual fields), better patient-environment interactions and improved functional and communicative abilities.
Case l. Muscular Dystrophy Patient with Modular Seating System
S. R. is a pleasant, bright 10-year-old boy with Duchenne muscular dystrophy who became wheelchairdependent shortly after his ninth birthday. He had hip-flexion contractures and tight tensor fascia lata, more pronounced on the left, and thoracolumbar scoliosis. Because his upper limbs were moderately weak, S. R. required help to dress but could feed himself and complete his school assignments independently.
S. R. was initially managed in a standard sling-back-and-seat wheelchair. This seating arrangement was not appropriate for S. R., as it did not provide adequate spinal stability, it promoted lumbar kyphosis and it put S. R. at great risk for developing decubitus ulcers over his ischial tuberosities and greater trochanters.
S. R. was fitted with a Modular seating system with a lap belt, lap board and headrest, at a cost of $695.00. This new SSD provided S. R. with much-needed lumbar lordosis, spinal support and symmetrical positioning. Hip-flexion contractures, scoliosis and the tightness of tensor fascia lata have not progressed since S. R. has been fitted with an SSD, and both S. R. and his parents feel the SSD is convenient and secure. SSDs have enhanced the life of S. R. and many other patients by delaying the progression of deformities while maximizing remaining functional ability.
Case 2. A Patient with Traumatic Quadriplegia in the Foam-in-Place Seating System
L. W. is an 18-year-old man with traumatic quadriplegia since age 15, from Cs downwards. L. W. also has kyphoscoliosis, upper-limb and lower-limb deformities and other related problems. L. W.'s wheelchair positioning proved a major challenge as his spine was becoming increasingly kyphotic, and the resultant shift in weight-bearing produced skin irritation over his ischial tuberosities and lower spinous processes. As L. W. continued to grow, his spine collapsed in further flexion, preventing him from operating either his standard or his electric wheelchair. He required Harrington rod instrumentation. Immediately following the procedure, L. W. was fitted with a Foam-in-Place seating system costing $849.00. L. W. required modifications to the SSD which were easily made. A recess cushion was inserted into the SSD to minimize pressure over L. W.'s coccyx, while abdominal pad, belt and thoracic supports provided adequate trunk support. A tray was added for use at meals and school, and adjustments were made to enable L. W. to operate the microswitch on his electric wheelchair. The cost of these adjustments totalled $363.25.
Since being fitted with an SSD, L. W. has acquired good sitting posture, adequate spinal support and has had no further problems with pressure sores. L. W. currently spends up to 14 1/2 hours a day in his chair, so his family is required to assist in fewer transfers. L. W. feels that the SSD provides adequate security and support, and he is now able to travel independently in his electric wheelchair at home and at school.
Case 3. A Child with Cerebral Palsy in a Cozy Seat
H. M. is a 3-year-old cerebral palsied patient (spastic quadriplegia) with developmental delay, secondary to perinatal difficulties. Until H. S. was 1 year old, his family had been using a modified car seat with a wedge and fixed pommel to meet his seating needs. At this time H. M.'s family was experiencing several difficulties in caring for him. H. M.'s tolerance for the car seat was low, and he was quite irritable while seated. H. M.'s crankiness promoted intrafamilial stress, and institutional care was being considered. He also showed asymmetric body positioning and was at risk for developing fixed contractures and bony deformities because of inadequate seating arrangements. H. M.'s mother stated that the position offered by the car seat made feeding H. M. difficult, and H. M. had poor upper-limb function. H. M. was fitted with a Cozy Seat, costing $596.90, to provide him with a flexed symmetrical sitting position to prevent progression of deformities, abnormal tone and reflex activity and to facilitate normal movement patterns. Shortly after receiving his Cozy Seat, H. M. tolerated longer sitting periods, was more responsive to handling and could bring his hands to a midline position (which was difficult previously). H. M.'s mother felt that feeding H. M. was made easier with the SSD and that H. M. was generally less irritable.
By his third birthday H. M. had grown too large for his Cozy Seat, so he was fitted with a Modular seating system at a cost of $416.50. Bolster and chest straps provided H. M. with the necessary lateral support, and a lap belt held his hips in flexion. A removable pommel controlled hip adduction, and footrests helped to maintain an optimal seated posture.
Providing H. M. with Cozy and Modular SSDs has enabled him to live with his family and attend a special needs school in Saskatoon, in a wheelchair.
In order to meet the needs of multiply handicapped wheelchair-using citizens, Saskatchewan developed its own comprehensively government-funded Specialized Seating Program. During its first three years in operation the program provided 129 new SSDs and maintenance for 164 SSDs at a total cost of $109,011.01, or $817.07 per patient.
An appropriately prescribed SSD is fundamental to patient comfort, security and to participation in educational, recreational and vocational activities. Medical problems are avoided with SSDs, and fixed deformities are adequately accommodated. Prescriptions for SSDs require the expertise of a team of health professionals including a physiatrist. Therapist, and orthotist, as well as the cooperation of government, university, and community-based volunteer organizations6,7. Regular follow-up assessments of patients fitted with SSDs suggest that SSDs have clinical and economic merit and, at the very least, make a patient's life more stimulating and enjoyable.
The Saskatchewan Specialized Seating Program is a worthwhile service that could serve as a prototype for the institution of similar programs elsewhere.
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