Abstract
Background The Department of Veterans Affairs (VA) and the Department of Defense published evidence-based guidelines to standardize and improve rehabilitation of veterans with lower limb amputations; however, no studies have examined the guidelines' impact.
Objectives The purposes of this study were: (1) to describe the utilization of rehabilitative services in the acute care setting by people who underwent major lower limb amputation in the VA from 2005 to 2010, (2) to identify factors associated with receipt of rehabilitation services, and (3) to examine the impact of the guidelines on service receipt.
Design A cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005, to December 31, 2010, was conducted. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases.
Methods Rehabilitation services were categorized as physical therapy, occupational therapy, and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined the impact of guideline implementation and identified factors associated with service receipt.
Results Patients were 1.45 and 1.73 times more likely to receive preoperative physical therapy and occupational therapy and 1.68 and 1.79 times more likely to receive postoperative physical therapy and occupational therapy after guideline implementation. Patients in the Northeast had the lowest likelihood of receiving preoperative and postoperative rehabilitation services, whereas patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified.
Limitations The sample included only veterans who had surgeries at VA Medical Centers and cannot be generalized to veterans with surgeries outside the VA or to nonveteran patients and settings.
Conclusions Further quality improvement efforts are needed to standardize delivery of rehabilitation services for veterans with amputations in the acute care setting.
The Department of Veterans Affairs (VA) and the Department of Defense (DoD) developed and promulgated evidence-based guidelines to standardize and improve rehabilitative care of people with lower limb amputations.1 The guidelines, published in 2007, build upon the scientific literature demonstrating the effectiveness of both inpatient and outpatient rehabilitative services in improving physical function and survival and reducing bodily pain after lower limb amputation. The guidelines delineate the goals and content of 5 phases of rehabilitation for people with amputations: (1) preoperative, (2) acute postoperative, (3) preprosthetic, (4) prosthetic training, and (5) long-term follow-up. According to the guidelines, physical therapy and occupational therapy are among the key disciplines that should be consulted during the preoperative and postoperative phases of rehabilitation, and both should be included in the development of the treatment plan.
In the preoperative phase, a comprehensive interdisciplinary baseline assessment of the patient's status should be conducted, and appropriate rehabilitation interventions should be initiated to maximize the patient's physical function before surgery.1 Rehabilitative services focus on mobility of other limbs that are not at risk for amputation, as well as maintaining full motion of the most proximal joints.2 Preoperative rehabilitative services may include physical function assessment and therapeutic exercise for strengthening, range of motion (ROM) and balance, mobility training, patient education about prosthetic options, and establishing a home exercise program. Interventions during the acute postoperative phase that should be “initiated as tolerated” include: ROM, strengthening, positioning, balance exercises, mobility activities as tolerated, and training in activities of daily living and patient education.1 Activities in the preprosthetic phase include ROM and therapeutic exercise, balance activities, progressing gait activities, functional training, and training in use of assistive devices.1 The prosthetic training phase includes continued ROM, therapeutic exercise progression and balance, gait and transfer training with and without the prosthesis, patient education, vocational and recreational training, and assistive device training.1 Interventions commonly included in long-term follow-up include reassessment of balance and gait, review and adjustment of ROM and home maintenance program, education about injury prevention and energy conservation, and provision of and training with appropriate assistive devices.1
Postoperative rehabilitation involves the 4 remaining phases and may occur in numerous settings beginning with the acute care hospital and, in some cases, progressing to specialized inpatient rehabilitation units or skilled nursing facilities, then to home care or outpatient care.1 Specialized inpatient rehabilitation is the most intensive, involving at least 3 hours a day of rehabilitation services consisting of at least 2 different types of therapy (such as physical therapy and occupational therapy). Specialized inpatient rehabilitation is provided in Commission on Accreditation of Rehabilitation Facilities (CARF)-accredited facilities that have designated rehabilitation beds. These facilities are called specialized rehabilitation units (SRUs) within the VA system of care and inpatient rehabilitation facilities (IRFs) outside of the VA. In contrast, rehabilitation in the acute care setting occurs on general hospital units, has no required minimum, and, therefore, is likely to be less intensive and more intermittent than care mandated by IRFs.
Many disciplines are involved in the delivery of rehabilitative care. Three of the most common types of rehabilitative services for people with amputations in the United States are physical therapy, occupational therapy, and prosthetic services delivered by a certified prosthetist. Physical therapy for people with lower limb amputations typically includes: physical function assessment, therapeutic exercise for strengthening and ROM, balance activities, gait and mobility training, and patient education regarding care of the residual limb and scar management. Occupational therapy involves learning adaptive techniques to complete activities of daily living, establishing equipment needs, and promotion of safety (such as fall prevention). Prosthetic services include advising about prosthetic components and managing problems such as skin breakdown and other complications resulting from prosthetic use; fitting and fabricating the prosthetic socket; and delivering, fitting, and repairing prosthetic componentry.
Are Patients Receiving Rehabilitation Services?
Although efforts to improve the quality of rehabilitation services for veterans and military service members have been under way for the past decade, few studies have reported on whether people with lower limb amputations receive recommended rehabilitative services.3,4 Although some studies have examined receipt of rehabilitation in settings outside of the VA,5–7 the bulk of research on this topic has been performed using VA data from people with incident amputations between the years 2002 and 2004, and most of the research focused on the receipt of specialized inpatient rehabilitation.3,4,8–10
Using data from 2002 to 2004, Stineman et al3 and Bates et al11 reported that 73% of VA patients with surgical amputations at the transtibial, transfemoral, and hip disarticulation level received some type of inpatient rehabilitation, either acute postoperative rehabilitation services (which they called “consultative rehabilitation”) or care on SRUs either at the hospital or after discharge. Some evidence suggests that referral and timing of referral for SRU care was not determined by patient needs alone but also influenced by facility-level factors such as co-location of an SRU11 within the hospital, geographic region, and hospital bed size.11,12 Zhou et al4 reported that 65% of veterans with incident transtibial and transfemoral amputations received outpatient rehabilitative services in their first year after discharge from the incident hospital stay. For every 10-year increase in age, Zhou et al reported that the likelihood of receiving outpatient rehabilitation decreased by 17%. In addition, patients with transfemoral or bilateral amputations and patients with serious comorbidities were less likely to receive outpatient rehabilitative services following lower limb amputation.4
In summary, knowledge about receipt of rehabilitation services in the VA is limited. Researchers have reported on the receipt of outpatient and SRU services for people with incident lower limb amputations in the VA during the period 2002 to 2004. These studies excluded people with amputation at the foot level. To our knowledge, no studies have been conducted using more recent VA data; thus, there is no way to evaluate whether patterns of care in the VA have changed over time. No prior study has examined the factors associated with the likelihood of receiving any rehabilitative care in the acute setting, nor have prior studies examined the prevalence or predictors of receipt of presurgical rehabilitation services. To our knowledge, there has been no previous research examining the receipt of specific services such as physical therapy and occupational therapy. Finally, despite major efforts to develop and promulgate evidence-based guidelines, there have been no studies that have examined the impact of the guidelines on receipt of care within the VA or DoD. Therefore, more research is needed.
The purposes of our study were: (1) to describe the utilization of rehabilitative services in the acute care setting by people who underwent major lower limb amputation (defined as transtibial, transfemoral, and foot/ankle level) in the VA from 2005 to 2010, (2) to identify factors associated with receipt of rehabilitation services, and (3) to examine whether prevalence of rehabilitative services has changed since the introduction of the VA/DoD rehabilitation guidelines. Although we initially were interested in including prosthetic services in our study, we chose not to do so when we discovered that these services are not coded consistently in the VA system and that major changes in structure of service delivery occurred in the past 5 years.
Method
Data Source
Data were obtained from Veterans Health Administration (VHA) administrative Patient Treatment File (PTF) databases used to track the health care utilization of veterans. The PTF is a National Data Extract that contains inpatient services.13 The databases included 4 Acute Care Inpatient Medical SAS (MedSAS) datasets and the Inpatient Encounters Medical SAS datasets files. The 4 Acute Care MedSAS datasets used were the main dataset, which contained information on demographics, diagnoses, and length of stay; the bed section dataset, which contained information on the specialty of the physician managing the patient care; the procedure dataset, which contained the procedure codes performed during the inpatient stay; and the surgery dataset, which contained all surgical procedure codes. The inpatient encounters dataset contained records of billable professional services received by patients during their inpatient stay. All datasets used in this study shared a common patient identifier, which allowed linkage of records from the different datasets.
Sample
Patients were included if they underwent a major surgical amputation of the lower limb at any VA medical center from January 1, 2005, to December 31, 2010. Major lower limb amputations were identified as surgeries with ICD-9-CM procedure codes of 84.12 to 84.17. Level of the surgical amputation was determined by using these ICD-9 procedure codes and classified as foot/ankle (8412–8414), below knee (8415), and above or at knee (8416, 8417). Cases that involved only toe amputations were excluded due to their lower severity, and cases involving disarticulation of the hip or abdominopelvic amputation were excluded due to their low frequency of occurrence.
In keeping with methods used in prior research,3,14 we utilized a 12-month look-back period to ensure that the sample would consist of people with first-time amputations only. Thus, we obtained data dating back to 2004 and “looked back” to determine whether there was a record of prior lower limb amputation. Once an amputation incident was identified from the surgical data, the PTF main data from that hospitalization episode were extracted. Any inpatient encounters data that occurred between the hospitalization's admission date and discharge date also were extracted. The 12-month look-back criteria were met by 12,599 patients.
Key Variables
Rehabilitation services.
The receipt of rehabilitation services was identified using both the acute PTF procedure data and the PTF inpatient encounters data. We classified type of rehabilitative service as: (1) physical therapy, (2) occupational therapy, and (3) receipt of either physical therapy or occupational therapy (any therapy). We wanted to examine receipt of each of these types of care because of their different, yet sometimes overlapping, roles.
Receipt of rehabilitation services was identified by satisfying one of the following criteria: (1) presence of inpatient procedure data for any of the following International Classification of Diseases (ICD-9) procedure codes: physical therapy=9301, 9304–9325, 9327, 9338, 9339, 9356, 9357, 9385, or 9389; occupational therapy=9383; or (2) having inpatient encounter data that included clinic stop codes of 174 or 205, or both, for physical therapy and 206 for occupational therapy.
Using the date of amputation surgery, we categorized all services as occurring either before or after the surgical amputation. Postsurgical rehabilitation was defined as services received after the date of the surgical amputation but before discharge from the acute care hospital or transfer to an inpatient rehabilitation bed within the same hospital.
Covariates.
We adjusted for patient demographics and other characteristics such as living arrangement prior to hospitalization and comorbidities that we hypothesized would be associated with rehabilitation service use. We also adjusted for facility characteristics that might be associated with differences in service utilization, including geographic region and bed size.
Demographic data collected included age, sex, income, length of stay, marital status, race, admission source before hospitalization, and year of amputation. Patient age (in years) at discharge was recategorized into the following groups: under 45, 45–54, 55–64, 65–74, 75–84, and 85 or older. Patient sex, income, and length of stay were abstracted directly from the main PTF dataset. Marital status was obtained from the PTF inpatient encounters data using the last entry for marital status between admission and discharge dates; categories included single, married, divorced, widowed, and unknown.
Information on racial group was extracted from the PTF main data and collapsed into 4 categories: white, black, other, and missing/unknown. Because race was missing for almost 40% of our sample, a known problem in VA data after 2003,15,16 we retrieved information on missing race by using the most recent non–missing race information contained in VA outpatient MedSAS data for the years 1998 to 2002. Using this strategy, we reduced the number of patients with missing race information from 38% to 16%.
We categorized admission source prior to hospitalization for amputation surgery as: nursing facility, hospital, or from the community. Year of amputation was identified using the PTF surgery data. The number of comorbid conditions was evaluated using the Healthcare Cost and Utilization Project's (HCUP) Elixhausen comorbidity software (version 2.1 for years 2005–2007 and version 3.7 for years 2008–2010), which uses the ICD-9 diagnosis codes listed in the main PTF dataset and calculates a total number of comorbidities.17 The comorbidities included in the Elixhausen Index are: peripheral vascular disease, hypertension, paralysis, neurological disorders, chronic pulmonary disease, diabetes with chronic complications, diabetes without chronic complications, hypothyroidism, renal failure, liver disease, peptic ulcer disease, acquired immune deficiency syndrome, lymphoma, metastatic cancer, solid tumor without metastasis, rheumatoid arthritis, coagulopathy, obesity, weight loss, fluid and electrolyte disorder, chronic blood loss anemia, deficiency anemia, alcohol abuse, drug abuse, psychoses, and depression. In this calculation, diabetes with complications and diabetes without complications were counted only once; similarly, only metastatic cancer and solid tumor without metastasis were counted toward the total number of comorbidities.
We also evaluated the presence of specific comorbid conditions that had been included in prior analyses of rehabilitation of people with lower limb amputations.4,8,10 These conditions included congestive heart failure, peripheral vascular disease, paralysis, other neurological disorders, diabetes, and renal failure. We also examined cerebral vascular disease for ICD-9 diagnosis codes between 4300 and 4389, but this comorbidity did not count toward the total number. Length of stay was added to the PTF data in 2006. It was calculated as [(discharge date-admission date) − (days patient was out on pass during inpatient and entire stay)] but has a minimum value of 1.
Our analyses also included admission and discharge bed section. Bed section refers to specialty of the admitting physician. Admitting bed sections were classified as medicine, cardiology, neurology, orthopedic, other podiatry, surgery, or vascular. Discharge bed sections were classified as medicine, cardiology, neurology, orthopedic, other podiatry, rehabilitation, surgery, or vascular. We were unable to use the category of rehabilitation as an admitting bed section because of the very low numbers of patients admitted to this bed section.
Our analyses included hospital geographic region, mapped into 4 regions (Northeast, South, Upper Midwest, and West)18 and hospital bed size, classified as ≤126 beds, 127 to 244 beds, 245 to 362 beds, and >362 beds.12
Statistics
Descriptive analyses.
We examined descriptive statistics for the entire sample and calculated the percentage of patients who received physical therapy, occupational therapy, and any therapy by geographic region for all years and for the years 2005 to 2007 and 2009 to 2010.
Factors associated with receipt of rehabilitation.
Bivariate analyses (t tests for continuous covariates and chi-square tests for categorical covariates) were used to compare characteristics of those who had received and those who had not received services before surgery and those who had received and those who had not received services after surgery. All of the variables examined, except sex, cerebral vascular disease, and income, were significant factors of in least 1 of the 6 dependent variables.
Separate multivariate logistic regression models using all of the significant factors identified in the bivariate analyses, as well as sex, were created to examine rehabilitation receipt before and after the amputation. Three models were created for presurgical rehabilitation: (1) any physical therapy, (2) any occupational therapy, and (3) any therapy. Similarly, 3 separate models were created for postsurgical rehabilitation. These models included the length of stay, number of comorbidities as measured by Elixhausen Index, income, age, amputation level, admission source before hospitalization, marital status, sex, race, comorbidities (congestive heart failure, peripheral vascular disease, paralysis, other neurological disorders, diabetes [with or without chronic complications], and renal failure), and the facility-level variables “hospital region” and “hospital bed size.” Additionally, we included the variable “admitting bed section” in the models predicting preoperative service receipt and the variable “discharge bed section” in the models predicting postoperative service receipt.
Rehabilitation receipt before and after guideline implementation.
To assess rehabilitation service receipt before and after guideline implementation for people with amputations, which were published in 2007, we developed 6 logistic regression models examining the effect of year, classified dichotomously as 2005 to 2007 or 2009 to 2010 on receipt of any (or service specific) preoperative or postoperative rehabilitation services (Figure), controlling for all of the case-mix covariates in the original full models. We eliminated 2008 from this analysis because we expected that major efforts to disseminate the guidelines occurred in the year after publication and that patterns of practice change would not be evidence during that year. These models controlled for all factors included in our full models: age, Elixhausen Index, length of stay, admission source before hospitalization, amputation level, marital status, sex, race, comorbidities, region, bed size, and bed section (either admitting or discharge).
Flow of participants into logistic regression models examining impact of guidelines on receipt of rehabilitative services in the acute care setting. PT=physical therapy, OT=occupational therapy.
Because prior researchers reported geographic variation in receipt of rehabilitation care for SRUs,11,12 we were interested in determining whether similar variation existed in acute care rehabilitation services and, if so, whether geographic variation in care receipt was ameliorated after guideline implementation. Therefore, we also examined the odds of receiving a service in one region compared with the odds of receiving services in another region using separate logistic regression for services received before 2008 and after 2008.
Results
There were 12,599 veterans with an incident lower limb amputation from 2005 to 2010. Characteristics of these patients are shown in Table 1. The mean age of the group was 66 years. The sample was 99% male, 47% were admitted from a hospital, 9% were admitted from a nursing facility, and 43.9% were admitted from the community. The average length of acute care hospital stay was 19.2 days. The most common comorbid conditions were peripheral vascular disease (60%) and diabetes (66%). Forty percent of the amputation surgeries in our sample occurred at southern hospitals compared with 18% in the Northeast, 21.4% in the Upper Midwest, and 20.5% in the West.
Characteristics of Patients With Incident Amputations, 2005–2010 (N=12,599)a
Factors Associated With Receipt of Rehabilitation Services
Multivariable analyses.
Results of the logistic regressions modeling receipt of preoperative and postoperative rehabilitation services are shown in Tables 2 and 3, respectively. For each additional day of hospitalization, the odds of a patient receiving any preoperative physical therapy, occupational therapy, or any therapy were 1.01 to 1.02 times higher. For each additional comorbidity, the odds of receipt of any preoperative physical therapy were 1.06 times higher, the odds of receiving preoperative occupational therapy were 1.15 times higher, and the odds of receiving any therapy were 1.07 times higher. The odds of receiving preoperative physical therapy for patients under 45 years of age were 0.47 compared with patients aged 55 to 64 years. Hospital bed size was associated with receipt of all types of services, but the pattern of relationship was not clear. Admitting bed section was related to service receipt, with patients admitted to neurology, orthopedics, surgery, or vascular sections having significantly lower odds of receiving physical therapy and those admitted to orthopedic, podiatry, surgery, or vascular sections having lower odds of receiving occupational therapy compared with those admitted to medicine.
Logistic Regression Models Predicting Preoperative Rehabilitation Receipt (n=12,587)a
Logistic Regression Models Predicting Postoperative Rehabilitation Receipt (n=12,587)a
Patients who had their surgeries in the Northeast had 0.67, 0.69, and 0.63 the odds receiving any preoperative physical therapy, occupational therapy, and any therapy services, respectively, compared with those in the South. Patients in hospitals in the Upper Midwest had 1.21, 1.35, and 1.17 times the odds of receiving any preoperative physical therapy, occupational therapy, and any therapy, respectively, compared with those in the South. Patients in the West had 1.32, 1.40, and 1.25 times the odds of receiving preoperative physical therapy, occupational therapy, and any therapy, respectively, compared with those in the South.
For each additional day of hospitalization, patients had 1.01 times greater odds of receiving any type of postoperative rehabilitation service. For each additional comorbidity, patients had 1.11 times the odds for receiving postoperative physical therapy and 1.10 times the odds for receiving any postoperative therapy. Patients over 75 to 84 years of age had 0.87 times the odds and those over age 85 years had 0.77 times the odds of receiving any postoperative therapy compared with those aged 55 to 64 years. Patients admitted from the community had 1.16 times the odds of receiving any physical therapy and 1.11 times the odds of receiving any therapy compared with those admitted from a hospital. Those admitted from nursing homes had 0.58 times the odds of receiving any physical therapy, 0.50 times the odds of receiving occupational therapy, and 0.54 times the odds of receiving any therapy compared with those admitted from a hospital. Patients with below-knee amputations or above-knee amputations had higher odds of receiving physical therapy and occupational therapy services compared with those with foot or ankle amputation. Black patients had 1.16 times the odds of receiving any postoperative physical therapy, 1.36 times the odds of receiving occupational therapy, and 1.26 times the odds of receiving any therapy compared with white patients. Additionally, patients with paralysis, diabetes, or renal failure had lower odds of receiving any postoperative physical therapy, whereas those with congestive heart failure had higher odds of receiving occupational therapy.
Substantial regional variation in receipt of postoperative rehabilitation services was observed. Patients who had their surgeries in the Northeast had 0.50, 0.42, and 0.43 the odds of receiving any postoperative physical therapy, occupational therapy, and any therapy services, respectively, compared with those in the South. Patients in hospitals in the Upper Midwest had 1.28 and 1.24 times the odds of receiving any preoperative physical therapy and any therapy, respectively, than those in the South. Patients in the West had a similar pattern, with 1.54 and 1.43 times the odds of receiving postoperative physical therapy and any therapy, respectively, compared with those in the South.
Discharge bed section was associated with postoperative rehabilitation service receipt. Those patients discharged from neurology had 0.37, 0.40, and 0.35 the odds of receiving physical therapy, occupational therapy, and any therapy, respectively, than those discharged from medicine. Patients discharged from orthopedics had 2.08, 1.67, and 1.95 times the odds of receiving physical therapy, occupational therapy, and any therapy, respectively, compared with those discharged from medicine. Patients discharged from rehabilitation had 0.32, 2.92, and 2.35 times the odds to receive physical therapy, occupational therapy, and any therapy, respectively, compared with those discharged from medicine.
Rehabilitation services before and after guideline implementation.
Examination of receipt of rehabilitation services by year (Tab. 4) shows that patients with incident amputation after 2008 (as opposed to those with amputations before 2008) had 1.45, 1.73, and 1.45 the odds of receiving preoperative physical therapy, occupational therapy, and any therapy, respectively. Patients in the later time period also had higher odds of receiving postoperative physical therapy, occupational therapy, any therapy (odds ratio=1.68, 1.79, and 1.72, respectively).
Logistic Regression Models Predicting Likelihood of Receipt of Preoperative and Postoperative Rehabilitation After 2008, After VA/DoD Clinical Practice Guideline Publication (n=6,376), Compared With Before 2008, Before Guideline Publication (n=4,180)a
Despite the increased prevalence of physical therapy and occupational therapy service receipt after guideline implementation, the regional variations in prevalence of care receipt persisted, as shown in Table 5. After guideline implementation, patients who had amputations in the West and Northeast regions had 1.43 and 1.33 times, respectively, the odds of receiving physical therapy compared with patients from the South. Similarly, after guideline implementation, patients in the West and Northeast regions had 1.69 and 0.36 times, respectively, the odds of receiving postoperative physical therapy services compared with patients from the South. Those in the Northeast also had 0.35 times the odds of receiving postoperative occupational therapy services.
Logistic Regression Models Predicting Rehabilitation Receipt: Results of Separate Modelsa
Discussion
Our study described the use of rehabilitation services following lower limb amputation surgery at VA Medical Centers in the years 2005 to 2010. Although prior research has examined factors associated with the use of inpatient rehabilitation, our study is the first to examine change in prevalence of receipt of rehabilitation services after the introduction of the VA/DoD Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation,1 a publication meant to improve quality of care throughout the VA and DoD. Our study examined factors associated with receipt of both preoperative and postoperative rehabilitation services in the acute care setting and is the first to examine prevalence of receipt of specific rehabilitation services, including physical therapy and occupational therapy services.
Overall, we found that receipt of any postoperative rehabilitation was much more prevalent than preoperative rehabilitation, with 13.6% of patients receiving some type of service preoperatively and 54.7% receiving services postoperatively. Physical therapy was the most common type of service provided preoperatively and postoperatively.
Our findings suggest that patients aged 75 to 84 years and those who were sicker were more likely to receive preoperative rehabilitation services than patients 55 to 64 years old, controlling for all other factors. However, patients over the age of 85 years were no more likely to receive services than those 55 to 64 years of age. It is unclear why these differences in service receipt exist, given that the guidelines recommend that physical therapy and occupational therapy professionals be involved in preoperative patient assessment of ROM, strength, mobility, and function, regardless of age or comorbidity.
Our findings suggest that patients who were less independent (admitted from nursing facilities) and were over age 75 years were less likely to receive postoperative rehabilitation in the acute care setting. Our results are similar to those reported by Zhou et al,4 who found that older people and those who were admitted from extended care facilities were less likely to receive outpatient therapy services after lower limb amputation. However, a study of rehabilitation receipt in the acute care setting in North Carolina showed that the relationship of age to service receipt varied by condition, with older age associated with an increased likelihood of receipt of rehabilitation services poststroke, but not after hip replacement.14 That study did not examine living location prior to admission and did not assess receipt of care after lower limb amputation.
We found that having more comorbid conditions (as measured by the Elixhausen Index) was associated with increased likelihood of receiving therapy (preoperatively and postoperatively), but that having conditions with greater severity, such as congestive heart failure, paralysis, and renal failure, was associated with a decreased likelihood of receiving physical therapy. Zhou et al4 did not report an association between total Elixhausen Index and likelihood of receipt of outpatient therapy, but they did find that people who had serious comorbidities in the acute setting were less likely to receive outpatient services. Freburger et al14 also reported that greater illness severity, as indicated by the presence of conditions such as hemorrhagic stroke and congestive heart failure, was associated with a lower likelihood of receiving physical therapy in the acute care setting.
We found that people who were discharged from acute care more quickly were less likely to have received postoperative rehabilitation services. Our results suggest that for each 10 additional days in the hospital, patients would have a 16% and 9% increased likelihood of receiving preoperative physical therapy and occupational therapy, respectively, and a 6% increased likelihood of receiving postoperative physical therapy or occupational therapy. Consistent with our findings regarding length of stay, Freburger et al14 also reported that longer hospital length of stay was associated with a greater likelihood of receiving physical therapy after stroke and joint replacement surgery. It is possible that some patients had been referred for therapy services but that those services were not delivered prior to discharge due to a short time frame, scheduling, or staffing issues.
We found considerable variation in receipt of preoperative rehabilitation that was associated with region of the country, even after controlling for patient characteristics, comorbidities, and admission source prior to hospitalization. Patients in the Northeast had the lowest likelihood of receiving any preoperative services (all categories), whereas patients in the West had the highest likelihood of receiving any preoperative services compared with patients in the South. This pattern was largely repeated for most postoperative rehabilitation services, with patients in the Northeast having approximately 0.50 lower odds of receiving postoperative services (all categories) and patients in the West having 1.54 the odds of receiving postoperative physical therapy compared with patients in the South. We do not know for certain what amount of service utilization is too little, too much, or just the clinically indicated amount. However, in an ideal health system and assuming that patient preferences are the same, wide variations in health care utilization should not occur.
The reasons for variation of care in this national VA sample are not clear, and we have no way of determining whether rehabilitation treatment delivered was clinically indicated or whether clinically indicated treatment was not delivered. Given that the guidelines suggest that physical therapy and occupational therapy providers should be consulted for postoperative patient assessment and should play a role in development of a treatment plan, we suspect the latter.
Although previous investigators reported variation in receipt of rehabilitation in an SRU associated with region and bed size,11,12 we did not expect to see similar variations in rehabilitation service delivery in the acute care setting. Access to specialized rehabilitative care varies, in part, due to supply and co-location within the hospital or area, whereas access to rehabilitation in the acute care setting should be more uniformly available because acute care hospitals typically have physical therapists and occupational therapists on site to provide services. Our findings, together with those of Zhou et al,4 suggest that there may be regional trends across the continuum of rehabilitation services postamputation, with prevalence of use the lowest in the Northeast and highest in the Midwest and West.
The pattern of relationship between hospital bed size and receipt of rehabilitation services was less clear. Although we expected that smaller hospitals may not have occupational therapists and may use physical therapists to perform functional rehabilitation, we did not observe a decreased likelihood of occupational therapy utilization for smaller hospitals. Instead, smaller hospitals of 127 to 244 beds were more likely to provide the most preoperative occupational therapy, as well as postoperative physical therapy and occupational therapy. This finding suggests larger hospitals may have lower therapist-to-hospital bed ratios and more unfilled vacancies. This finding contrasts with that of Freburger et al,14 who reported that patients at larger hospitals were more likely to receive acute care physical therapy after hip joint replacement or stroke. However, Freburger and colleagues' study included only hospitals in a single state, whereas our study included all VA medical centers in the country.
In summary, the reasons for geographic variation in receipt of rehabilitation services in the acute care setting are unclear, but could be due to regional and hospital level differences in practice patterns as well as hospital staffing levels.
Our study did not examine data after discharge from the acute hospital stay, and thus we are unable to determine whether these patients, with apparently greater need for rehabilitation, did ultimately receive rehabilitation services, albeit in a delayed time frame. However, Zhou et al4 reported that older veterans and those admitted from long-term care facilities were less likely to receive outpatient rehabilitation, perhaps because of a perceived lack of rehabilitation potential.
We found that the likelihood of receiving preoperative and postoperative physical therapy and occupational therapy services was significantly greater after the introduction of the guidelines. Although this increase in receipt of physical therapy and occupational therapy services was expected, we are unable to state with any certainty that the relationship between introduction of the guidelines and prevalence of rehabilitation receipt was causal because the study design was observational. Instead, any observed associations may have been due to changing practice patterns over this time period and were not directly related to guideline introduction. We are unaware of any similar studies that would provide historical comparisons for non-VA hospitals. Because this was an observational study and we had no relationship to the work group that developed the guidelines, we had limited information on how they were disseminated. The VA has an office of quality management that disseminates evidence-based guidelines for all types of conditions.1 Although regional variation in dissemination of the guidelines may have existed, we have no information on the methods used to disseminate the guidelines or whether these methods differed across VA medical centers.
Another study limitation is that the sample included only those veterans who had amputation surgeries within the VA system. No attempt was made to identify veterans who had their surgeries at other facilities. Therefore, the findings cannot be generalized to veterans who had their surgeries outside the VA or to nonveteran patients and settings.
We encountered known problems with missing race information in our VA secondary data sources. Race information was recaptured for more than half of those patients missing it by using VA MedSAS outpatient data. Nevertheless, 16% of patients had this information missing, threatening the validity of the findings about the relationship between being black and likelihood of rehabilitation service receipt.
The sample was limited to veterans with new amputations by using a 12-month look-back period, similar to the one used by prior researchers.4,8–10 However, it is possible that some patients had revisions of amputations performed prior to that date, or outside of the VA. It is possible that rehabilitation receipt varied for bilateral amputees; however, we were not able to examine this issue because there is no way to identify whether patients had bilateral amputations, as side of amputation surgery is not coded in the data.
Although we attempted to control for patient characteristics that we believed might influence receipt of rehabilitation and included key variables reported in prior literature, we had no measures of wound healing, functional status, or cognitive function prior to amputation, which we could expect would be associated with service receipt. Thus, there may have been unmeasured confounders.
Lastly, the study was largely descriptive; we did not attempt to examine the impact of rehabilitation receipt on outcomes, such as functional status, health care costs, discharge destination, or use of rehabilitation services outside of the acute hospital stay. Further research is needed to link additional data sources to examine these types of questions.
Conclusions and Implications
This study described the use of rehabilitation services prior to and following lower limb amputation surgery at VA medical centers in the years 2005 to 2010 and compared rates of utilization of services prior to and after the introduction of the VA/DoD Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation.1 We found that prevalence of receipt of preoperative and postoperative therapy services (physical therapy and occupational therapy) in the acute care setting increased after the introduction of the guidelines. The analyses identified variations in receipt of rehabilitation by geographic region and hospital bed size that were not explained by patient characteristics. These findings suggest that further quality improvement efforts are needed to standardize delivery of rehabilitation services for veterans with amputations in the acute care setting.
Footnotes
Both authors provided concept/idea/research design, writing, and data analysis. Dr Resnik provided project management.
- Received October 10, 2012.
- Accepted April 26, 2013.
- © 2013 American Physical Therapy Association
References
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