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Objectives: To determine patient, treatment, or facility characteristics that influence decisions to initiate a rehabilitation assessment before transtibial or transfemoral amputation within the Veterans Affairs (VA) health care system. Design: Retrospective database study. Setting: VA medical centers. Participants: A total of 4226 veterans with lower extremity amputations discharged from a VA medical center between October 1, 2002, and September 30, 2004. Outcome: Evidence of a preoperative rehabilitation assessment after the index surgical stay admission but before the surgical date. Results: Evidence was found that 343 of 4226 veterans (8.12%) with lower extremity amputations received preoperative rehabilitation assessments. Veterans receiving preoperative rehabilitation were more likely to be older, admitted from home, or transferred from another hospital. Patients who underwent surgical amputation at smaller-sized hospitals or in the South Central or Mountain Pacific regions were more likely to receive preoperative rehabilitation compared with patients in mid-sized hospitals or in the Northeast, Southeast, or Midwest regions. Patients with evidence of paralysis, patients treated in facilities with programs accredited by the Commission on Accreditation of Rehabilitation Facilities (P < .01), and patients in the second data wave were less likely to receive preoperative rehabilitation. After accounting for patient-, treatment-, and facility-level structural characteristics, we found that older patients were more likely to receive preoperative rehabilitation services (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.02). Patients with a contributing amputation etiology of a previous amputation complication were more likely to receive preoperative consultation rehabilitation services (OR 1.50, 95% CI 1.02-2.19) compared with patients who did not have this etiology. Compared with patients treated in the Southeast region of the United States, those treated in the South Central region (OR 2.52, 95% CI 1.82-3.48) or Mountain Pacific region (OR 1.62, 95% CI 1.11-2.37) were more likely to receive preoperative consultation rehabilitation services. Patients with evidence of paralysis were less likely to receive preoperative rehabilitative services compared with patients who did not have this condition (OR 0.29, 95% CI 0.09-0.93), and patients treated in mid-sized hospitals also were less likely to receive preoperative rehabilitative services compared with patients treated in smaller-sized facilities (OR 0.38, 95% CI 0.27-0.53). Veterans in the second data year were less likely to receive services compared with patients in the first year (OR 0.74, 95% CI 0.58-0.94). Conclusions: Rehabilitation assessment before lower extremity amputation surgery is a rare occurrence in the VA health care system. Practice patterns appear to be driven by location and not by patient characteristics. [Copyright &y& Elsevier]

Abstract: Zhou J, Bates BE, Kurichi JE, Kwong PL, Xie D, Stineman MG. Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation. Objective: To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services after lower extremity amputation within the Veterans Affairs (VA) system. Design: Observational study. Setting: All Veterans Affairs Medical Centers (VAMCs). Participants: Veterans (N=4165) with lower extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004. Interventions: Not applicable. Main Outcome Measures: Receipt of outpatient rehabilitation services up to 1 year postdischarge. A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services. Results: Sixty-five percent of veterans with lower extremity amputation received outpatient services. Older veterans, patients admitted for surgical amputation from extended care rather than transferred from another hospital, and those with transfemoral and/or bilateral rather than unilateral transtibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous system disorders, active cardiac pathology, serious nutritional compromise, and severe renal disease during the surgical hospitalization less often initiated outpatient care. Patients who received inpatient consultative rehabilitation compared with inpatient specialized rehabilitation, and who were treated in the Northeast compared with the Southeast less often initiated outpatient care. Finally, those discharged to home or other locations rather than extended care had an initial increased likelihood of receiving outpatient service, but by 180 days postdischarge those discharged to extended care were more likely to initiate outpatient services. Conclusions: Both clinical characteristics and types of rehabilitation services received appear to influence the receipt of outpatient rehabilitation services. Geographic location also affected the receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation. [Copyright &y& Elsevier]

Background: Although comorbid neurological conditions are not uncommon for individuals undergoing lower-extremity (LE) amputation, short- and long-term prognosis is unclear. Methods: This cohort study on the survival of United States veterans with LE amputations examined the association between different preexisting neurological conditions and short- and long-term (in-hospital and within 1-year of surgical amputation) mortality. χ2 and t test statistics compared baseline characteristics for patients with and without neurological disorders. Multiple logistic regression and Cox proportional hazard models were used to examine short- and long-term survival and identify predictors limited to the subset of those with neurological conditions adjusting for age, amputation level and etiology, and co-morbidities. Results: Of 4,720 patients, 43.3% had neurological disorders documented. Most prevalent were stroke or hemiparesis (18.3%) and peripheral nervous system (PNS) disorders (20.3%). Among patients with neurological conditions, those with a PNS disorder or spinal cord injury (or paralysis) were significantly less likely to die in hospital and within 1 year (p < 0.05) when compared to the other types of neurological condition groups including stroke (or hemiparesis), cerebral degenerative diseases, movement disorders and autonomic disorders. Conclusions: The high prevalence of preexisting neurological disorders among LE amputees and the varying effect of different conditions on risk of mortality highlights the need to further characterize the diverseness of this understudied subpopulation. While preexisting spinal cord injury and PNS disorders appear to carry a decreased risk among amputees, those with central nervous system disorders have comparatively greater mortalities. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Stineman MG, Kwong PL, Kurichi JE, Prvu-Bettger JA, Vogel WB, Maislin G, Bates BE, Reker DM. The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system. Objective: To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. Design: An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. Setting: Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. Participants: A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. Interventions: Not applicable. Main Outcome Measures: One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. Results: After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26–1.80) and home discharge (OR=2.58; 95% CI, 2.17–3.06). Prosthetic limb procurement did not differ significantly between groups. Conclusions: The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation. [Copyright &y& Elsevier]

Abstract: Bates BE, Kurichi JE, Marshall CR, Reker D, Maislin G, Stineman MG. Does the presence of a specialized rehabilitation unit in a Veterans Affairs facility impact referral for rehabilitative care after a lower-extremity amputation? Objective: To determine if the presence of specialized rehabilitation units (SRUs) within Veterans Affairs medical centers (VAMC) influences access to rehabilitation services. Design: Retrospective cohort analysis. Setting: Two types of VAMCs: those with and without SRUs. Participants: Veterans with lower-extremity amputations discharged from VAMCs between October 1, 2002, and September 30, 2003. There were a total of 2375 veterans with amputations: 99% were men; and 60% had transtibial, 40% had transfemoral, and less than 1% had hip disarticulation amputations. Nine hundred sixty-six patients (41%) were seen at a VAMC with an SRU. Interventions: Not applicable. Main Outcome Measure: Level of service provided expressed as: no evidence of rehabilitation during the hospitalization, generalized rehabilitation through consultation only, or admission to an SRU. Results: There were no differences between patients treated at facilities with SRUs and those treated in a facility without SRU beds with respect to age, sex, marital status, source of hospital admission, or level of amputation (all P<.05). Patients with lower initial FIM instrument scores were more likely to be treated in facilities with SRUs, and to have longer lengths of acute hospitalization (P<.01). Patients at facilities with an SRU compared with those without an SRU had comparable likelihoods of being seen for an initial rehabilitation consultation (75% vs 74%, P=.56), but were more likely to be admitted for high intensity specialty rehabilitation services (26% vs 11%, P<.01). Conclusions: Although the majority of patients were seen in consultation, structural differences in service availability among clinically similar populations appear to be causing access disparities to specialized rehabilitation among amputees in the VAMC setting. The implication of these differences with regard to patient outcomes will need to be determined. [Copyright &y& Elsevier]

Background: Understanding comorbidity prevalence and the effects of comorbidities in older veterans with lower extremity amputations may aid in assessing patient outcomes, resource use, and facility-level quality of care.Objectives: To determine the degree to which adding outpatient to inpatient administrative data sources yields higher comorbidity prevalence estimates and improved explanatory power of models predicting 1-year mortality and to compare the Charlson/Deyo and Elixhauser comorbidity measures.Methods: A retrospective cohort study applying frequencies, cross-tabulations, and logistic regression models was conducted, including data from 2,375 veterans with lower extremity amputations. Comorbidity prevalence according to the Charlson/Deyo and Elixhauser measures, 1-year mortality rates, and standardized mortality ratios (SMRs) were analyzed.Results: Comorbidity prevalence estimates increased sharply for both the Charlson/Deyo and Elixhauser measures with the addition of data from multiple settings. The Elixhauser compared to the Charlson/Deyo generally yielded higher estimates but did not improve explanatory power for mortality. Modeling expected versus actual deaths produced varying SMRs across geographic regions but was not dependent on which measure or data sources were used.Conclusions: Merging outpatient with inpatient data may reduce the under coding of comorbidities but does not enhance mortality prediction. Compared to the Charlson/Deyo, the Elixhauser has a more complete coding scheme for comorbid conditions, such as diabetes mellitus and peripheral vascular disease, important to addressing lower extremity amputation etiology. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine how advanced age influences prosthetic prescription. DESIGN: Retrospective cohort analysis with theory-driven logistic regression models. A Post Amputation Quality-of-Life (PAQ) framework of outcomes was proposed and empirically tested. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Two thousand three hundred seventy-five veterans with lower extremity amputations discharged between October 1, 2002, and September 30, 2003. MEASUREMENTS: Prosthetic prescription within 1 year of amputation. RESULTS: Patients younger than 76 were 4.5 times as likely to receive a prescription compared to those aged 86 and older (odds ratio=4.51, 95% confidence interval=1.36–14.99) after controlling for sex, marital status, living circumstance before hospitalization, anatomical level, etiologies, comorbidities, medical acuity, and initial functional status. Patients admitted from extended care and patients with peripheral vascular disease, systemic sepsis, renal failure, congestive heart failure, psychoses, metastatic cancer, paralysis, or other neurological disorders were less likely to receive a prescription, as were patients who underwent procedures for acute central nervous system disorders, severe renal disease, or serious nutritional compromise. Veterans evaluated initially as more cognitively and physically able had higher likelihood of prosthetic prescription, and those with transtibial amputations had higher likelihood of prosthetic prescription than those with transfemoral amputations. CONCLUSION: Amputees aged 75 and older are less likely to receive a prosthetic limb prescription than younger individuals, even after controlling for comorbidities and functional status. Findings support the PAQ framework, in which contexts, etiologies, anatomic level, comorbidities, medical acuity, and initial function are determinants of outcome. Medical and functional conditions that adversely affect level of energy, ability to move independently, or ability to exercise judgment reduce the likelihood of prosthetic prescription. [ABSTRACT FROM AUTHOR]

Odds ratios (OR) and 95% confidence intervals (CI) were obtained to determine the characteristics of receiving preoperative rehabilitation services. Compared with patients treated in the southeastern region of the country, those treated in the south central (OR, 2.52 [95% CI, 1.82-3.48]) or Mountain Pacific (OR, 1.62 [95% CI, 1.11-2.37]) were more likely to receive preoperative rehabilitation. Objective To determine which patient- or facility-level characteristics influence the decision to initiate rehabilitation before lower-extremity amputation within the Veterans Affairs health care system. [Extracted from the article]