Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2012 Sep 1.
Published in final edited form as: Arch Phys Med Rehabil. 2011 Sep;92(9):1455–1461. doi: 10.1016/j.apmr.2011.03.029

Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation

Jianxun Zhou 1, Barbara E Bates 1, Jibby E Kurichi 2, Pui L Kwong 2, Dawei Xie 2, Margaret G Stineman 2
PMCID: PMC3188813  NIHMSID: NIHMS315204  PMID: 21878217

Abstract

Objective

To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services following lower extremity amputation within Veterans Affairs (VA) system.

Design

A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services.

Setting

All VA Medical Centers.

Participants

4,165 veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004.

Intervention

Not applicable.

Main Outcome Measures

Receipt of outpatient rehabilitation services up to one year post-discharge.

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 trans-femoral and/or bilateral rather than unilateral trans-tibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous 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 to inpatient specialized rehabilitation; and who were treated in the Northeast compared to the Southeast region 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 post-discharge those discharged to extended care were more likely to initiate outpatient services.

Conclusion

Both clinical characteristics and types of rehabilitation services received appear to influence receipt of outpatient rehabilitation services. Geographic location also impacted receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation.

Keywords: lower extremity amputation, outpatient rehabilitation, veterans

Veterans who have undergone lower extremity amputation may experience long-term challenges after discharge from their acute hospitalization. For patients with the potential to walk with a prosthetic limb, continuity of rehabilitation after discharge is critical. For patients who are not appropriate for prosthetic fitting, mobility needs including wheelchair and transfer skills may be best managed in an outpatient rehabilitation setting. Patients may also have pain management needs for phantom pain and stump pain and require follow-up of the quality and functionality of the residual extremity 1. Psychosocial adjustment to a lower extremity amputation can last for up to 2 years 2 requiring ongoing outpatient services.

Rehabilitation services following lower extremity amputation provide the opportunity for rehabilitation specialists to assess patients' functional goals and adjust interventions to achieve maximum independence and function. Cumulative evidence supports the notion that inpatient rehabilitation leads to better outcomes, including reduced mortality, fewer subsequent amputations, greater medical stability, greater likelihood of home discharge, prosthetic fitting, and improved physical functioning 3-6.

Given their long-term challenges, it is reasonable to assume that most patients could benefit from outpatient rehabilitation following hospitalization for an amputation. However, many patients with severe lower extremity trauma requiring amputation received no physical therapy services despite the perceived need 7. Castillo et. al. (2008) found that, compared with those who received no physical therapy services, there is a beneficial effect of physical therapy for patients with severe lower-extremity trauma requiring amputation or reconstruction 8. Little is known about participation in outpatient rehabilitation services following lower extremity amputation for non-traumatic etiologies. In this study, we examined patient-, treatment-, and facility-level characteristics associated with participation in outpatient rehabilitation following lower extremity amputation within the Veterans Affairs (VA) health care system. Identification of these characteristics may help clinicians better understand the barriers to receiving outpatient rehabilitation and take appropriate action when needed for patients with lower extremity amputation.

Methods

This observational study was approved by the Institutional Review Boards at the Samuel S. Stratton Veterans Affairs Medical Center (VAMC) in Albany, New York, the University of Pennsylvania in Philadelphia, Pennsylvania, and North Florida/South Georgia Veterans Health System in Gainesville, Florida.

1. Description of Databases

Data were obtained from 8 Veterans Health Administration (VHA) administrative databases used to track the health status and health care utilization of veterans. The databases included 4 inpatient datasets referred to as the Patient Treatment Files (PTF) (main, procedure, bed section, and surgery) 9, 2 outpatient care files (visit and event)10, the Beneficiary Identification Record Locator System (BIRLS) death file11 and the Functional Status and Outcomes Database (FSOD)12. Description of the PTF, BIRLS, and FSOD databases and our data extraction methods have been described previously 13-16. The outpatient files track any outpatient services received along with diagnoses coded during those visits and visit dates. To ensure that all visits were captured, we created our “outpatient rehabilitation indicated” by combining information from 2 variables: “clinic stop” which describes the types of services received and “provider type” which records who saw the patient.

2. Study Population

Patients were included from VAMCs with acute hospital discharge dates between October 1, 2002, and September 30, 2004, for a trans-tibial or trans-femoral amputation identified through the following surgical International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes: 84.10, 84.13-84.19, and 84.91 17. Cases were excluded if the amputation involved toes only or if there was a record of a previous lower extremity amputation within the 12 months preceding the hospitalization since the objective was to study only new amputations. The hospitalization (admission to discharge) at the time of the new amputation represented the “index surgical stay” or acute hospital stay. We combined records from the PTF bed section files with admission dates within one day of the patient's main hospitalization discharge date to capture the entire acute amputation hospitalization stay. Data include information up to the one year post surgical date.

We started with a total of 4,727 subjects. Because the focus of the study was to determine which characteristics predicted the receipt of outpatient rehabilitation services after the patients were discharged from hospital, the following groups of patients were excluded: 364 patients who died during the index surgical stay, 17 patients whose index surgical stay extended more than 365 days after the surgical amputation, and 131 who were discharged to another hospital. We also excluded 50 more patients because of they were missing at least one of the predictors. In detail, there were 49 patients with a V57 code indicating that they received inpatient rehabilitation, but had no evidence of a FSOD record to designate which type of rehabilitation was received during the surgical hospitalization, and 1 patient with missing living location before hospitalization. Thus, 4,165 veterans with a lower extremity amputation were included in the analyses.

3. Description of Inpatient and Outpatient Rehabilitation Services

The type of inpatient rehabilitation was included to determine whether or not having some form of rehabilitation acutely after surgery made continued outpatient care more or less likely. Details of inpatient rehabilitation services have been described previously 5. Briefly, in the VA, inpatient rehabilitation is classified into consultation rehabilitation and specialized rehabilitation. In consultation rehabilitation, patients may have one to several therapy sessions while hospitalized and functional restoration is not typically the primary therapeutic focus. Inpatient rehabilitation on a specialized rehabilitation unit (SRU) occurs on designated units, in which restorative therapy occurs daily, and rehabilitation is the primary therapeutic focus. In the VHA, sub-acute and acute SRU beds within hospitals are considered to be similar, and in this study both were categorized as a SRU because of the low frequency of veterans who receive SRU and sub-acute rehabilitation services after their amputations.

Outpatient rehabilitation occurs after discharge from the index surgical stay. There are multiple types of outpatient rehabilitation services that patients can receive and are described in detail in the outcome sub-section.

4. Patient-, treatment-, and facility-level characteristics definitions

Table 1 shows details of these characteristics. Patients with both a unilateral trans-tibial and a unilateral trans-femoral amputation were categorized as bilateral trans-femoral amputations because of the low prevalence of bilateral trans-femoral amputations, and because patient-level characteristics were more closely related to trans-femoral amputations, i.e., functional prognosis declines sharply once the knee is lost 18.

Table 1. Summary of patient-, treatment-, and facility-level characteristics. See text for explanations.

Variables Descriptions
Patient-level

  1. General: Age; Gender; Marital status; Living location (extended care1, home, or hospital).

  2. Level of amputation: Unilateral trans-tibial, unilateral trans-femoral, bilateral trans-tibial, and bilateral trans-femoral.

  3. Contributing amputation etiologies: Chronic osteomyelitis, device infection, diabetes mellitus type I, diabetes mellitus type II, local significant infection, peripheral vascular disease, pervious amputation complication, skin breakdown, systemic sepsis, and trauma.

  4. Elixhauser comorbidities: include 31 conditions: congestive heart failure, arrhythmias, valvular disease, pulmonary circulation disease, peripheral vascular disease, hypertension, hypertension with complication, paralysis, other neurological disorders, chronic pulmonary disease, diabetes mellitus, diabetes mellitus with complication, hypothyroidism, renal failure, liver disease, peptic ulcer disease, acquired immune deficiency syndrome, lymphoma, metastatic cancer, solid tumor without metastases, rheumatoid arthritis, coagulopathy, obesity, weight loss, fluid and electrolyte disorders, chronic blood loss anemia, deficiency anemia, alcohol abuse, drug abuse, psychoses, and depression.

    Note: Diabetes mellitus and peripheral vascular disease were excluded to avoid double counting since they were already in the etiologies.
Treatment-level

  1. Treatments/procedures for: active pulmonary, central nervous system, cardiac or severe renal pathology, nutritional compromise, ongoing wound problems, and mental status issues or substance abuse.

  2. Admission onto an intensive care unit.

  3. Average number of bed sections.

  4. Average days from hospital admission to surgery.

  5. Average days from surgical date to discharge date.

  6. Type of inpatient rehabilitation (no inpatient rehabilitation, consultation rehabilitation, or specialized rehabilitation).

  7. Discharge location: extended care1, home, or other 2
Facility-level

  1. Geographic region: Northeast, Southeast, Midwest, South Central, or Pacific Mountain.

  2. Hospital bed size: ≤126, 127-244, 245-362, or >362.
Open in a new tab
1

Extended care: nursing home, domiciliary, long term.

2

Other: leave against medical advice, or other placements including hospital based home care, spinal cord injury program, home care unit program, MCARE home health and other home health

Etiologies and comorbidities were identified using ICD-9-CM diagnosis codes from outpatient care files 3 months prior to the hospital admission and from the main and bed section PTF files up to the surgical date. Congenital deformity and lower-extremity cancer were not sufficiently prevalent to be included in the analyses. We used the 2003 version of the Elixhauser comorbidity measure, which includes 31 conditions and distinguishes hypertension with and without complications in this study 19-20. No cases had the ICD-9-CM code for obesity, and thus obesity was not included. Diabetes mellitus and peripheral vascular disease were not included as comorbidities since they were categorized as amputation etiologies. Admission onto an intensive care unit (ICU) was intended to indicate that the patient had a high level of medical acuity at some point in the surgical hospitalization. Discharge locations include home, extended care including nursing home, domiciliary, and long term care, and others (See Table 1).

5. Outcome Measure

The outcome of this study was time to the first outpatient rehabilitation service from the discharge date of the index hospitalization. Evidence of outpatient rehabilitation was obtained combining information from clinic stops and type of provider codes in the outpatient care files each of which include a date of service. This outcome was structured so that it captured both a) whether the individual had any or no outpatient rehabilitation and b) time between discharge from the surgical hospitalization and the first outpatient visit. The clinician authors reviewed and combined both outpatient clinic stops codes and types of providers. These codes, obtained from the outpatient record, were used to categorize the nature of the first outpatient rehabilitation contact as follows: physical medicine, recreation therapy, physical therapy, occupational therapy, kinesiotherapy, and post-amputation clinic 10. Further details about the codes used for each category are in Table 2.

Table 2. The types of first outpatient rehabilitation services received post-acute surgical hospitalization discharge.

Service classification Clinic Stop/ Providers type N (%) Time (in days) between discharge date and first outpatient visit
Mean (SD) Median Range (days)
Physical medicine Physical Medicine & Rehabilitation Service (PM&RS) / Physical Medicine & Rehabilitation 205 (7.6) 50.7 (57.5) 33 334
Recreation therapy Recreation therapy service / Recreation Therapist 25 (0.9) 69.7 (58.8) 65 178
Physical therapy Physical therapy / Physical Therapist 350 (13.0) 37.0 (53.4) 15 293
Occupational therapy Occupational therapy / Occupational Therapist 187 (6.9) 44.2 (60.5) 19 289
Kinesiotherapy Kinesiotherapy 144 (5.3) 41.0 (60.5) 17 343
Post-amputation clinic Amputation follow-up clinic, Prosthetic, orthotics, evaluation, fitting, and/or measuring, Amputation clinic, Prosthetic supply ordering services 1786 (66.2) 35.8 (52.3) 13 330
Overall 2697 (100%) 38.3 (54.2) 15 343
Open in a new tab

6. Statistical Analyses

Baseline patient-, treatment-, and facility-level characteristics were compared between patients who did and did not receive outpatient rehabilitation services. These comparisons were conducted through Chi-square tests for categorical variables or Student t-tests for continuous variables.

A time to event analysis, i.e., Cox proportional hazards model, was used to determine the hazard ratio (HR) and 95% confidence interval (CI) of veterans to receive outpatient rehabilitation services. Veterans who died after discharge without evidence of any outpatient rehabilitation were censored at the death date. There were only 26 patients falling into this category so we did not consider analysis to resolve the competing risk issue. Each patient-, treatment-, and facility-level variable was entered alone to predict time to receipt of outpatient rehabilitation services. If the p-value was <0.05, then the variable was included in the multivariate model. In the multivariate model, we also included clinically important variables such as age, marital status, amputation level, living location before hospitalization, and discharge location. Backward selection was then used to remove variables one at a time to construct the final main effects model in which all p values were <0.05.

The proportional hazards assumption for Cox regression model was tested to determine if the HRs remained constant over time. To do this, the interaction between each predictor in the final main effect model and time to receipt of outpatient rehabilitation services was added to the final main effects model. We added all interactions with p-value <0.05 in the previous step before a final backward selection procedure was conducted to obtain the final model with main effect and interactions. If a variable violated the proportional hazards assumption, it means the HR for this variable is changing over time and we chose to show the HRs at some discrete time points during the follow-up period. Specifically, HRs and 95% CIs at 0, 90, 180, 270, and 365 days after discharge from the index surgical stay were calculated. The constant HRs and 95% CIs for the predictors not violating the hazards assumption were reported. All models took into account the correlation among patients from the same facility. This was necessary because patients from the same facility might have correlated outcomes even after adjusting for all the covariates in our dataset. For example, the clinicians from the same facility might have similar approaches to outpatient service use causing correlations of outcomes within a center after removing the effects of all observed covariates. Accounting for the correlation allows us to obtain the correct variance estimate.

PROC TPHREG in SAS 9.1 21 was used for all time-to-event analyses. P-values were two-sided, with statistical significance at p <0.05 in the final model. Our tables included only the variables that were statistically significantly associated with outpatient use.

Results

There were a total of 2,697 (64.75%) veterans with lower extremity amputation who received outpatient rehabilitation services based on clinic stop and provider type codes, while 1,468 (35.25%) did not. Among those who received outpatient rehabilitation services, the average time between discharge from the surgical hospitalization and first visit was 38.3 days (standard deviation (SD)=54.2, Table 2). Outpatient services were most commonly initiated by a visit to an amputee clinic. This was the pattern for 66.2% of all veteran amputees with any outpatient services after discharge.

Table 3 compares baseline unadjusted characteristics of patients who did and did not receive outpatient rehabilitation services. Only statistically significant associations are shown. After adjusting for patient-, treatment-, and facility-level characteristics, some of these associations are no longer statistically significant. Table 4 shows the patient-, treatment-, and facility-level characteristics that remained independently associated with receipt of outpatient services after adjustment. With every 10 year increase in age, the likelihood of receiving outpatient rehabilitation declined (HR=0.83, 95% CI, 0.80-0.86). Veterans who were married were more likely to receive outpatient services (HR=1.19, 95% CI, 1.10-1.29). Those patients who were admitted to the hospital from extended care compared to being transferred from another hospital were less likely to receive outpatient services (HR=0.41, 95% CI, 0.30-0.56), while there was no difference for those admitted from home (p=0.50). Patients with trans-femoral or bilateral amputations were less likely to initiate outpatient services than those with a single trans-tibial amputation (p < .0001). Patients with comorbidities of congestive heart failure (p=0.002), neurological disorders (p=0.02), psychoses (p=0.0003), valvular diseases (p=0.04), and weight loss (p=0.04) were all less likely to receive outpatient rehabilitation services. Patients with evidence of acute organ dysfunction associated with their surgical hospitalization as evidenced by procedures suggestive of acute CNS disorders (p=0.009), ongoing active cardiac pathology (p=0.04), serious nutritional compromise (p=0.005) and severe renal disease (p<.0001) were less likely to obtain services. When compared to those who had specialized rehabilitation services, those who received consultation rehabilitation services during their index surgical stay were less likely to receive outpatient service (p<.0001), and those with no evidence of rehabilitation in that time period had no differences in the likelihood of receiving outpatient rehabilitation care.

Table 3. Baseline patient-, treatment-, and facility-level characteristics that are significantly associated with outpatient rehabilitation service use.

Do not have outpatient
(n=1,468)
n (%)		 Had outpatient
(n=2,697)
n (%)		 p-value
Demographic variables
 Average age, years (SD) 69.8 (10.7) 64.8 (11.1) <.0001
 Marital status 0.0002
  Not married 863 (37.7) 1426 (62.3)
  Married 605 (32.3) 1271 (67.7)
 Living location before hospitalization <.0001
  Extended care 349 (74.4) 120 (25.6)
  Hospital 30 (33.0) 61 (67.0)
  Home 1089 (30.2) 2516 (69.8)
Level of amputation <.0001
 Unilateral trans-tibial 456 (26.3) 1276 (73.7)
 Unilateral trans-femoral 359 (35.6) 649 (64.4)
 Bilateral trans-tibial 39 (43.8) 50 (56.2)
 Bilateral trans-femoral 614 (46.0) 722 (54.0)
Amputation etiology
 Device infection
No		 1331 (36.1) 2360 (63.9) 0.002
Yes 137 (28.9) 337 (71.1)
 Diabetes mellitus type I
No		 1263 (36.0) 2249 (64.0) 0.02
Yes 205 (31.4) 448 (68.6)
 Local significant infection
No		 292(30.0) 680 (70.0) 0.0001
Yes 1176 (36.8) 2017 (63.2)
 Peripheral vascular disease
No		 158 (28.6) 394 (71.4) 0.0005
Yes 1310(36.3) 2303 (63.7)
 Systemic sepsis
No		 1307 (34.6) 2467 (65.4) 0.01
Yes 161 (41.2) 230 (58.8)
 Trauma
No		 1280 (35.9) 2282 (64.1) 0.02
Yes 188 (31.2) 415 (68.8)
Elixhauser comorbidities
 Arrhythmias
No		 1181 (34.0) 2297 (66.0) <.0001
Yes 287 (41.8) 400 (58.2)
 Chronic pulmonary disease
No		 1137 (33.9) 2213 (66.1) 0.0003
Yes 331 (40.6) 484 (59.4)
 Congestive heart failure
No		 1070 (33.2) 2150 (66.8) <.0001
Yes 398 (42.1) 547 (57.9)
 Deficiency anemias
No		 1082 (33.6) 2134 (66.4) <.0001
Yes 386 (40.7) 563 (59.3)
 Drug abuse
No		 1448 (35.6) 2614 (64.4) 0.0007
Yes 20 (19.4) 83 (80.6)
 Fluid and electrolyte disorders
No		 1122 (34.0) 2175 (66.0) 0.001
Yes 346 (39.9) 522 (60.1)
 Hypertension
No		 583 (37.7) 964 (62.3) 0.01
Yes 885 (33.8) 1733 (66.2)
 Other neurological disorders
No		 1410 (34.8) 2647 (65.2) <.0001
Yes 58 (53.7) 50 (46.3)
 Paralysis
No		 1428 (35.7) 2575 (64.3) 0.004
Yes 40 (24.7) 122 (75.3)
 Psychoses
No		 1339 (34.6) 2529 (65.4) 0.002
Yes 129 (43.4) 168 (56.6)
 Renal failure
No		 1167 (34.1) 2253 (65.9) 0.001
Yes 301 (40.4) 444 (59.6)
 Valvular disease
No		 1380 (34.7) 2598 (65.3) 0.0005
Yes 88 (47.1) 99 (52.9)
 Weight loss
No		 1373 (34.7) 2581 (65.3) 0.002
Yes 95 (45.0) 116 (55.0)
Treatment variables
 Procedures
  Active pulmonary pathology
No		 1450 (35.1) 2683 (64.9) 0.01
Yes 18 (56.2) 14 (43.8)
  Acute central nervous disorder
No		 1338 (34.6) 2533 (65.4) 0.0008
Yes 130 (44.2) 164 (55.8)
  Ongoing active cardiac pathology
No		 1284 (34.6) 2426 (65.4) 0.01
Yes 184 (40.4) 271 (59.6)
  Serious nutritional compromise
No		 1389 (34.4) 2643 (65.6) <.0001
Yes 79 (59.4) 54 (40.6)
  Severe renal disease
No		 1309 (34.3) 2510 (65.7) <.0001
Yes 159 (46.0) 187 (54.0)
 ICU admission
No		 864 (32.4) 1803 (67.6) <.0001
Yes 604 (40.3) 894 (59.7)
 Average number of bed sections (SD) 2.4 (1.8) 2.3 (1.7) 0.04
 Average days from hospital admission to surgery (SD) 8.9 (16.3) 7.8 (11.5) 0.02
 Acute postoperative type of rehabilitation <.0001
 No evidence of inpatient rehabilitation 543 (45.6) 649 (54.4)
 Consultative 806 (33.9) 1571 (66.1)
 Specialized 119 (20.0) 477 (80.0)
 Discharge location <.0001
  Home 609 (24.4) 1892 (75.3)
  Extended care 852 (52.1) 782 (47.9)
  Other 7 (23.3) 23 (76.7)
Hospital characteristics <.0001
 Regions
  Northeast 270 (47.4) 300 (52.6)
  Southeast 458 (36.3) 804 (63.7)
  Midwest 219 (28.1) 561 (71.9)
  South central 292 (32.0) 622 (68.0)
  Mountain Pacific 229 (35.8) 410 (64.2)
Open in a new tab

All numbers in the table are frequencies and percentages, unless otherwise indicated. For categorical variables, p-values correspond to the significance of the association between the outpatient rehabilitation service use and the overall variable.

Abbreviations: SD, standard deviation.

Statistical significance was set at p<.05.

Table 4. Cox proportional hazard analysis demonstrating characteristics still associated with the receipt of outpatient services after statistical adjustment.

Characteristics Hazard Ratio 95 % Confidence Interval p-value
Demographic contents
 Every 10 year increase in age 0.83 0.80 - 0.86 <.0001
 Marital Status (ref: being unmarried)
 Married 1.19 1.10 - 1.29 <,0001
 Living location prior to surgical hospitalization (ref: hospital)
  Overall <.0001
  Home 1.09 0.85 - 1.41 0.50
  Extended care 0.41 0.30 - 0.56 <.0001
Level of amputation (ref: unilateral trans-tibial)
 Overall <.0001
 Unilateral trans-femoral 0.88 0.79 - 0.96 0.006
 Bilateral trans-tibial 0.66 0.50 - 0.88 0.005
 Bilateral trans-femoral 0.61 0.48 - 0.77 <.0001
Elixhauser comorbidities
 Congestive heart failure 0.86 0.78 - 0.94 0.002
 Other neurological disorders 0.72 0.55 - 0.96 0.02
 Psychoses 0.75 0.64 - 0.88 0.0003
 Valvular disease 0.81 0.66 -0.99 0.04
 Weight loss 0.82 0.68 - 0.99 0.04
Baseline complexity from surgical stay
 Procedures
 Acute central nervous disorder 0.81 0.69 - 0.95 0.009
 Ongoing active cardiac pathology 0.88 0.77 - 0.99 0.04
 Serious nutritional compromise 0.68 0.51 -0.89 0.005
 Severe renal disease 0.73 0.63 - 0.85 <.0001
Hospital characteristics of early rehabilitation
 Regions (ref: Southeast) <.0001
  Midwest 1.32 1.18 - 1.47 <.0001
  Mountain Pacific 1.06 0.94 - 1.20 0.36
  Northeast 0.73 0.64 - 0.83 <.0001
  South Central 1.09 0.98 - 1.21 0.12
Rehabilitation (ref: specialized)
 Consultative rehabilitation 0.78 0.70 - 0.86 <.0001
 No evidence of inpatient Rehabilitation 0.98 0.76 - 1.27 0.89
Open in a new tab

Compared to the Southeast region of the country, those in the Midwest (HR=1.32, 95% CI, 1.18-1.47) were more likely to receive outpatient rehabilitation services while those in the Northeast (HR=0.73, 95% CI, 0.64-0.83) were less likely.

There was only a single clinical characteristic that violated the proportional hazards assumption. Thus, the HRs for this variable did not remain constant over time (see table 5). Compared to patients discharged to an extended care facility, the likelihood of receiving outpatient rehabilitation services for those discharged home or to a different location were much higher initially but then declined over time. By 180 days post discharge, patients discharged home were less likely to initiate outpatient services and those initially discharged to an extended care facility became more likely to receive outpatient services.

Table 5. Hazards Ratios at Different Time Points for Discharge Location which Violated the Assumption of Proportional Hazards.

Hazard ratio (95%CI)
0 days 90 days 180 days 270 days 365 days
Discharge location from hospital (ref: Extended care)
 Home 3.6
(3.2 –4.1)		 1.3
(1.2 – 1.5)		 0.5
(0.4 – 0.6)		 0.2
(0.1 – 0.3)		 0.06
(0 – 0.1)
 Other 4.5
(2.7 – 7.4)		 0.6
(0.2 – 2.0)		 0.0
(0 – 1.1)		 0
(0 – 0.6)		 0
(0 – 0.3)
Open in a new tab

Discussion

Identification of factors influencing receipt of outpatient rehabilitation services is important for gaining a better understanding of barriers to participation, and hence may enhance survival and quality of remaining life by improving mobility and function1, 5. In this observational study, we found that 65% of veterans with a lower extremity amputation received outpatient rehabilitation services. Similar observations have been found in patients with severe lower-extremity trauma requiring amputation or reconstruction 7. However, the majority of lower-extremity amputations are performed as a result of dysvascular conditions and most patients are elderly with many comorbidities 22 and may have different functional needs from those with traumatic lower extremity amputation.

Our data demonstrates that veterans who were younger and underwent a unilateral trans-tibial amputation were more likely to receive outpatient rehabilitation. These patients usually had less severe comorbidities, might be considered “healthier,” and may be perceived as being more likely to benefit from outpatient services. In contrast, veterans who were older, underwent higher level trans-femoral or bilateral amputations, had more severe comorbidities, and who underwent procedures for complications during their surgical stay were less likely to receive outpatient rehabilitation services. There are several plausible explanations for their decreased participation. First, their functional goals may not be easily met in an outpatient setting or prosthetic prescriptions may not be feasible 15. Second, medical complications and ongoing medical interventions may have interfered or made them less likely to tolerate rehabilitation therapies. Lastly, other barriers may exist, such as difficulty traveling to and from an outpatient rehabilitation program or lack of social supports to assist with getting to outpatient clinics.

Compared to discharge to extended care facilities, discharge to home or a different location are associated with an initial increased likelihood of receiving outpatient services, and then followed by decreased likelihood by 180 days. It is likely that those discharged to home or to other locations begin their outpatient services earlier than those discharged to extended care facilities. The “late onset” service pattern associated with extended care may reflect a lack of caregiver availability to be able to go home to begin with resulting in the extended care stay in the first place. Patients receiving care in a VA extended care setting, such as nursing home or domiciliary, may be discharged to the community at a later time, and then be considered eligible for outpatient rehabilitation after the majority of those discharged directly home have already begun those services.

Being married was associated with increased likelihood of receiving outpatient rehabilitation emphasizing the importance of psychosocial support in improving function following lower-extremity amputation. Married people may be more able to cope with new illness or disability 23, may be more likely to be encouraged by a spouse to utilize rehabilitation services, and may be more likely to have someone to transport them to an outpatient clinic and help them negotiate the visit. Also, married people are more likely to be discharged home and thus may be more eligible for outpatient rehabilitation sooner.

Interestingly, veterans who received only inpatient consultation rehabilitation were less likely to receive outpatient rehabilitation services than those who received care on an SRU. The possible barriers may be associated with their greater illness burden24, which can reduce the likelihood of prosthetic prescription15.

This study showed facility-level differences in the receipt of outpatient rehabilitation. Patients who received care in the Midwest were more likely to receive outpatient rehabilitation services. The reason for the regional difference is unclear, but may be related to differences in rehabilitation care patterns or service availability.

Limitations

This study includes only veterans, a predominantly older, male population, therefore results may not be generalized to the general population or to females. Although our definition of outpatient rehabilitation services is broad, it is likely that some patients might receive only home therapies or receive non-VA rehabilitation services, which the VA datasets would not capture. Vocational rehabilitation and mental health services were not included in this study, but have been considered to be common rehabilitation needs for patients with lower extremity trauma 25. Future research efforts are needed to identify what other types of services patients received.

Conclusions

Both clinical characteristics and types of inpatient rehabilitation received influence receipt of outpatient rehabilitation services following lower extremity amputation in the Veteran population. Geographic location also impacted receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation. Further understanding of these factors that result in variations may lead to improvements in the health care system.

Acknowledgments

Financial Disclosure: We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated AND, if applicable, we certify that all financial and material support for this research (eg, NIH or NHS grants) and work are clearly identified in the title page of the manuscript.

List of Abbreviations

VA

Veterans Affairs

VAMC

Veterans Affairs Medical Center

VHA

Veterans Health Administration

PTF

Patient Treatment Files

BIRLS

Beneficiary Identification Record Locator System

FSOD

Functional Status and Outcomes Database

ICD-9-CM

International Classification of Diseases, 9th Revision, Clinical Modification

CARF

Commission on Accreditation of Rehabilitation Facilities

SRU

Specialized rehabilitation unit

ICU

Intensive care unit

HR

Hazard ratio

CI

Confidence interval

SAS

Statistical analysis software

SD

Standard deviation

AMA

Against medical advice

Footnotes

Device Status Statement: The manuscript submitted does not contain information about medical device(s).

Reprints availability: reprints will not be available from the authors.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  • 1.Cutson TM, Bongiorni DR. Rehabilitation of the older lower limb amputee: a brief review. J Am Geriatr Soc. 1996 Nov;44(11):1388–1393. doi: 10.1111/j.1532-5415.1996.tb01415.x. [DOI] [PubMed] [Google Scholar]
  • 2.Horgan O, MacLachlan M. Psychosocial adjustment to lower-limb amputation: a review. Disabil Rehabil. 2004;26(14-15):837–850. doi: 10.1080/09638280410001708869. Jul 22-Aug 5. [DOI] [PubMed] [Google Scholar]
  • 3.Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil. 2000 Mar;81(3):292–300. doi: 10.1016/s0003-9993(00)90074-1. [DOI] [PubMed] [Google Scholar]
  • 4.Dillingham TR, Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Arch Phys Med Rehabil. 2008 Jun;89(6):1038–1045. doi: 10.1016/j.apmr.2007.11.034. [DOI] [PubMed] [Google Scholar]
  • 5.Stineman MG, Kwong PL, Kurichi JE, et al. 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. Arch Phys Med Rehabil. 2008 Oct;89(10):1863–1872. doi: 10.1016/j.apmr.2008.03.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Kurichi JE, Small DS, Bates BE, et al. Possible incremental benefits of specialized rehabilitation bed units among veterans after lower extremity amputation. Med Care. 2009 Apr;47(4):457–465. doi: 10.1097/MLR.0b013e31818b08c6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Castillo RC, MacKenzie EJ, Webb LX, Bosse MJ, Avery J. Use and perceived need of physical therapy following severe lower-extremity trauma. Arch Phys Med Rehabil. 2005 Sep;86(9):1722–1728. doi: 10.1016/j.apmr.2005.03.005. [DOI] [PubMed] [Google Scholar]
  • 8.Castillo RC, MacKenzie EJ, Archer KR, Bosse MJ, Webb LX. Evidence of beneficial effect of physical therapy after lower-extremity trauma. Arch Phys Med Rehabil. 2008 Oct;89(10):1873–1879. doi: 10.1016/j.apmr.2008.01.032. [DOI] [PubMed] [Google Scholar]
  • 9.Edward J, Hines J. FY2000 VHA Medical SAS Inpatient Datasets. VA Hospital, Hines, IL: Veterans Affairs Information Resource Center; Apr, 2003. VIReC Research User Guide. [Google Scholar]
  • 10.Edward J, Hines J. FY2000 VHA Medical SAS Inpatient Datasets. VA Hospital, Hines, IL: Veterans Affairs Information Resource Center; Jan, 2003. VIReC Research User Guide. [Google Scholar]
  • 11.Kubal JD, W S, Cooper DC, Waight S, Hynes DM. A primer on US mortality databases used in health services research. Vol. 5 Hines, IL: VA Information Resource Center; 2000. [Google Scholar]
  • 12.VHA Office of Information. VHA Corporate Databases Monograph. [Accessed April 18, 2007]; http://vaww4.va.gov/nds/CorporateDatabasesMonograph/Monograph_2008.pdf.
  • 13.Bates B, Stineman MG, Reker DM, Kurichi JE, Kwong PL. Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation. J Rehabil Res Dev. 2006 Nov-Dec;43(7):917–928. doi: 10.1682/jrrd.2006.03.0030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.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? Arch Phys Med Rehabil. 2007 Oct;88(10):1249–1255. doi: 10.1016/j.apmr.2007.06.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Kurichi JE, Kwong PL, Reker DM, Bates BE, Marshall CR, Stineman MG. Clinical factors associated with prescription of a prosthetic limb in elderly veterans. J Am Geriatr Soc. 2007 Jun;55(6):900–906. doi: 10.1111/j.1532-5415.2007.01187.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Kurichi JE, Stineman MG, Kwong PL, Bates BE, Reker DM. Assessing and using comorbidity measures in elderly veterans with lower extremity amputations. Gerontology. 2007;53(5):255–259. doi: 10.1159/000101703. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT, Sangeorzan BJ. Survival following lower-limb amputation in a veteran population. J Rehabil Res Dev. 2001 May-Jun;38(3):341–345. [PubMed] [Google Scholar]
  • 18.McWhinnie DL, Gordon AC, Collin J, Gray DW, Morrison JD. Rehabilitation outcome 5 years after 100 lower-limb amputations. Br J Surg. 1994 Nov;81(11):1596–1599. doi: 10.1002/bjs.1800811110. [DOI] [PubMed] [Google Scholar]
  • 19.Agency for Healthcare Research and Quality. Comorbidity Software 3.1. 2006 http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp#variables.December.
  • 20.Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8–27. doi: 10.1097/00005650-199801000-00004. [DOI] [PubMed] [Google Scholar]
  • 21.Statistical Analysis Software (SAS) [computer program] Version 9.1. Cary, NC: SAS Institute Inc.; 2005. [Google Scholar]
  • 22.Rommers GM, Vos LD, Groothoff JW, Schuiling CH, Eisma WH. Epidemiology of lower limb amputees in the north of The Netherlands: aetiology, discharge destination and prosthetic use. Prosthet Orthot Int. 1997 Aug;21(2):92–99. doi: 10.3109/03093649709164536. [DOI] [PubMed] [Google Scholar]
  • 23.Berg CA, Wiebe DJ, Butner J, et al. Collaborative coping and daily mood in couples dealing with prostate cancer. Psychol Aging. 2008 Sep;23(3):505–516. doi: 10.1037/a0012687. [DOI] [PubMed] [Google Scholar]
  • 24.Bates BE, Kwong PL, Kurichi JE, et al. Factors influencing decisions to admit patients to veterans affairs specialized rehabilitation units after lower-extremity amputation. Arch Phys Med Rehabil. 2009 Dec;90(12):2012–2018. doi: 10.1016/j.apmr.2009.07.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Archer KR, Castillo RC, MacKenzie EJ, Bosse MJ. Perceived need and unmet need for vocational, mental health, and other support services after severe lower-extremity trauma. Arch Phys Med Rehabil. 2010 May;91(5):774–780. doi: 10.1016/j.apmr.2010.01.006. [DOI] [PubMed] [Google Scholar]

RESOURCES