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Factors Associated With Utilization of
Preoperative and Postoperative
Rehabilitation Services by Patients
With Amputation in the VA System:
An Observational Study
Linda J. Resnik, Matthew L. Borgia
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 w^ith 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 w^ith amputations in the acute care
setting.
Post a Rapid Response to
this article at:
ptjournal. apta, org
September 201 3
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Physical Therapy
1197
he Department of Veterans
Affairs (VA) and the Department of Defense (DoD) developed and promulgated evidencebased guidelines to standardize and
improve rehabilitative care of people with lower limb amputations.'
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
Umb 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 foUovsr-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.
1198
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Method
Data Source
Data were obtained from Veterans
Health Administration (VHA) administrative Patient Treatment File (PTF)
databases used to track the health
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1199
1200
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Full Sample:
Incident amputations
2005-2010
Exclude:
Incident amputations in 2008
1
1
preoperative services:
PT
OT
PT/OT
postoperative services:
PT
OT
PT/OT
Figure.
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.
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.
AU of the variables examined, except
sex, cerebral vascular disease, and
income, were signicant 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
September 201 3
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
faure, 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 preopera. tive service receipt and the variable
"discharge bed section" in the models predicting postoperative service
receipt.
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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 6G
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.
Factors Associated With Receipt
of Rehabilitation Services
Multivariable analyses. Results
of the logistic regressions modeling
receipt of preoperative and postoperative rehabitation 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 comor1202
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Categoricai Covariates
N (%)
Age(y)
<45
45-54
1,353(10.7)
55-64
4,943 (39.2)
65-74
2,968 (23.6)
75-84
2,489(19.8)
Elixhausen Index
Income (dollars in thousands)
Categoricai Covariates
N C/o)
Amputation level
166(1.3)
s85
680 (5.4)
Foot/ankle
3,340 (26.5)
Medicine
Below knee
5,032 (39.9)
Cardiology
141 (1.1)
Above or at knee
4,227 (33.6)
Neurology
156(1.2)
Orthopedic
851 (6.8)
Admission source
4,097 (32.5)
Hospital
5,927(47.1)
Other
Nursing
1,136(9.0)
Podiatry
399 (3.2)
Community
5,524 (43.9)
Surgery
3,812(30.3)
Vascular
3,094 (24.6)
Marital status
Single
1,804(14.3)
49 (0.4)
Divorced
3,501 (27.8)
Medicine
Married
4,999 (39.7)
Cardiology
3,377 (26.8)
127(1.0)
Unknown
1,006(8.0)
Neurology
182(1.4)
Widowed
1,289(10.2)
Orthopedic
815(6.5)
Sex
Other
Male
12,467(99.0)
Podiatry
Female
Rehabilitation
132(1.1)
Race
3,396 (27.0)
Vascular
3,461 (27.5)
7,492(59.5)
Black
2,928 (23.2)
Preoperative PT
158(1.3)
Preoperative OT
Unknown
2,021 (16.0)
Comorbidities
CHF
1,906(15.1)
PVD
7,472 (59.3)
Paralysis
Other neurological disease
729 (5.8)
573 (4.6)
Diabetes
8,268 (65.6)
Renal failure
2,606 (20.7)
142(1.1)
Region
865 (6.9)
Surgery
White
Other
42 (0.3)
334 (2.7)
1,532(12.2)
617(4.9)
1,710(13.6)
Postoperative PT
6,373 (50.6)
Postoperative OT
4,009(31.8)
6,936(55.1)
Year.
Before 2008
6,376 (60.4)
After 2008
4,180(39.6)
Bed size
<126
4,087 (32.4)
127-244
4,564 (36.2)
South
5,048(40.1)
245-362
3,243 (25.7)
Northeast
2,279(18.1)
>362
Upper Midwest
2,696(21.4)
West
2,576 (20.5)
705 (5.6)
CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational therapy.
September 201 3
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1203
1.02(1.01-1.02)*
1.01 (1.01-1.01)*
1.02(1.01-1.02)*
Elixhausen Index
1.06(1.00-1.11)*
1.15(1.06-1.24)*
1.07(1.01-1.12)*
Age(y)
55-64 (reO
<45
0.47 (0.23-0.98)*
0.52(0.19-1.43)
0.52(0.27-1.01)
45-54
0.95(0.78-1.16)
0.70(0.50-0.97)*
0.94(0.78-1.14)
65-74
1.12(0.97-1.30)
1.14(0.92-1.41)
1.11 (0.96-1.27)
75-84
1.14(0.98-1.34)
1.14(0.90-1.44)
1.16(1.00-1.35)*
85
1.00(0.76-1.32)
0.89(0.58-1.37)
0.91 (0.27-:1.01)
Admission source
Hospital (ref)
Nursing
0.84 (0.67-1.04)
0.99(0.72-1.34)
0.91 (0.74-1.12)
Community
0.97 (0.86-1.09)
0.96(0.80^1.15)
0.96 (0.85-1.07)
Below knee
1.02(0.88-1.17)
1.19(0.96-1.48)
1.03(0.90-1.18)
Above or at knee
0.98 (0.98-0.84)
1.03(0.81-1.31)
0.99(0.86-1.16)
Amputation level
Foot/ankle (ref)
Marital status
Single (ref)
Divorced
0.93(0.78-1.11)
0.91 (0.70-1.18)
0.95(0.80-1.12)
Married
0.90(0.76-1.06)
0.93(0.72-1.20)
0.93(0.79-1.10)
Unknown
0.41 (0.30-0.56)*
0.46 (0.29-0.73)*
0.39 (0.29-0.52)*
Widowed
0.93(0.74-1.17)
1.00(0.72-1.40)
0.96(0.77-1.19)
0.93(0.51-0.72)
1.47(0.68-3.21)
0.91 (0.51-1.64)
Black
1.02(0.87-1.20)
1.10(0.87-1.39)
1.03(0.88-1.19)
Other
1.01 (0.58-1.76)
1.54(0.78-3.02)
1.02(0.60-1.73)
Unknown
1.07(0.94-1.21)
0.90(0.73-1.09)
1.06(0.94-1.19)
HF
1.00(0.85-0.17)
0.80(0.63-1.01)
0.95(0.81-1.11)
PVD
1.09 (0.96-1.25)
1.00(0.82-1.22)
1.08(0.95-1.23)
Paralysis
1.10(0.85-1.17)
1.22(0.85-1.74)
1.05(0.81-1.35)
0.74 (0.55-0.99)*
0.79(0.52-1.19)
0.83 (0.63-1.08)
Diabetes
0.91 (0.80-1.04)
0.88(0.72-1.08)
0.94 (0.82-1.06)
Renal failure
0.98(0.84-1.14)
0.89(0.71-1.11)
0.92(0.79-1.06)
Northeast
0.67 (0.56-0.80)*
0.69 (0.52-0.92)^
0.63 (0.53-0.74)*
Upper Midwest
1.21 (1.04-1.42)*
1.35(1.07-1.71)*
1.17(1.00-1.35)*
West
1.32(1.13-1.54)*
1.40(1.12-1.77)+
1.25(1.07-1.45)t
Sex
Male (ref)
Female
Race
White (reO
Comorbidities
Region
South (ref)
(Continued)
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September 201 3
Bed size
sl26(ref)
127-244
1.11 (0.98-1.27)
1.49(1.22-1.82)*
1.20(1.06-1.36)'
245-362
0.52 (0.43-0.62)*
0.79(0.60-1.02)
0.53 (0.44-0.62)*
>362
0.92(0.70-1.21)
0.80(0.50-1.28)
0.98(0.75-1.26)
Cardiology
0.82(0.50-1.36)
0.38(0.14-1.05)
0.81 (0.50-1.30)
Neurology
0.31 (0.17-0.58)*
0.47(0.22-1.01)
0.35(0.19-0.63)
Orthopedic
0.44 (0.32-0.60)*
0.57 (0.38-0.86)+
0.44 (0.33-0.59)*
Other
1.17(0.57-2.39)
3.20(1.56-6.57)'
1.62(0.84-3.10)*
Podiatry
0.75(0.55-1.03)
0.59 (0.36-0.97)*
0.71 (0.52-0.96)*
Surgery
0.65 (0.56-0.75)*
0.55 (0.44-0.68)*
0.62(0.54-0.71)*
Vascular
0.63 (0.54-0.74)*
0.47 (0.37-0.60)*
0.61 (0.52-0.70)*
0.08
0.07
0.09
Max-rescaled R^ (Nagelkerke)
OR=odds ratio, 95% Cl=95% confidence interval, CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational
therapy, ref=reference. *P<.05, 'P<.01, *P<.001.
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,' a publication meant to improve qualit)' 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
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1205
1.01 (1.00-1.01)*
1.01 (1.00-1.01)*
1.01 (1.01-1.01)*
Elixhausen Index
1.11 (1.07-1.50)*
1.04 (1.00-1.08)*
1.10(1.06-1.14)*
<45
0.99(0.70-1.38)
0.86 (0.60-1.22)
1.07(0.76-1.51)
45-54
1.03(0.90-1.17)
0.88(0.77-1.01)
1.01 (0.89-1.15)
65-74
0.97(0.88-1.07)
0.94(0.85-1.04)
0.97 (0.88-1.08)
75-84
0.91 (0.81-1.01)
0.82 (0.73-0.92)*
0.87(0.78-0.97)*
85
0.83 (0.70-0.99)*
0.71 (0.58-0.86)*
0.77(0.64-0.91)+
Nursing
0.58 (0.50-0.66)*
0.50 (0.43-0.59)*
0.54 (0.48-0.63)*
Community
1.16(1.07-1.26)*
1.01 (0.92-1.09)
1.11 (1.02-1.20)*
Below knee
1.59(1.44-1.75)*
2.13(1.92-2.38)*
1.74(1.58-1.92)*
Above or at knee
1.24(1.12-1.38)*
1.67(1.48-1.88)*
1.34(1.20-1.49)*
Age(y)
55-64 (reO
Admission source
Hospital (ref)
Amputation level
Foot/ankle (ref)
Marital status
Single (reO
Divorced
0.96 (0.85-1.08)
0.93(0.81-1.05)
0.96 (0.85-1.08)
Married
0.96 (0.86-1.08)
0.98(0.87-1.11)
0.96 (0.85-1.08)
Unknown
0.31 (0.26-0.37)*
0.34 (0.28-0.42)*
0.27 (0.22-0.32)*
Widowed
0.87(0.74-1.02)
0.85(0.71-1.00)
0.87(0.75-1.03)
0.74(0.51-1.08)
0.85 (0.56-1.27)
0.80(0.55-1.16)
Sex
Male (ref)
Female
Race
White (ref)
Black
1.16(1.04-1.29)+
1.36(1.21-1.51)*
1.26(1.14-1.41)*
Other
0.72(0.49-1.06)
0.96(0.64-1.44)
0.89(0.60-1.30)
Unknown
1.11 (1.02-1.21)*
0.98 (0.89-1.07)
1.05(0.96-1.14)
CHF
0.89 (0.79-0.99)*
1.18(1.05-1.32)*
0.94 (0.84-1.05)
PVD
1.10(1.00-1.20)*
1.09(0.99-1.20)
1.07(0.98-1.18)
Paralysis
0.75(0.62-0.91)+
0.92(0.75-1.12)
0.77(0.64-0.93)+
0.82 (0.68-0.99)*
0.91 (0.75-1.11)
0.90(0.75-1.09)
Diabetes
0.92(0.84-1.01)
0.96 (0.87-1.05)
0.91 (0.83-0.99)
Renal failure
0.81 (0.74-0.90)*
0.93 (0.83-1.04)
0.81 (0.73-0.91)*
Northeast
0.50 (0.45-.56)*
0.42 (0.37-0.48)*
0.43 (0.38-0.48)*
Upper Midwest
1.28(1.15-1.43)*
1.05(0.94-1.18)
1.24(1.11-1.39)*
West
1.54(1.38-1.71)*
1.05(0.94-1.18)
1.43(1.28-1.59)*
Comorbidities
Region
South (ref)
(Continued)
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PT, OR ( 9 5 % Ci)
OT, OR ( 9 5 % Ci)
Bed size
s i 26 (reO
127-244
1.38(1.26-1.52)*
1.16(1.05-1.28)f
1.41 (1.28-1.54)*
245-362
0.64 (0.67-0.72)*
1.03(0.91-1.16)
0.76 (0.68-0.85)*
>362
2.10(1.74-2.54)*
0.63(0.51-0.78)*
2.02 (1.66-2.45)*
Cardiology
0.84(0.58-1.23)
0.86(0.57-1.30)
0.83(0.57-1.20)
Neurology
0.37 (0.24-0.57)*
0.40 (0.25-0.64)*
0.35 (0.23-0.53)*
Orthopedic
2.08(1.75-2.48)*
1.67 (1.40-1.99)*
1.95(1.63-2.32)*
Other
1.00(0.53-1.91)
1.31 (0.67-2.53)
1.14(0.59-2.20)
Podiatry
0.80 (0.62-1.02)
0.47 (0.32-0.68)*
0.78(0.61-1.01)
Rehabilitation
2.32(1.95-2.76)*
2.92 (2.47-3.45)*
2.35(1.97-2.82)*
Surgery
1.48(1.33-1.65)*
1.37(1.22-1.54)*
1.52(1.36-1.69)*
Vascular
1.28(1.15-1.42)*
1.21 (1.08-1.35)'
1.31 (1.18-1.45)*
0.15
0.13
0.16
Max-rescaled R^ (Nagelkerke)
OR=odds ratio, 95% Cl=95% confidence interval, CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational
therapy, ref = reference. *P<.05, 'P<.01, *P<.001.
Table 4.
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)
OR ( 9 5 % Ci)
Services
Preoperative PT
1.45(1.27-1.65)**
Preoperative OT
1.72(1.41-2.10)**
1.45 (1.28-1.65)* *
Postoperative PT
1.68(1.53-1.84)*-*
Postoperative OT
1.79(1.63-1.97)**
1.72(1.57-1.89)*-*
OR=odds ratio, 95% Cl=95% confidence interval, PT=physical therapy, OT=occupational therapy.
* Results of separate models controlling for length of stay, Elixhausen Index, inconne, age, amputation
level, admission source before hospitalization, marital status, sex, race, congestive heart failure,
peripheral vascular disease, paralysis, other neurological disorders, diabetes, renal failure, hospital
region, and hospital bed size. Admitting bed section was included in models predicting preoperative
service receipt, and discharge bed section was included In the models predicting postoperative service
receipt. * P<.001.
i
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1207
OT
Any Tiierapy
Before 2008
After 2008
Before 2008
After 2008
Before 2008
After 2008
OR (95% CI)
OR (95% Cl)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% Ci)
Northeast
0.76(0.58-0.99)*
0.67 (0.50-0.90)+
0.74(0.48-1.14)
0.68(0.43-1.07)
0.72 (0.55-0.92)*
0.61 (0.46-0.81)*
Upper Midwest
1.58(1.25-2.01)*
1.11 (0.86-1.43)
1.52(1.04-2.23)*
1.36(0.95-1.95)
1.51 (1.20-1.90)*
1.04(0.82-1.33)
West
1.38(1.09-1.76)+
1.43(1.11-1.84)+
1.78(1.25-2.55)+
1.32(0.92-1.90)
1.36(1.09-1.72)+
1.28(1.01-1.64)*
Region
South (reO
Postoperative Services
PT
Region
OT
PT/OT
Before 2008
After 2008
Before 2008
After 2008
Before 2008
After 2008
OR (95% Ci)
OR (95% CI)
OR (95% CI)
OR (95% Ci)
OR (95% Ci)
OR (95% Ci)
South (ref)
Northeast
0.69(0.59-0.81)*
0.36 (0.30-0.45)*
0.57 (0.48-0.68)*
0.35 (0.28-0.43)*
0.62 (0.53-0.72)*
0.30 (0.24-0.36)*
Upper Midwest
1.72(1.47-2.01)*
0.94(0.77-1.15)
1.16(0.98-1.38)
0.96(0.79-1.16)
1.65(1.41-1.94)*
0.88(0.72-1.07)
West
1.53(1.31-1.78)*
1.69(1.39-2.06)*
1.07(0.90-1.26)
1.20(0.99-1.45)
1.37(1.17-1.59)*
1.57(1.28-1.93)*
'OR=odds ratio, 95% Cl=95% confidence interval, PT=physical therapy, OT=occupational therapy. *P<.05, +P<.01, *P<.001.
Physical Therapy
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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 w^e had no relationship to
the w^ork group that developed the
guidelines, we had limited information on how they were disseminated.
The VA has an office of quality management that disseminates evidencebased guidelines for all types of conditions.' 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, l6% of patients
had this information missing, threatening the validity of the findings
about the relationship between
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Conclusions and
Implications
This study described the use of rehabilitation services prior to and following lower Umb 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
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Physical Therapy
Volume 93
Number 9
September 2013
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