factors associated with utilization of preoperative and postop rehab services by patietns with...

7/23/2019 Factors Associated With Utilization of Preoperative and Postop Rehab Services by Patietns With Amputation in the

1/15

Military Rehabilitation

Special Issue

Factors Associated W ith Utilization of

Preoperative and Postoperative

Rehabilitation Services by Patients

W ith Amputation in the VA System:

An Observational Study

LindaJ.Resnik, Matth ew L. Borgia

Ba ck g r o u nd

The Department of Veterans Affairs (VA) and the Department of

Defense published evidence-based guidelines to standardize and improve rehabilita-,

tion of veterans with lower limb amputations; however, no studies have examined

the guidelines impact.

Obj e c t i v e s 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 guide-

lines on service receipt.

De s i g n Across-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 Admin-

istration databases.

Me t h o d s

Rehabilitation services were categorized as physical therapy, occupa-

tional therapy, and either (any therapy), before or after amputation. Separate multi-

variate logistic regressions examined the impact of guideline implementation and

identified factors associated with service receipt.

Resu l t s 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.

Limi ta t i on s

The sample included only veterans wh o had surgeries atVA Medical

Centers and cannot be generalized to veterans with surgeries outside the VA or to

nonveteran patients and settings.

Con c l u s i o n s Further quality improvement efforts are needed to standardize

delivery of rehabilitation services for veterans w^ith amputations in the acute care

setting.

L.). Resnik, PT, PhD, Center

for Gerontology and Health Care

Research, Brown University, 2

Stimson Ave, Providence, Rl

02912 US A). Address all cor-

respondence to Dr Resnik at:

[email protected].

M.L. Borgia, AM, Department of

Veterans Affairs-Research, Provi-

dence, Rhode Island.

[ResnikL), Borgia M L. Factors asso-

ciated with utilization of preoper-

ative and postoperative rehabilita-

tion services by patients with

amputation in the VA system: an

observational study. hy s

Ther

2013;93:1197-1210.]

2013 American Physical Therapy

Association

Published Ahead of Print:

May 2 , 2013

Accep ted: April 26, 2013

S ubmitted: October 0, 2012

Post a Rapid Response to

this article at:

ptjournal. apta org

September 2013

Volume 93 Nu mber 9 Physical Therapy 1197


2/15

utilization of Rehabilitation Services by Patients With Amputation in the VA System

T

he Department of Veterans

Affairs (VA) and the Depart-

ment of Defense (DoD) devel-

oped and promulgated evidence-

based guidelines to standardize and

improve rehabilitative care of peo-

ple with lower limb amputations.'

The guidelines, published in 2007,

build upon the scientific literature

demonstrating the effectiveness of

both inpatient and outpatient reha-

bilitative 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) prepros-

thetic, (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 con-

sulted 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 com-

prehensive interdisciplinary baseline

assessment of the patient's status

should be conducted, and appro-

priate rehabilitation interventions

should be initiated to maximize the

patient's physical function before

surgery. 1 Rehabilitative services

focus on mobility of other limbs

Available With

This Article at

ptjournal.apta.org

' Listen to a special

Craikcast

on

the Military Rehabilitation Special

Issue with editors John Childs and

Alice Aiken.

Audio Podcast Advancing the

Evidence Base in Rehabilitation

for Military Personnel and

Veterans symposium recorded at

APTA Conference 2013, )une 28,

2013, in Salt Lake City, Utah.

that are not at risk for amputation,

as well as maintaining full motion

of the most proximal joints.^ Pre-

operative rehabilitative services may

include physical function assess-

ment and therapeutic exercise for

strengthening, range of motion

(ROM) and balance, mobility train-

ing, patient education about pros-

thetic options, and establishing a

home exercise program. Interven-

tions during the acute postoperative

phase that should be initiated as tol-

erated include: ROM, strengthen-

ing, positioning, balance exercises,

mobility activities as tolerated, and

training in activities of daily living

and patient education.' Activities in

the preprosthetic phase include

ROM and therapeutic exercise, bal-

ance activities, progressing gait activ-

ities, functional training, and training

in use of assistive de vices.' The pros-

thetic training phase includes con-

tinued ROM, therapeutic exercise

progression and balance, gait and

transfer training with and without

the^ prosthesis, p atient education,

vocational and recreational training,

and assistive device training.' Inter-

ventions commonly included in

long-term foUow^-up include reassess-

ment of balance and gait, review and

adjustment of

ROM

and home main-

tenance program, education about

injury prevention and energy conser-

vation, and provision of and training

with appropriate assistive devices.'

Postoperative rehabilitation involves

the 4 remaining phases and may

occur in numerous settings begin-

ning 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.'

Specialized inpatient reha-

bilitation is the most intensive,

involving at least 3 hours a day of

rehabilitation services consisting of

at least 2 different types of ther-

apy (such as physical therapy and

occupational therapy). Specialized

inpatient rehabilitation is provided

in Commission on Accreditation of

Rehabilitation Facilities (CARF)-

accredited facilities that have desig-

nated rehabilitation beds. These

facilities are called specialized reha-

bilitation units (SRUs) within the

V

system of care and inpatient rehabil-

itation facilities (IRFs) outside of the

VA. In contrast, rehabilitation in the

acute care setting occurs on general

hospital units, has no required mini-

mum, 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 reha-

bilitative 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 assess-

ment, 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 ther-

apy involves learning adaptive tech-

niques to complete activities of

daily living, establishing equipment

needs,

and prom otion of safety (such

as fall prevention). Prosthetic ser-

vices include advising about pros-

thetic components and managing

problems such as skin breakdown

and other complications resulting

from prosthetic use; fitting and fab-

ricating the prosthetic socket; and

delivering, fitting, and repairing

prosthetic componentry.

Are Patients Receiving

Rehabilitation Services?

Although efforts to improve the qual-

ity of rehabilitation services for vet-

erans and military service members

have been under w^ay for the past

decade, few studies have reported

1198 Physical Therapy Volume 93 Num ber 9

September 2013


3/15

Utilization of Rehabilitation Services by Patients With Amputation in the VA System

on w^hether people with lower limb

amputa t ions rece ive recommended

reha bilitativ e services.^ * A lthou gh

some studies have examined receipt

of rehabilitation in settings outsid e of

the VA,5- the bulk of resea rch on

this topic has been performed using

VA data from p eop le with incident

ampu tations betrween the years 2002

and 2004, and most of the research

focused on the receipt of specialized

inpatient rehabilitation.5'' '^-'

Using data from 2002 to 2004, Stine-

man et aP and Bates et al' ' rep ort ed

that

73%

ofV patients with surgical

amputations at the transtibial, trans-

femoral, and hip disarticulation level

received some type of inpatient reha-

bilitation, either acute postoperative

rehabilitation services (wliich they

called consultative rehabilitation )

or care on SRUs eithe r at the h ospital

or after discharge. Some evidence

suggests that referral and timing of

referral for SRU care was not deter-

mined by patient needs alone but

also influenced by facility-level fac-

tors such as co-location of an SRU

w^ithin the hospital, geographic

region, and hospital bed s iz e. '^

Zhou et

al *

rep orted that 65% of vet-

erans 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 receiv-

ing outpatient rehabilitation decreased

by 17% . In addition, patients w ith

transfemoral or buateral amputations

and patients with serious comorbidi-

ties were less likely to receive outpa-

tient rehabilitative services following

lower Hmb am putation.''

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 peo ple

with amputation at the foot level. To

our knowledge, no studies have

been conducted us ing more recent

VA data; thus, there is no way to

evaluate whether patterns of care

in the VA have chang ed over time.

No prior study has exam ined the fac-

tors 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 presurgi-

cal rehabilitation services. To our

knowledge, there has been no previ-

ous 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 . There-

fore, 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 under-

went 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 rehabilita-

tion services, and (3) to examine

whether prevalence of rehabilitative

services has changed since the intro-

duction o fthe VA/DoD rehabilitation

guidelines. Although we initially were

interested in including prosthetic ser-

vices in our study, we chose no t to do

so whe n w e discovered that these ser-

vices are not cod ed consistently in th e

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) admin-

istrative Patient Tr eatm ent File (PTF)

databases used to track the health

care utilization of veterans. The PTF

is a National Data Extract that con-

tains inpatient serv ices . The data-

bases included 4 Acute Care Inpa-

tient Medical SAS (MedSAS) datasets

and the Inpatient Encounters Medi-

cal SAS datasets files. The 4 Acute

Care MedSAS datasets used were

the main dataset, which contained

information on demographics, diag-

noses, 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 con-

tained the procedure codes per-

formed during the inpatient stay; and

the surgery dataset, which contained

aU surgical proce du re codes. The

inpatient encounters dataset con-

tained records of blable profes-

sional services received by patients

during their inpatient stay. All data-

sets used in this study shared a

common patient identifier, which

allowed linkage of records from the

different datasets.

Sample

Patients were included if they under-

went a major surgical amputation of

the lower limb at any VA medical

center from January 1, 2005, to

December 31, 2010. Major lower

Umb 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 procedu re codes

and classified as foot/ankle (8412-

8414), below knee (8415), and above

or at knee (84l6, 8417). Cases that

involved only toe amputations were

excluded due to their lower severity,

and cases involving disarticulation of

the hip or abdominopelvic amputa-

tion were excluded due to their low

frequency of occurrence.

In keeping with methods used in

prior research,31'' we utilized a

12-month look-back period to en sure

that the sample would consist of

people with first-time amputations

September

2 1

Volume 9 Num ber 9 Physical Therapy

1199


4/15


only. Thus, we obtained data dating

back to 2004 and looked back to

determine whether there was a

record of prior lower limb amputa-

tion. Once an amputation incident

was identified from the surgical data,

the PTF main data from that hospi-

talization episode were extracted.

Any inpatient encounters data that

occurred between the hospitaliza-

tion's admission date and discharge

date also wêre extracted. The 12-

month look-back criteria were met

by 12,599 patients.

Key Variables

Rehabilitation services The receipt

of rehabilitation services was identi-

fied using both the acu te PTF proce-

dure data and the PTF inpatient

enc ou nte rs d ata. We classified type .

of rehabilitative service as: (1) phys-

ical therapy, (2) occupational ther-

apy, and (3) receipt of either physi-

cal therapy or occupational therapy

(any therapy). We wanted to exam-

ine receipt of each of these types of

care because of their different, yet

sometimes overlapping, roles.

Receipt of rehabilitation services

was identified by satisf>'ing one of

the followîng criteria: (1) presence

of inpatient procedure data for any

of the following International Classi-

fication of Diseases (ICD-9) proce-

dure codes : physica l therapy=9301,

9304-9325,9327,9338, 9339 , 9356 ,

9357,

9385, or 9389; occupational

therapy=9383; or (2) having inpa-

tient 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 sur-

gery, we categorized all services as

occurring either before or after the

surgical amputation. Postsurgical

rehabilitation wa s defined as ser-

vices received after the date of the

surgical amputation but before dis-

charge from the acute care hospital

or transfer to an inpatient rehabilita-

tion bed wîthin the same hospital.

Covariates We adjusted for

patient demographics and other

characteristics such as living arrange-

ment prior to hospitalization and

comorbidities that we hypothesized

would be associated wîth rehabilita-

tion service use. We also adjusted for

facility characteristics that might be

associated with differences in ser-

vice utilization, including geo-

graphic region and bed size.

Demographic data collected included

age, sex, income, length of stay, mari-

tal 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,

5 5-6A

65-74,

7 5 -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

enc oun ters 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

kno wn problem in VA data after

2003, ' ^

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

num ber of patients with missing race

information from 38% to l6% .

We categorized admission source

prior to hospitalization for ampu-

tation 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 vers ion 3 7 for years 20 08 -

2010), which uses the ICD-9 diag-

nosis codes listed in the main PTF

dataset and calculates a total num-

ber of comorbidities. '^ The comor-

bidities included in the Elixhausen

Index are: peripheral vascular dis-

ease,

hypertension, paralysis, neuro-

logical disorders, chronic pulmo-

nary disease, diabetes with chronic

complications, diabetes without

chronic complications, hypothyroid-

ism, renal failure, liver disease, pep-

tic ulcer disease, acquired immune

deficiency syndrome, lymphoma, met-

astatic cancer, solid tumor without

metastasis, rheumatoid arthri-

tis,coagulopathy, obesity, weight loss,

fluid and electrolyte disorder, chronic

blood loss anemia, deficiency anemia,

alcohol abuse, drug abuse, psychoses,

and d epression . In this calculation, dia-

betes with comp lications and d iabetes

without complications were counted

only once; similarly, only metastatic

cancer and solid tum or witho ut metas-

tasis 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.'*'^ ' These

conditions included congestive heart

failure, peripheral vascular disease,

paralysis, other neurological disor-

ders,

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.

12 Physical Therapy Volum e 93 Num ber 9

September 2 13


5/15


Our analyses also included admission

and discharge bed section. Bed sec-

tion refers to specialty of the admit-

ting physician. Admitting bed sec-

tions were classified as medicine,

cardiology, neurology, orthopedic,

other podiatry, surgery, or vascular.

Discharge bed sections we re classified

as medicine, cardiology, neurology,

orthopedic, other podiatry, rehabilita-

tion, surgery, or vascular. We were

unable to use the category of rehabil-

itation 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) '^ and hospital

bed size, classied as ^126 beds ,

127 to 244 beds, 245 to 362 beds,

and >362

Statistics

Descriptive analyses We exam-

ined descriptive statistics for the

entire sample and calculated the per-

centage of patients who received

physical therapy, occupational ther-

apy, 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

rehabil i tat ion Bivariate analyses

t tests for continuous covariates and

chi-square tests for categorical cova-

riates) were used to compare char-

acteristics of those who had received

and those who had not received ser-

vices before surgery and those who

had received and those who had

not received services after surgery.

of the variables examined, exce pt

sex, cerebral vascular disease, and

income, were signicant factors of in

least 1 of the 6 dependent variables.

Separate multivariate logistic regres-

sion models using all of the signifi-

cant factors identified in the bivari-

ate analyses, as well as sex, were

created to examine rehabilitation

Full Sample:

Incident amputations

2005-2010

r

Sample to Examine Impact

of Guidelines:

Incident amputations before 2008

Incident amputations after 2008

3 Logistic Regression Models

preoperative services:

PT

OT

PT/OT

Exclude:

Incident amputations in 2008

3 Logistic Regression Models

postoperative services:

PT

OT

PT/OT

Figure.

Flow of participants into logistic regression m odels exam ining impact of guidelines on

receipt of rehabilitative services in the acute care setting. PT=physical therapy

OT=occupational therapy.

receipt before and after the amputa-

tion. Three models were created

for presurgical rehabilitation: (1) any

physical therapy, (2) any occupa-

tional therapy, and (3) any therapy.

Similarly, 3 separate models were

created for postsurgical rehabilita-

tion. These models included the

length of stay, number of comor-

bidities as measured by Elixhausen

Index, income, age, amputation

level, admission source before hos-

pitalization, marital status, sex, race,

comorbidities (congestive heart

faure, peripheral vascular disease,

paralysis, other neurological disor-

ders, diabetes [with or without

chronic complications], and renal

failure), and the facility-level vari-

ables hospital region and hospital

bed size. Additionally, w e included

the variable admitting bed section

in the models predicting preopera-

. tive service receipt and th e variable

discharge bed section in the mod-

els 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 dichoto-

mously as 2005 to 2007 or 2009 to

2010 on receipt of any (or service

specific) preoperative or postopera-

tive rehabilitation services (Figure),

controlling for all of the case-mix

covariates in the original full mod els.

We eliminated 2008 from this analy-

sis because we expected that major

efforts to disseminate the guide-

lines occurred in the year after

publication and that patterns of

practice change would not be evi-

dence during that year. These mod-

els contro lled for all factors includ ed

in our full models: age, Elixhausen

Index, length of stay, admission

source before hospitalization, ampu-

tation level, marital status, sex, race,

comorbidities, region, bed size, and

September

2 1

3

Volume 93 Num ber 9 Physical Therapy

1201


6/15


bed section (either admitting or

discharge).

Because prior researchers reported

geographic variation in receipt of

rehabilitation care for SR Us , '^

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 receiv-

ing a service in one region compared

witli the odds of receiving services in

another region using separate logistic

regression for services received before

2008 and after 2008.

sults

There were 12,599 veterans with an

incident lower limb amputation

from 200 5 to 2010. Characteristics of

these patients are shown in Table 1.

The mean age of the group was6G

years. The sample was 99% male,

47% were admitted from a hospital,

9% we re adm itted from a nursing

facility, and 43.9% w ere adm itted

from the community. The average

length of acute care hospital stay was

19.2 days. The most com mon comor-

bid conditions were peripheral vas-

cular disease (60%) and diabetes

{66 ). Forty percent of the ampu-

tation surgeries in our sample

occurred at southern hospitals com-

pared w ith 18% in the No rtheast,

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 post-

operative rehabitation services are

shown in Tables 2 and 3, respec-

tively. For each additional day of hos-

pitalization, 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 comor-

bidity, the odds of receipt of any

preoperative physical therapy were

1.06 times hig her, th e odd s of receiv-

ing preoperative occupational ther-

apy were 1.15 times higher, and the

odds of receiving any therapy were

1.07 times higher. The odds of

receiving preoperative physical ther-

apy for patients under 45 years of

age were 0.47 compared w^ith

patients aged 55 to

A

years. Hospital

bed size was associated with receipt

of all types of services, but the pat-

tern of relationship was not clear.

Admitting bed section was related to

service receipt, with patients admitted

to neurology, orthopedics, surgery, or

vascular sections having significandy

lower odds of receiving physical tlier-

apy and those admitted to ortho pedic,

podiatry, surgery, or vascular sections

having lower odds of receiving occu-

pational therapy compared with those

admitted to medicine.

Patients who had their surgeries in

the Northeast had 0.67, 0.69, and

0.63 the odd s receiving any preoper-

ative 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 ther-

apy, 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 ther-

apy, and any therapy, respectively,

compared with those in the South.

For each additional day of hospital-

ization, 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. P atients adm itted

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 ther-

apy, and 0.54 times the odds of receiv-

ing 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 occu-

pational therapy services compared

with those with foot or ankle amputa-

tion. Black patien ts had 1.16 times t he

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, o r renal failure had

lower od ds of receiving any po stoper-

ative physical therapy, whereas those

with congestive heart failure had

higher odd s of receiving occupational

therapy.

Substantial regional variation in

receipt of postoperative rehabilita-

tion services w^as observed. Patients

wh o had th eir surgeries in the North-

east had 0.50, 0.42, and 0.43 the

odds of receiving any postopera-

tive 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

12 2 Physical Therapy Volume 93 Num ber 9

September 2 13


7/15


Table 1 .

Characteristics of Patients With Incident Amputations, 2005-2010 (N=12,599)

Continuous Covar iates

Length

of stay (d)

Hospital

days prior to surgery

Hospitaldays after surgery

Elixhausen

Index

Income

(dollars in thousands)

Categoricai Covariates

Amputat ion

level

Foot/ankle

Belowknee

Above

or at knee

Admission

source

Hospital

Nursing

Communi ty

Mari tal

status

Single

Divorced

Married

Unknown

Widowed

Sex

Male

Female

Race

White

Black

Other

Unknown

Comorbidi ties

CHF

PVD

Paralysis

Other

neurological disease

Diabetes

Renalfailure

Cerebral

vascular disease

Region

South

Northeast

Upper

Midwest

West

iVIean SD) [Median]

19.2 (26.4) [13.0]

7.0 (15.7) [3.0]

12.3 (17.5) [8.0]

3.2 (1.5) [3.0]

20.7 (32.5) [14.6]

N C/o)

3,340

(26.5)

5,032

(39.9)

4,227 (33.6)

5,927(47.1)

1,136 9.0

5,524(43.9)

1,804 14.3

3,501 (27.8)

4,999 (39.7)

1,006 8.0

1,289 10.2

12,467(99.0)

132(1.1)

7,492(59.5)

2,928 (23.2)

158(1.3)

2,021 (16.0)

1,906 15.1

7,472

(59.3)

729 (5.8)

573 (4.6)

8,268

(65.6)

2,606 (20.7)

142(1.1)

5,048(40.1)

2,279(18.1)

2,696(21.4)

2,576 (20.5)

Categoricai Covariates

Age(y)


8/15


Table 2.

Logistic Regression Models Predicting Preoperative Rehabilitation Receipt (n=12,587)

Variable

Lengthof stay (d)

Elixhausen

Index

Age y

55 -64(reO


9/15


Table 2.

Continued

Variable

Bed

size

sl26(ref)

127-244

245-362

>362

Admission

bed

section

Medicine

(ref)

Cardiology

Neurology

Orthopedic

Other

Podiatry

Surgery

Vascular

Max-rescaled

R^

(Nagelkerke)

PT, OR

9SO/O

Ci )

1.11

(0.98-1.27)

0.52

(0.43-0.62)*

0.92(0.70-1.21)

0.82(0.50-1.36)

0.31

(0.17-0.58)*

0.44 (0.32-0.60)*

1.17(0.57-2.39)

0.75(0.55-1.03)

0.65 (0.56-0.75)*

0.63

(0.54-0.74)*

0.08

OT, OR (9 5 Ci)

1.49(1.22-1.82)*

0.79(0.60-1.02)

0.80(0.50-1.28)

0.38(0.14-1.05)

0.47(0.22-1.01)

0.57

(0.38-0.86)+

3.20(1.56-6.57)

0.59

(0.36-0.97)*

0.55 (0.44-0.68)*

0.47

(0.37-0.60)*

0.07

Any Tiierapy OR (9 5 Ci)

1.20(1.06-1.36)

0.53

(0.44-0.62)*

0.98(0.75-1.26)

0.81

(0.50-1.30)

0.35(0.19-0.63)

0.44

(0.33-0.59)*

1.62(0.84-3.10)*

0.71

(0.52-0.96)*

0.62(0.54-0.71)*

0.61

(0.52-0.70)*

0.09

OR =o dds ratio, 95 Cl =9 5 confidence interval, CHF=congestive heart failure, PVD= peripheral vascular disease, PT=physical therapy, OT=occu pational

therapy, ref=reference. *P


10/15


Table 3.

Logist ic Regression Models Predict ing Postoperat ive Rehabi l i tat ion Receipt (n=12,587)

Variable

Length of stay (d)

Elixhausen Index

Age(y )

55-64 (reO


11/15


Table 3.

Continued

Variabie

Bed size

s i 26 (reO

127-244

245-362

>362

Discharge bed section

Medicine (ref)

Cardiology

Neurology

Orthopedic

Other

Podiatry

Rehabilitation

Surgery

Vascular

Max-rescaled (Nagelkerke)

PT ,

OR (9 5 C i )

1.38(1.26-1.52)*

0.64 (0.67-0 .72)*

2.10(1.74-2.54)*

0.84(0.58-1.23)

0.37 (0.24-0.57)*

2.08(1.75-2.48)*

1.00 0.53-1.91

0.80 (0.62-1.02)

2.32(1.95-2.76)*

1.48(1.33-1.65)*

1.28(1.15-1.42)*

0.15

OT,

OR (9 5 C i )

1.16 1.05-1.28 f

1.03 0.91-1.16

0.63(0.51-0.78)*

0.86(0.57-1.30)

0.40 (0.25-0.64)*

1.67 (1.40-1.99)*

1.31 (0.67-2.53)

0.47 (0.32-0.68)*

2.92 (2.47-3.45)*

1.37(1.22-1.54)*

1.21 (1.08-1.35)'

0.13

Any Ti ierapy, OR (9 5 Ci )

1.41 (1.28-1.54)*

0.76 (0.68-0.85)*

2.02 (1.66 -2.45)*

0.83(0.57-1.20)

0.35 (0.23-0.53 )*

1.95(1.63-2.32)*

1.14 0.59-2.20

0.78(0.61-1.01)

2.35(1.97-2.82)*

1.52(1.36-1.69)*

1.31 (1.18-1.45)*

0.16

OR=o dds ratio, 95 Cl =9 5 confidence interval, CHF=congestive heart failure,

therapy, ref = reference. *P< .05,'P


12/15


Table 5.

Logistic Regression Models Predicting Rehabilitation Receipt: Results of Separate Models

Region

South (reO

Northeast

Upper Midwest

West

Region

South (ref)

Northeast

Upper Midwest

West

Preoperative Services

PT

Before 2 008

OR (95

CI)

0.76(0.58-0.99)*

1.58(1.25-2.01)*

1.38(1.09-1.76)+

After 2008

OR (95

Cl)

0.67 (0.50-0.90)+

1.11

(0.86-1.43)

1.43(1.11-1.84)+

OT

Before 2008

OR (95 CI)

0.74(0.48-1.14)

1.52(1.04-2.23)*

1.78(1.25-2.55)+

After 2008

OR (95 CI)

0.68(0.43-1.07)

1.36(0.95-1.95)

1.32(0.92-1.90)

Any Tiierapy

Before 200 8

OR (95 CI)

0.72 (0.55-0.92)*

1.51(1.20-1.90)*

1.36(1.09-1.72)+

After 2008

OR (95 Ci)

0.61 (0.46-0.81)*

1.04(0.82-1.33)

1.28(1.01-1.64)*

Postop erative Services

PT

Before 2008

OR (95 Ci)

0.69(0.59-0.81)*

1.72(1.47-2.01)*

1.53(1.31-1.78)*

After 2008

OR (95 CI)

0.36 (0.30-0.45)*

0.94(0.77-1.15)

1.69(1.39-2.06)*

OT

Before 2008

OR (95 CI)

0.57 (0.48-0.68)*

1.16(0.98-1.38)

1.07(0.90-1.26)

After 2008

OR (95 Ci)

0.35 (0.28-0.43)*

0.96(0.79-1.16)

1.20(0.99-1.45)

PT/OT

Before 2008

OR (95 Ci)

0.62 (0.53-0.72)*

1.65(1.41-1.94)*

1.37(1.17-1.59)*

After 2008

OR (95 Ci)

0.30 (0.24-0.36)*

0.88(0.72-1.07)

1.57(1.28-1.93)*

'OR= odds ratio, 95% Cl= 95% confidence interval, PT=physical therapy, OT=occupational therapy. *P


13/15


ing postoperative physical therapy

compared w ith 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. Howêver, 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 nationalV sample are not clear,

and wê have no way of determin-

ing whether rehabilitation treatment

delivered was clinically indicated or

whether clinically indicated treat-

ment 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 develop-

ment of

a

treatment plan, we suspect

the latter.

Although previous investigators

reported variation in receipt of reha-

bilitation in an SRU associated with

region and bed size , '^ ^ e did not

expect to see similar variations in

rehabilitation service delivery in the

acute care setting. Access to special-

ized 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 uni-

formly available because acute care

hospitals typically have physical

therapists and occupational thera-

pists on site to provide services. Our

findings, together w ith those of

Zhou et al,** suggest that there may

be regional trends across the contin-

uum of rehabilitation services post-

amputation, with prevalence of use

the lowest in the Northeast and high-

est in the Midwest and West.

The pattern of relationship between

hospital bed size and receipt of reha-

bilitation services was less clear.

Although we expected that smaller

hospitals may not have occupational

therapists and may use physical ther-

apists to perform functional reha-

bilitation, we did not observe a

decreased likelihood of occupational

therapy utilization for smaller hos-

pitals.

Instead, smaller hospitals of

127 to 244 beds were more likely to

provide the most preoperative occu-

pational therapy, as well as postop-

erative physical therapy and occupa-

tional therapy. This finding suggests

larger hospitals may have lower

therapist-to-hospital bed ratios and

more unfilled vacancies. This finding

contrasts with that of Freburgeretal,' ''

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 aU

V

medical centers in the country.

In summary, the reasons for geo-

graphic variation in receipt of reha-

bilitation services in the acute care

setting are unclear, but could be due

to regional and hospital level differ-

ences 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 deter-

mine whether these patients, with

apparently greater need for rehabili-

tation, did ultimately receive rehabil-

itation services, albeit in a delayed

time frame. However, Zhou et al''

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 reha-

bilitation potential.

We found that the likelihood of

receiving preoperative and post-

operative physical therapy and occu-

pational therapy services wassignif

icantly greater after the introduction

of the guidelines. Although this

increase in receipt of physical ther-

apy and occupational therapy ser-

vices 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 obser-

vational. Instead, any observed asso-

ciations 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 stud-

ies that would provide historical

comparisons for non-VA hospitals.

Because this was an observational

study and

w e

had no relationship to

the wôrk group that developed the

guidelines, we had limited informa-

tion on how they were disseminated.

The

V

has an office of quality man-

agement that disseminates evidence-

based guidelines for all types of con-

ditions.' Although regional variation

in dissemination of the guidelines

may have existed, we have no infor-

mation on the methods used to dis-

seminate 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

informationwasrecaptured for more

than half of those patients missing

it by using VA MedSAS outpatient

data. Nevertheless, l6% of patients

had this information missing, threat-

ening the validity of th e findin gs

about the relationship between

September 2 13

Volume 93 Num ber 9 Physical Therapy 12 9


14/15


being black and likelihood of reha-

bilitation 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 research-

5-5.4.8-10 However, it is possible that

some pa tients had revisions of ampu-

tations 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

wh ether patients had bilateral ampu-

tations, as side of amputation surgery

is not coded in the data.

Although we attempted to control

for patient characteristics that w^e

believed might influence receipt of

rehabilitation and included key vari-

ables reported in prior literature,

we had no measures of wound heal-

ing, functional status, or cognitive

function prior to amputation, which

we could expect would be associ-

ated with service receipt. Thus,

there may have been unmeasured

confounders.

Lastly, the study was largely descrip-

tive;

we did not attempt to examine

the impact of rehabilitation receipt

on outcomes, such asftmctionalsta-

tus,

health care costs, discharge des-

tination, or use of rehabilitation ser-

vices outside of the acute hospital

stay. Further research is needed to

link additional data sources to exam-

ine these types of questions.

Conclusions and

Implications

This study described the use of reha-

bilitation services prior to and fol-

lowing lower Umb amputation sur-

gery 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

VAA)oD Clinical Practice Guideline

for Rehabilitation of Lower Limb

Am putation. We found that preva-

lence 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 identi-

fied variations in receipt of reha-

bilitation by geographic regin and

hospital bed size that were not

explained by patient characteris-

tics.

These findings suggest that ftir-

ther quality improvement efforts

are needed to standardize delivery of

rehabilitation services for veterans

with amputations in the acute care

setting.

Both authors provided concept/idea/

research design wr itin g and data analysis.

Dr Resnik provided project management.

DOI: 10.2522/ptj.20120415

References

1 u s D epartm ent of Veterans Affairs. VA/

DoD Clinical Practice Guideline for Reha-

bilitation of Lower Limb Amputation.

Available at: http://w ww .health qualit) .

va.gov/Lower_Limb_Amputation.asp. Ac-

cessed March 30, 2011.

2 Esquenazi A, Meier

R Jr

Rehabilitation in

limb deficiency, 4: l imb amputation. Arch

Phys Med Rehabii 1966;77(3 suppl):S18 -

S28.

3 Stineman MG, Kw ong PL, Xie D, et aL

Prognostic differences for functional

recover) after major lower limb amputa-

tion: effects of the timing and type of inpa-

tient rehabilitation services in the Veter-

ans Health Administration.

PM R

2010;2:

232- 243 .

4 Zhou J, Bates BE, Kurich i JE, et al. Factors

influencing receipt of outpatient rehabili-

tation services among veterans following

lower extremit) amputation. Arch Phys

Med Rehabii 2 0 1 1 ;9 2 : l4 5 5 - l4 6 l .

5 D illingham TR, Pezzin LE. Pos tacut e car e

services use for dysvascular amputees: a

population-based study of Massachusetts.

Am f Phys Med Rehabit 2005 ;84 : l47-

152.

6 Dillingham TR, Pezzin LE, MacK enzie

EJ. Incidence, acute care length of stay,

and discharge to rehabilitation of trau-

matic amputee patients: an epidemiologic

study. Arch Phys Med Rehabii 1998;79:

2 7 9 -2 8 7 .

7 Dillingham TR, Pezzin LE, Mackenzie EJ.

Discharge destination after dysvascular

lower-limb amputations.

Arch Phys Med

Rehabii 2 0 0 3 ;8 4 : l6 6 2 - l6 6 8 .

8 Stineman MG, Kwong PL, KurichiJE , et al.

The effectiveness of inpatient rehabilita-

tion in the acute postoperative phase of

care after transtibial or transfemoral ampu-

tation: study of an integrated health care

deliver) system. Arch Phys Med Rehabii

2008;89:1863-1872.

9 Bates BE, Kw ong PL, Kurichi

JE ,

et al. Fac-

tors influencing decisions to admit

patients to veterans affairs specialized

rehabilitation units after lower-extremit)

amputation. Arch Phys Med Rehabii

2009:90:2012-2018.

10 Kurichi JE, Small DS, Bates BE, et al. Pos-

sible incremental benefits of specialized

rehabilitation bed units among veterans

after lower extremity amputation.

Med

Care 2009:47 :457-465 .

11 B ates BE, Kurichi JE, M arshaU CR, et al.

Does the presence of a specialized reha-

bilitation unit in a Veterans Affairs facility

impact referral for rehabilitative care after

a lower-extremity amputation? Arch Phys

Med Rehabii

2007 :88 :1249-1255 .

12 Kurichi

JE ,

Xie D, Kwo ng PL, et al.fa cto rs

associated with late specialized rehabilita-

tion among veterans with low er extremit)

amputation who underwent immediate

postoperative rehabilitation. Am f Phys

Med Rehabit 2011:90:387-398.

13 Smith MW, Su P, Phibbs CS. Matching

prosthetics order records in VA National

Prosthetics Patient Database to healthcare

utilization datab ases. / Rehabii Res Dev

2010:47:725-737.

14 Freburger JK, Heatwole Shank K, Knauer

SR, Montmeny RM. Delivery of physical

therapy in the acute care setting: a

population-based study. Phys Ther 2012:

92:251-265.

15 Center

VIR

Data Qualit) : Race and Ethnic-

ity Information in Medical SAS Datas ets.

Available at: http://www.virec.research.va.

gov/DataQuality/Overview.htm. Accessed

May 29, 2013.

16 Center VIR. VIReC Technical Report: VA

Race Data Quatity

Hines, IL: US Depart-

ment of Veterans Affairs, Health Services

Research and Development Service: 2011.

17 HCUP Comorbidity Software. Healthcare

Cost and Utilization Project [SAS macro

code] .

Available at: http://www.hcup-

us .ahrq .gov/ too ls sof tware /comorb id i ty /

comorbid it) .jsp. Accessed Nove mber 15,

2011 .

18 Konety BR, Dhaw an V, Allareddy

V ,

Joslyn

SA. Impact of hospital and surgeon volume

on in-hospital mortalit) from radical cys-

tectomy: data from the health care utiliza-

t ion p ro jec t . / Urot 2005:173:1695-1700.

1210 Physical Therapy Volume 93 Num ber 9

September 2013


15/15

C o p y r i g h t o f P h y s i c a l T h e r a p y i s t h e p r o p e r t y o f A m e r i c a n P h y s i c a l T h e r a p y A s s o c i a t i o n a n d

i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e

c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l

a r t i c l e s f o r i n d i v i d u a l u s e .

factors associated with utilization of preoperative and postop rehab services by patietns with...

Documents