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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:
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
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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
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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
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utilization of Rehabilitation Services by Patients With Amputation in the VA System
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 w^ere 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 follow^ing 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 w^ithin 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 w^ith 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.
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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)
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
Table 2.
Logistic Regression Models Predicting Preoperative Rehabilitation Receipt (n=12,587)
Variable
Lengthof stay (d)
Elixhausen
Index
Age y
55 -64(reO
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utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System
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. How^ever, 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 w^e 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 w^ork 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
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utilization of Rehabilitation Services by Patients With Amputation in the VA System
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.
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7/23/2019 Factors Associated With Utilization of Preoperative and Postop Rehab Services by Patietns With Amputation in the
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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 .