Pui L. Kwong

The Effectiveness of Inpatient Rehabilitation in the Acute Postoperative Phase of Care After Transtibial or Transfemoral Amputation: Study of an Integrated Health Care Delivery System

OBJECTIVE To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Clinical Factors Associated with Prescription of a Prosthetic Limb in Elderly Veterans

OBJECTIVES: To determine how advanced age influences prosthetic prescription.

Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation.

This study explored medical conditions associated with mortality among veterans following transfemoral amputation, transtibial amputation, or hip disarticulation. We applied logistic regression models to identify clinical factors associated with mortality postoperatively. The participants included patients with lower-limb amputations (n = 2,375) who were discharged from Veterans Health Administration hospitals between October 1, 2002, and September 30, 2003. Most (98.9%) were male. We measured cumulative in-hospital, 3-month, and 1-year mortality. The results were 180 in-hospital deaths, 368 by 3 months, and 634 by the 1-year postsurgical amputation date. Those who had perioperative systemic sepsis (odds ratio = 4.28, 95% confidence interval = 2.87-6.39) had more than a fourfold increased likelihood of in-hospital mortality. Congestive heart failure, renal failure, and liver disease were significantly associated with mortality at all time periods. Metastatic cancer was associated only at 3 months and 1 year. We concluded that high medical complexity and mortality rates attest to the need for careful medical oversight during the postacute rehabilitation period.

Assessing and Using Comorbidity Measures in Elderly Veterans with Lower Extremity Amputations

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

Prognostic Differences for Functional Recovery After Major Lower Limb Amputation: Effects of the Timing and Type of Inpatient Rehabilitation Services in the Veterans Health Administration

To compare the recovery of mobility and self‐care functions among veteran amputees according to the timing and type of rehabilitation services received.

Survival Analysis in Amputees Based on Physical Independence Grade Achievement

BACKGROUND Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE Cumulative 6-month survival after rehabilitation discharge. RESULTS The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

Possible Incremental Benefits of Specialized Rehabilitation Bed Units Among Veterans After Lower Extremity Amputation

Background:Little is known about the effect of different types of inpatient rehabilitation on outcomes of patients undergoing lower extremity amputation for nontraumatic reasons. Objective:To compare outcomes between patients who received inpatient rehabilitation on specific rehabilitation bed units (specialized) to patients who received rehabilitation on general medical/surgical units (generalized) during the acute postoperative period. Methods:This was an observational study including 1339 veterans who underwent lower extremity amputation between October 1, 2002 and September 30, 2004. Data were compiled from 9 administrative databases from the Veterans Health Administration. Propensity score risk adjustment methodology was used to reduce selection bias in looking at the effect of type of rehabilitation on outcomes (1-year survival, home discharge from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge). Results:After applying propensity score risk adjustment, there was strong evidence that patients who received specialized versus generalized rehabilitation were more likely to be discharged home (risk difference = 0.10), receive a prescription for a prosthetic limb (risk difference = 0.13), and improve physical functioning (gains on average 6.2 points higher). Specialized patients had higher 1-year survival (risk difference = 0.05), but the difference was not statistically significant. The sensitivity analysis demonstrated our findings to be unaffected by a moderately strong amount of unmeasured confounding. Conclusions:Receipt of specialized compared with generalized rehabilitation during the acute postoperative inpatient period was associated with better outcomes. Future studies will need to look at different intensity, timing, and location of rehabilitation services.

One-Year All-Cause Mortality After Stroke: A Prediction Model

By using data from Department of Veterans Affairs (VA) national databases, this article presents and internally validates a 1‐year all‐cause mortality prediction index after hospitalization for acute stroke.

Development and validation of a discharge planning index for achieving home discharge after hospitalization for acute stroke among those who received rehabilitation services.

ObjectiveThe aim of this study was to develop an index for establishing the probability of being discharged home after hospitalization for acute stroke using information about previous living circumstances, comorbidities, hospital course, and the physical grades and cognitive stages of independence achieved. DesignThis is a longitudinal observational population-based study. All 6515 persons treated for acute stroke who received rehabilitation services in 110 Veterans Affairs facilities within a 2-yr period were included. ResultsThere were eight independent predictors of home discharge identified, and points were assigned through logistic regression: married (2 points); location before hospitalization (extended care = 0 points, other hospital = 9 points, home = 11 points); discharge physical grade (grade I, II, or III = 0 points; grade IV or V = 3 points; grade VI or VII = 5 points); discharge cognitive stage (stage I = 0 points; stage II, III, IV, or V = 3 points; stage VI or VII = 5 points); and absence of liver disease (2 points), mechanical ventilation (3 points), nonoral feeding (2 points), and intensive care unit admission (1 point). The points were added for all present factors to calculate scores. The probabilities of home discharge ranged from 65.03% in the least likely (⩽21 points) to 98.24% in the most likely group (≥27 points). ConclusionsThe treatment team might apply prognostic estimates from this index in discharge planning and functional goal setting after initial physical medicine and rehabilitation assessment.

Factors Influencing Decisions to Admit Patients to Veterans Affairs Specialized Rehabilitation Units After Lower-Extremity Amputation

UNLABELLED Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN Database study. SETTING All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Admission to an SRU. RESULTS There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.