Collaborators from the Samuel S. Stratton Veterans Affairs Medical Center in Albany, N.Y. and the University of Pennsylvania have been investigating the effects of comprehensive rehabilitative services for patients undergoing amputations.
“Around the time that we were looking at this information, the VA and Department of Defense published national practice guidelines on rehabilitation after lower extremity amputation,” Barbara E. Bates, MD, MBA, the lead researcher, told O&P Business News.
These guidelines recommend that a patient receive a comprehensive rehabilitative assessment before undergoing a lower limb amputation. This entails a preoperative assessment of a patient’s physical and cognitive abilities by a multidisciplinary team including a rehabilitation specialist in an effort to increase preoperative physical function, streamline the rehabilitation process and decrease postoperative complications.
“We started looking at our care patterns and comparing them to what should be done as part of the guidelines,” Bates said. “We were noticing differences, and the pre-op assessment was one of them. So we wanted to take a critical look at what was happening within the VA. If the consensus from the VA is that it would be a good thing to do, we wanted to see if folks were doing it.”
Funded by a grant from the National Institutes of Health, Bates and her colleagues identified 4,226 patients who were discharged from a VA medical center between Oct. 1, 2002 and Sept. 30, 2004 after a lower limb amputation and found that only 8.12% of these patients received a preoperative rehabilitative assessment.
“What did surprise me was that as much as the VA touts these practice guidelines and evidence-based medicine, it was such a small number [of patients receiving a preoperative assessment],” Bates said.
Within the patient population, the researchers looked at patient-, treatment- and facility-level characteristics that influenced whether a patient received a preoperative assessment. Patient-level characteristics included the patient’s age, gender, marital status and living location before hospitalization. Treatment-level characteristics comprised active pulmonary pathology, acute central nervous system pathology, mental status issues or substance abuse, ongoing active cardiac pathology, ongoing wound problems, serious nutritional compromise and severe renal disease during surgical hospitalization. Facility-level factors included geographic region, the number of beds within the hospital and Commission on Accreditation of Rehabilitation Facilities accreditation of the facility in which the surgery occurred.
The researchers determined that a patient is more likely to receive a preoperative assessment if he or she is older, had evidence of a previous amputation complication or was admitted from home rather than an extended-care facility. Preoperative assessments occurred more frequently in smaller facilities and facilities in the South Central or Pacific Mountain regions of the US.
“It was the characteristics of the facility that drove whether patients had this assessment and not necessarily the medical needs of the patients or anything related to their clinical characteristics,” Bates said.
Bates added that it is also unclear whether a thorough preoperative assessment is critical for patients, but she advised that it would be beneficial for the clinical team because it can predict potential outcomes and determine optimal levels of amputation.
“We don’t know if patients have better outcomes if they get this pre-op assessment,” Bates said. “But when you get that input from a rehab specialist, the rest of the team will have a better sense of what the discharge planning process will be like.”
Likelihood of prosthetic use
A preoperative assessment can also identify which patients are more likely to use a prosthesis after the amputation. Not every patient is a candidate for prosthesis use, so if the patient’s ambulatory function and long-term goals are established before the surgery, the risk of future surgery is mitigated and a postoperative rehabilitation plan focusing on those goals can be implemented.
“It really gives the patients a better sense of what is going on and what to expect in the future,” Bates said. “I recently had a patient where the decision was made to go straight to an AK amputation rather than risking poor healing and a second surgery, because that patient was probably never going to walk again.
“The surgeon might have performed a BK thinking that he was doing a good thing for the patient, but the reality is that he probably would have been setting the patient up for a second surgery,” Bates added.
Bates and her colleagues expect to use this information to further investigate the effects of a comprehensive preoperative assessment on patient outcomes. — by Megan Gilbride
Disclosure: The authors have no relevant financial disclosures.