Veterans with lower limb amputations were less likely to die within 3 years of surgery if they received a prescription for a prosthetic limb within 1 year after amputation, according to data recently published in the Journal of Rehabilitation Research and Development.
“Time is of the essence,” said study author Jibby E. Kurichi, MPH, of the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “It may be important that patients with amputations who are initially clinically appropriate for a prosthetic limb prescription be stabilized as soon as possible so that they might receive the prostheses in as timely a manner as possible.”
Kurichi and colleagues had previously found that younger veterans, those with transtibial rather than transfemoral lower limb amputations and those with higher physical and cognitive abilities are more likely to receive a prescription for a prosthetic limb. They also found that factors negatively influencing prosthetic limb receipt include admission to the hospital from extended care rather than home, numerous amputation etiologies, comorbidities and undergoing certain procedures when hospitalized. Older age, higher amputation level, more comorbidities, inpatient procedures for pulmonary and renal problems, central nervous system procedures, treatment in the intensive care unit or medical bed section and regional differences have been associated with mortality 1 year post surgery.
In addition, data have shown that the hazards of death for prosthetic users among patients with lower limb amputation were 80% less than for those patients without prostheses in adjusted analyses. However, the relationship between a prescription receipt for a prosthetic limb and mortality after surgery among veterans with lower limb amputation had not been previously studied.
Kurichi and colleagues conducted a retrospective, observational study among 4,578 veterans hospitalized for lower limb amputation during 2003 to 2004 to determine the relationship between receiving a prescription for a prosthetic limb and mortality at 3 years post surgery.
They found that 46% (n = 2,086) of the entire sample died within 3 years after surgical amputation, and 28.4% (n = 1,300) of the sample received a prescription for a prosthetic limb within 1 year after surgical amputation. Among those veterans who received a prescription for a prosthetic limb, 25.5% died within 3 years after surgery.
After controlling for patient-, treatment- and facility-level characteristics and year, the researchers found veterans with lower limb amputation who received a prescription for a prosthesis within 1 year after surgery were less likely to die after surgery compared with veterans without a prescription with a hazard ratio of 0.68.
Kurichi and her colleagues hope the data will increase clinicians’ focus on patient-centered care, which includes patients’ choice, opinion and acceptance of the prosthetic limb and could lead to a higher rate of prosthetic limb use and longer survival among this population.
“Post-discharge plans to ensure patients return to see a prosthetic team should be a priority as intensive rehabilitation followup after hospital discharge could increase the prevalence of prosthetic limb users,” Kurichi said. “Tracking patients via an amputation clinic or other rehabilitation clinic until they are ready for a prosthetic prescription might make a difference in timing of the prescription for those delayed by complicating factors and ultimately it may result in greater survival.”
Kurichi also said it is likely the patients who receive a prescription for a prosthetic limb within 1 year may be those who have had no post-amputation surgery or late complications and are therefore more likely to be fitted early with a prosthesis.
“Those patients with wound infections or slow-healing surgical sites, severe cardiovascular disease, local or systemic infections or other complicating factors such as nonhealing wounds on their sound limb may see significant delays in the prosthetic fitting process,” she said. “These patients may be more medically compromised in general than those who tolerate the post amputation surgery and recovery without any complications and thus have a higher mortality rate in general.”
Therefore, the early prosthetic prescription may not be the cause of the improved mortality rate, but rather a marker or threshold for a lower 3-year mortality rate. – by Tina DiMarcantonio
- Kurichi JE, et al. J Rehabil Res Dev. 2015;52:385–396.
Disclosure: The researchers report the research for this manuscript was supported by the NIH (R01-HD042588-05A2). It is also supported by resources and the use of facilities at the University of Pennsylvania in Philadelphia; the Samuel S. Stratton Department of Veterans Affairs Medical Center in Albany, N.Y.; and the North Florida/South Georgia Veterans Health System (NF/SG VHS) in Gainesville, Fla. Support for VA/CMS data is provided by the VA, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).