Quality gaps in care of military and Veterans with upper limb amputation have been reported. In 2008, amputees receiving prosthetic care in the VA were reported to be less satisfied than counterparts receiving care in the private sector. In 2011, reported widespread dissatisfaction amongst combat Veterans with upper limb loss led to calls for efforts to evaluate needs of Veterans with traumatic upper limb amputations to improve satisfaction. Major efforts to improve quality of prosthetic care have been made since these studies were conducted. In 2009, the VA reorganized its amputation system of care, and in 2014 the VA and DOD released the Evidence-Based Clinical Practice Guidelines (CPGs) for the rehabilitation of persons with upper limb amputation. It is now time for a comprehensive study to assess the current state of quality and outcomes of amputation rehabilitation for upper limb amputees and to track quality and outcomes over time. OBJECTIVES Our objective is to provide comprehensive cross-sectional and longitudinal data on function, needs, preferences, and satisfaction of Veterans and service members with major upper limb amputation. This project modification adds subaims 1a and 2a to provide comprehensive data on women Veterans with upper limb amputation.
SPECIFIC AIMS /HYPOTHESES 1) Describe patterns of prosthesis use; identify the impact of amputation and prosthesis use on function, activities and participation; and identify unmet prosthetic needs This aim will test 5 major hypotheses: 1) rates of prosthesis use and scores on prosthesis satisfaction scales will be higher for transradial (TR) amputees as compared to persons with more proximal amputations ; 2) there will be higher rates of prosthesis use and satisfaction amongst those with amputation in the past 5 years as compared to those who sustained amputation 6 or more years ago; 3) any prosthesis use, and myoelectric use will be associated with lower ratings of disability and neck pain compared to no prosthesis use and body-powered use respectively; 4) perceived difficulty of everyday activity function will be rated similarly for persons with unilateral upper limb amputation regardless of level, with no differences between users by type of prosthetic device. However, perceived difficulty in performing activities that require bimanual involvement will be greater for persons with more proximal as compared to TR amputation; 5) a greater proportion of activities will be performed using the prosthesis by persons with TR amputation as compared to more proximal amputation. 1a. Compare findings by gender. This sub aim will test the hypotheses that there will be an effect modification by gender, with female upper limb amputees being less satisfied with their prosthesis regardless years since amputation, 2) Conduct a one year longitudinal follow-up survey to examine changes in satisfaction with care and prosthetic services, physical performance, self-reported quality of life and physical function to assess the implementation of new clinical practice guidelines (CPGs).
This aim will test the following associated hypotheses: 1) There will be geographic variation in VA compliance with CPG recommendations with amputation related services that parallels findings from prior research; 2) There will be improvements over time in satisfaction with care for upper limb amputees receiving care at the VA and DoD but not for Veterans receiving care from other sources; and 3) There will be improvements over time in indicators of CPG compliance. 2a. Compare findings by gender. This sub aim would test the hypotheses 1) that there will be no differences between compliance with CPG recommendations between male and female Veterans with upper limb amputation, and 2) there will be no differences between female and male Veterans? satisfaction with quality of care. 3) Quantify physical function using a battery of performance based tests.
This aim i s descriptive in nature, and thus there are no associated hypotheses. STUDY DESIGN This is a 3-part study. Part 1 will survey a stratified random sample of 1850 of persons with upper limb amputation that receive care in the VA and all service members with upper limb amputation who have not transitioned to VA care. This N represents ~41% of the population, which is 97% male. We will stratify by level of amputation, oversample the smallest groups, and use sampling weights in analyses. For the expansion of this project, we propose sampling ALL female Veterans with major upper limb amputation, which we estimate, based on 2016 VA amputation briefing book would be 130 additional subjects in our study. The survey will include items from prior surveys, standardized measures (SF-12, QuickDASH, TAPES satisfaction, and OPUS care satisfaction) and new items on risk-benefit assessment, and elements of quality. Part 2 is a one year longitudinal follow-up survey of 667 respondents from Part 1 and an estimated 80 female respondents (given that we anticipate a 61% response rate). Part 3 will involve 5 data collection sites that will administer measures of dexterity and activity performance to 125 persons at two time points one year apart.
This study will provide an understanding of prosthetic use, functional abilities, needs, preferences, and risk tolerance of Veterans and service members with upper limb amputation; yield data on quality of amputation care in the VA and DoD; and provide evidence on the impact of new VA/DoD evidence based guidelines for the rehabilitation of persons with upper limb amputation. The expanded study will include a robust sample of female Veterans and allow comparisons of findings by gender. Results will be generalizable to all Veterans and service members with major upper limb loss. Understanding benefits, drawbacks, and acceptability of currently available devices and advanced and emerging technologies is crucial. Data from this study will ultimately be used to improve quality of care in the VA and DoD, and inform evidence based policies for device prescription, provision of rehabilitation services and FDA regulatory approval.
