Do Amputees Benefit from Comprehensive Rehabilitation Services? . The policy relevance of this ongoing work is critical. This reapplication is in direct response to a call from the NIH and Center for Medicare and Medicaid Services (CMS).to develop NIH-level research providing evidence supporting the practices of rehabilitation. Without evidence of effectiveness, rehabilitation access will likely be curtailed or eliminated to the detriment of people with potentially reducible disabilities related to trans-tibial or trans-femoral amputation Changes in both Veterans Health Administration (VHA) and Medicare policies are stimulating shifts from inpatient to outpatient services without empirical evidence either supporting or not supporting those services. There are few, if any, sources of longitudinal data in the private sector available to address the benefits of alternative rehabilitation care patterns or associated long-term outcomes. Results from our current project provide evidence supporting the effectiveness of both generalized consultative rehabilitation services and those provided on a specialized rehabilitation bed unit for veterans while still hospitalized following trans-tibial or trans-femoral amputation. Only 33% of the 4,727 amputees in our initial sample received inpatient rehabilitation during the """"""""acute postoperative"""""""" period. Our proposed renewal is motivated by the need to study rehabilitation services received by the majority (67%) of amputees with no evidence of inpatient rehabilitation during the acute postoperative period. We propose to explore variation in outcomes comparing different rehabilitation care patterns according to the time (other than acute postoperative), place, and type of rehabilitation services received. The degree of functional recovery will be determined at conclusion of rehabilitation, and home discharge from the hospital will be addressed for inpatient patterns only. One-, 2- and 3-year outcomes of survival, long-term care placement, re-amputation, re-hospitalization, prosthetic prescription, and total health care costs will be determined for all patterns analyzed. Methods will include a series of observational studies on an estimated cohort of 7,000 amputees with a sub-group analysis of those 65 years of age and older using propensity score matching and instrumental variable analyses to adjust for selection bias and mixed models to account for patient clustering within facilities. These methods will be applied to determine if the benefits of rehabilitation found in the acute postoperative period hold for different types of rehabilitation applied at diverse times and places. We will identify the types of patients most likely to receive various rehabilitation care patterns and the associated expected discharge and 3 year outcomes. To our knowledge, this ongoing study of the veteran amputee population represents a first attempt to image the full continuum of acute, rehabilitation, and long-term care services received by a defined group of patients. We anticipate that this research will greatly expand the limited body of empirical knowledge of relevance to the rehabilitation and post-acute care of amputees. Such evidence-based knowledge will be essential to guide future practice and policies in the VHA and private sectors alike.
It is important to identify optimal ways of integrating rehabilitation services with acute and long-term care services so that the most effective types of care can be streamlined, maintained, and strengthened to enhance the quality of life of people after lower limb amputation. The Veterans Health Administration is studied because it is a model of integrated care. In estimating the societal costs of health care, it is vital to fully characterize use and linkages between rehabilitation, medical, and surgical services, and between the VHA and Medicare systems of care in the elderly and most costly segment of the population.
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