Military Rehabilitation

Special Issue
Factors Associated With Utilization of
Preoperative and Postoperative
Rehabilitation Services by Patients
With Amputation in the VA System:
An Observational Study
Linda J. Resnik, Matthew L. Borgia

Background. The Department of Veterans Affairs (VA) and the Department of

Defense published evidence-based guidelines to standardize and improve rehabilita-,
tion of veterans with lower limb amputations; however, no studies have examined
the guidelines' impact.
Objectives. The purposes of this study were: (1) to describe the utilization of
rehabilitative services in the acute care setting by people who underwent major
lower limb amputation in the VA from 2005 to 2010, (2) to identify factors associated
with receipt of rehabilitation services, and (3) to examine the impact of the guidelines on service receipt.
Design, A cross-sectional study of 12,599 patients, who underwent major surgical
amputation of the lower limb at a VA medical center from January ^1, 2005, to
December 31, 2010, was conducted. Data were obtained from main and surgical
inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases.
Methods. Rehabilitation services were categorized as physical therapy, occupational therapy, and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined the impact of guideline implementation and
identified factors associated with service receipt.

L.). Resnik, PT, PhD, Center

for Gerontology and Health Care
Research, Brown University, 2
Stimson Ave, Providence, Rl
02912 (USA). Address all correspondence to Dr Resnik at:
linda_resnik@brown.edu.
M.L. Borgia, AM, Department of
Veterans Affairs-Research, Providence, Rhode Island.
[Resnik L), Borgia ML. Factors associated with utilization of preoperative and postoperative rehabilitation services by patients with
amputation in the VA system: an
observational study. Phys Ther.
2013;93:1197-1210.]
2013 American Physical Therapy
Association
Published Ahead of Print:
May 2, 2013
Accepted: April 26, 2013
Submitted: October 10, 2012

Results. Patients were 1.45 and 1.73 times more likely to receive preoperative
physical therapy and occupational therapy and 1.68 and 1.79 times more likely to
receive postoperative physical therapy and occupational therapy after guideline
implementation. Patients in the Northeast had the lowest likelihood of receiving
preoperative and postoperative rehabilitation services, whereas patients in the West
had the highest likelihood. Other patient characteristics associated w^ith service
receipt were identified.
Limitations. The sample included only veterans who had surgeries at VA Medical
Centers and cannot be generalized to veterans with surgeries outside the VA or to
nonveteran patients and settings.
Conclusions. Further quality improvement efforts are needed to standardize
delivery of rehabilitation services for veterans w^ith amputations in the acute care
setting.
Post a Rapid Response to
this article at:
ptjournal. apta, org

September 201 3

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utilization of Rehabilitation Services by Patients With Amputation in the VA System

he Department of Veterans
Affairs (VA) and the Department of Defense (DoD) developed and promulgated evidencebased guidelines to standardize and
improve rehabilitative care of people with lower limb amputations.'
The guidelines, published in 2007,
build upon the scientific literature
demonstrating the effectiveness of
both inpatient and outpatient rehabilitative services in improving
physical function and survival and
reducing bodily pain after lower
Umb amputation. The guidelines
delineate the goals and content of 5
phases of rehabilitation for people
with amputations: (1) preoperative,
(2) acute postoperative, (3) preprosthetic, (4) prosthetic training, and
(5) long-term foUovsr-up. According
to the guidelines, physical therapy
and occupational therapy are among
the key disciplines that should be consulted during the preoperative and
postoperative phases of rehabilitation,
and both should be included in the
development of the treatment plan.

that are not at risk for amputation,

as well as maintaining full motion
of the most proximal joints.^ Preoperative rehabilitative services may
include physical function assessment and therapeutic exercise for
strengthening, range of motion
(ROM) and balance, mobility training, patient education about prosthetic options, and establishing a
home exercise program. Interventions during the acute postoperative
phase that should be "initiated as tolerated" include: ROM, strengthening, positioning, balance exercises,
mobility activities as tolerated, and
training in activities of daily living
and patient education.' Activities in
the preprosthetic phase include
ROM and therapeutic exercise, balance activities, progressing gait activities, functional training, and training
in use of assistive devices.' The prosthetic training phase includes continued ROM, therapeutic exercise
progression and balance, gait and
transfer training with and without
the^ prosthesis, patient education,
vocational and recreational training,
In the preoperative phase, a com- and assistive device training.' Interprehensive interdisciplinary baseline ventions commonly included in
assessment of the patient's status long-term foUow^-up include reassessshould be conducted, and appro- ment of balance and gait, review and
priate rehabilitation interventions adjustment of ROM and home mainshould be initiated to maximize the tenance program, education about
patient's physical function before injury prevention and energy consersurgery. 1 Rehabilitative services vation, and provision of and training
focus on mobility of other limbs with appropriate assistive devices.'
Available With
This Article at
ptjournal.apta.org
' Listen to a special Craikcast on
the Military Rehabilitation Special
Issue with editors John Childs and
Alice Aiken.
Audio Podcast: "Advancing the
Evidence Base in Rehabilitation
for Military Personnel and
Veterans" symposium recorded at
APTA Conference 2013, )une 28,
2013, in Salt Lake City, Utah.

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Postoperative rehabilitation involves

the 4 remaining phases and may
occur in numerous settings beginning with the acute care hospital
and, in some cases, progressing to
specialized inpatient rehabilitation
units or skilled nursing facilities,
then to home care or outpatient
care.' Specialized inpatient rehabilitation is the most intensive,
involving at least 3 hours a day of
rehabilitation services consisting of
at least 2 different types of therapy (such as physical therapy and
occupational therapy). Specialized
Number 9

inpatient rehabilitation is provided

in Commission on Accreditation of
Rehabilitation Facilities (CARF)accredited facilities that have designated rehabilitation beds. These
facilities are called specialized rehabilitation units (SRUs) within the VA
system of care and inpatient rehabilitation facilities (IRFs) outside of the
VA. In contrast, rehabilitation in the
acute care setting occurs on general
hospital units, has no required minimum, and, therefore, is likely to be
less intensive and more intermittent
than care mandated by IRFs.
Many disciplines are involved in the
delivery of rehabilitative care. Three
of the most common types of rehabilitative services for people with
amputations in the United States
are physical therapy, occupational
therapy, and prosthetic services
delivered by a certified prosthetist.
Physical therapy for people with
lower limb amputations typically
includes: physical function assessment, therapeutic exercise for
strengthening and ROM, balance
activities, gait and mobility training,
and patient education regarding
care of the residual limb and scar
management. Occupational therapy involves learning adaptive techniques to complete activities of
daily living, establishing equipment
needs, and promotion of safety (such
as fall prevention). Prosthetic services include advising about prosthetic components and managing
problems such as skin breakdown
and other complications resulting
from prosthetic use; fitting and fabricating the prosthetic socket; and
delivering, fitting, and repairing
prosthetic componentry.

Are Patients Receiving

Rehabilitation Services?
Although efforts to improve the quality of rehabilitation services for veterans and military service members
have been under w^ay for the past
decade, few studies have reported
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System

on w^hether people with lower limb
amputations receive recommended
rehabilitative services.^"* Although
some studies have examined receipt
of rehabilitation in settings outside of
the VA,5-^ the bulk of research on
this topic has been performed using
VA data from people with incident
amputations betrween the years 2002
and 2004, and most of the research
focused on the receipt of specialized
inpatient rehabilitation.5'''^-'
Using data from 2002 to 2004, Stineman et aP and Bates et al' ' reported
that 73% of VA patients with surgical
amputations at the transtibial, transfemoral, and hip disarticulation level
received some type of inpatient rehabilitation, either acute postoperative
rehabilitation services (wliich they
called "consultative rehabilitation")
or care on SRUs either at the hospital
or after discharge. Some evidence
suggests that referral and timing of
referral for SRU care was not determined by patient needs alone but
also influenced by facility-level factors such as co-location of an SRU"
w^ithin the hospital, geographic
region, and hospital bed size."'^
Zhou et al"* reported that 65% of veterans with incident transtibial and
transfemoral amputations received
outpatient rehabilitative services in
their first year after discharge from
the incident hospital stay. For every
10-year increase in age, Zhou et al
reported that the likelihood of receiving outpatient rehabilitation decreased
by 17%. In addition, patients with
transfemoral or buateral amputations
and patients with serious comorbidities were less likely to receive outpatient rehabilitative services following
lower Hmb amputation.''
In summary, knowledge about
receipt of rehabilitation services in
the VA is limited. Researchers have
reported on the receipt of outpatient
and SRU services for people with
incident lower limb amputations in
the VA during the period 2002 to
September 201 3

2004. These studies excluded people

with amputation at the foot level. To
our knowledge, no studies have
been conducted using more recent
VA data; thus, there is no way to
evaluate whether patterns of care
in the VA have changed over time.
No prior study has examined the factors associated with the likelihood
of receiving any rehabilitative care
in the acute setting, nor have prior
studies examined the prevalence
or predictors of receipt of presurgical rehabilitation services. To our
knowledge, there has been no previous research examining the receipt
of specific services such as physical
therapy and occupational therapy.
Finally, despite major efforts to
develop and promulgate evidencebased guidelines, there have been
no studies that have examined the
impact of the guidelines on receipt
of care within the VA or DoD. Therefore, more research is needed.
The purposes of our study were:
(1) to describe the utilization of
rehabilitative services in the acute
care setting by people who underwent major lower limb amputation
(defined as transtibial, transfemoral,
and foot/ankle level) in the VA from
2005 to 2010, (2) to identify factors
associated with receipt of rehabilitation services, and (3) to examine
whether prevalence of rehabilitative
services has changed since the introduction ofthe VA/DoD rehabilitation
guidelines. Although we initially were
interested in including prosthetic services in our study, we chose not to do
so when we discovered that these services are not coded consistently in the
VA system and that major changes in
structure of service delivery occurred
in the past 5 years.

care utilization of veterans. The PTF

is a National Data Extract that contains inpatient services." The databases included 4 Acute Care Inpatient Medical SAS (MedSAS) datasets
and the Inpatient Encounters Medical SAS datasets files. The 4 Acute
Care MedSAS datasets used were
the main dataset, which contained
information on demographics, diagnoses, and length of stay; the bed
section dataset, which contained
information on the specialty of the
physician managing the patient care;
the procedure dataset, which contained the procedure codes performed during the inpatient stay; and
the surgery dataset, which contained
aU surgical procedure codes. The
inpatient encounters dataset contained records of blable professional services received by patients
during their inpatient stay. All datasets used in this study shared a
common patient identifier, which
allowed linkage of records from the
different datasets.
Sample
Patients were included if they underwent a major surgical amputation of
the lower limb at any VA medical
center from January 1, 2005, to
December 31, 2010. Major lower
Umb amputations were identified as
surgeries with ICD-9-CM procedure
codes of 84.12 to 84.17. Level of the
surgical amputation was determined
by using these ICD-9 procedure codes
and classified as foot/ankle (84128414), below knee (8415), and above
or at knee (84l6, 8417). Cases that
involved only toe amputations were
excluded due to their lower severity,
and cases involving disarticulation of
the hip or abdominopelvic amputation were excluded due to their low
frequency of occurrence.

Method
Data Source
Data were obtained from Veterans
Health Administration (VHA) administrative Patient Treatment File (PTF)
databases used to track the health

In keeping with methods used in

prior research,31'' we utilized a
12-month look-back period to ensure
that the sample would consist of
people with first-time amputations

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utilization of Rehabilitation Services by Patients With Amputation in the VA System

only. Thus, we obtained data dating
back to 2004 and "looked back" to
determine whether there was a
record of prior lower limb amputation. Once an amputation incident
was identified from the surgical data,
the PTF main data from that hospitalization episode were extracted.
Any inpatient encounters data that
occurred between the hospitalization's admission date and discharge
date also w^ere extracted. The 12month look-back criteria were met
by 12,599 patients.
Key Variables
Rehabilitation services. The receipt
of rehabilitation services was identified using both the acute PTF procedure data and the PTF inpatient
encounters data. We classified type .
of rehabilitative service as: (1) physical therapy, (2) occupational therapy, and (3) receipt of either physical therapy or occupational therapy
(any therapy). We wanted to examine receipt of each of these types of
care because of their different, yet
sometimes overlapping, roles.
Receipt of rehabilitation services
was identified by satisf>'ing one of
the follow^ing criteria: (1) presence
of inpatient procedure data for any
of the following International Classification of Diseases (ICD-9) procedure codes: physical therapy=9301,
9304-9325,9327,9338, 9339, 9356,
9357, 9385, or 9389; occupational
therapy=9383; or (2) having inpatient encounter data that included
clinic stop codes of 174 or 205, or
both, for physical therapy and 206
for occupational therapy.
Using the date of amputation surgery, we categorized all services as
occurring either before or after the
surgical amputation. Postsurgical
rehabilitation was defined as services received after the date of the
surgical amputation but before discharge from the acute care hospital

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or transfer to an inpatient rehabilitation bed w^ithin the same hospital.

Covariates. We
adjusted
for
patient demographics and other
characteristics such as living arrangement prior to hospitalization and
comorbidities that we hypothesized
would be associated w^ith rehabilitation service use. We also adjusted for
facility characteristics that might be
associated with differences in service utilization, including geographic region and bed size.
Demographic data collected included
age, sex, income, length of stay, marital status, race, admission source
before hospitalization, and year of
amputation. Patient age (in years) at
discharge was recategorized into the
following groups: under 45, 45-54,
55- 6A, 65-74, 75- 84, and 85 or older.
Patient sex, income, and length of stay
were abstracted directly from the
main PTF dataset. Marital status was
obtained from the PTF inpatient
encounters data using the last entry for
marital status between admission and
discharge dates; categories included
single, married, divorced, widowed,
and unknown.
Information on racial group was
extracted from the PTF main data
and collapsed into 4 categories:
white, black, other, and missing/
unknown. Because race was missing
for almost 40% of our sample, a
known problem in VA data after
2003,"'"^ we retrieved information
on missing race by using the most
recent non-missing race information
contained in VA outpatient MedSAS
data for the years 1998 to 2002.
Using this strategy, we reduced the
number of patients with missing race
information from 38% to l6%.
We categorized admission source
prior to hospitalization for amputation surgery as: nursing facility,
hospital, or from the community.
Year of amputation was identified

Number 9

using the PTF surgery data. The

number of comorbid conditions was
evaluated using the Healthcare Cost
and Utilization Project's (HCUP)
Elixhausen comorbidity software
(version 2.1 for years 2005-2007
and version 3 7 for years 20082010), which uses the ICD-9 diagnosis codes listed in the main PTF
dataset and calculates a total number of comorbidities.'^ The comorbidities included in the Elixhausen
Index are: peripheral vascular disease, hypertension, paralysis, neurological disorders, chronic pulmonary disease, diabetes with chronic
complications, diabetes without
chronic complications, hypothyroidism, renal failure, liver disease, peptic ulcer disease, acquired immune
deficiency syndrome, lymphoma, metastatic cancer, solid tumor without
metastasis,
rheumatoid
arthritis, coagulopathy, obesity, weight loss,
fluid and electrolyte disorder, chronic
blood loss anemia, deficiency anemia,
alcohol abuse, drug abuse, psychoses,
and depression. In this calculation, diabetes with complications and diabetes
without complications were counted
only once; similarly, only metastatic
cancer and solid tumor without metastasis were counted toward the total
number of comorbidities.
We also evaluated the presence of
specific comorbid conditions that
had been included in prior analyses
of rehabilitation of people with
lower limb amputations.'*'^"' These
conditions included congestive heart
failure, peripheral vascular disease,
paralysis, other neurological disorders, diabetes, and renal failure.
We also examined cerebral vascular
disease for ICD-9 diagnosis codes
between 4300 and 4389, but this
comorbidity did not count toward
the total number. Length of stay was
added to the PTF data in 2006. It
was calculated as [(discharge dateadmission date) (days patient was
out on pass during inpatient and entire
stay)] but has a minimum value of 1.
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System

Our analyses also included admission
and discharge bed section. Bed section refers to specialty of the admitting physician. Admitting bed sections were classified as medicine,
cardiology, neurology, orthopedic,
other podiatry, surgery, or vascular.
Discharge bed sections were classified
as medicine, cardiology, neurology,
orthopedic, other podiatry, rehabilitation, surgery, or vascular. We were
unable to use the category of rehabilitation as an admitting bed section
because of the very low numbers of
patients admitted to this bed section.
Our analyses included hospital
geographic region, mapped into 4
regions (Northeast, South, Upper
Midwest, and West)'^ and hospital
bed size, classied as ^126 beds,
127 to 244 beds, 245 to 362 beds,
and >362

Full Sample:
Incident amputations
2005-2010

Sample to Examine Impact

of Guidelines:

Exclude:
Incident amputations in 2008

Incident amputations before 2008

Incident amputations after 2008

1
1

3 Logistic Regression Models

3 Logistic Regression Models

preoperative services:
PT
OT
PT/OT

postoperative services:
PT
OT
PT/OT

Figure.
Flow of participants into logistic regression models examining impact of guidelines on
receipt of rehabilitative services in the acute care setting. PT=physical therapy,
OT=occupational therapy.

Statistics
Descriptive analyses. We examined descriptive statistics for the
entire sample and calculated the percentage of patients who received
physical therapy, occupational therapy, and any therapy by geographic
region for all years and for the years
2005 to 2007 and 2009 to 2010.
Factors associated with receipt of
rehabilitation. Bivariate analyses
(t tests for continuous covariates and
chi-square tests for categorical covariates) were used to compare characteristics of those who had received
and those who had not received services before surgery and those who
had received and those who had
not received services after surgery.
AU of the variables examined, except
sex, cerebral vascular disease, and
income, were signicant factors of in
least 1 of the 6 dependent variables.
Separate multivariate logistic regression models using all of the significant factors identified in the bivariate analyses, as well as sex, were
created to examine rehabilitation
September 201 3

receipt before and after the amputation. Three models were created
for presurgical rehabilitation: (1) any
physical therapy, (2) any occupational therapy, and (3) any therapy.
Similarly, 3 separate models were
created for postsurgical rehabilitation. These models included the
length of stay, number of comorbidities as measured by Elixhausen
Index, income, age, amputation
level, admission source before hospitalization, marital status, sex, race,
comorbidities (congestive heart
faure, peripheral vascular disease,
paralysis, other neurological disorders, diabetes [with or without
chronic complications], and renal
failure), and the facility-level variables "hospital region" and "hospital
bed size." Additionally, we included
the variable "admitting bed section"
in the models predicting preopera. tive service receipt and the variable
"discharge bed section" in the models predicting postoperative service
receipt.

Rehabilitation receipt before and

after guideline implementation.
To assess rehabilitation service
receipt before and after guideline
implementation for people with
amputations, which were published
in 2007, we developed 6 logistic
regression models examining the
effect of year, classified dichotomously as 2005 to 2007 or 2009 to
2010 on receipt of any (or service
specific) preoperative or postoperative rehabilitation services (Figure),
controlling for all of the case-mix
covariates in the original full models.
We eliminated 2008 from this analysis because we expected that major
efforts to disseminate the guidelines occurred in the year after
publication and that patterns of
practice change would not be evidence during that year. These models controlled for all factors included
in our full models: age, Elixhausen
Index, length of stay, admission
source before hospitalization, amputation level, marital status, sex, race,
comorbidities, region, bed size, and

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Utilization of Rehabilitation Services by Patients With Amputation in the VA System

bed section (either admitting or
discharge).
Because prior researchers reported
geographic variation in receipt of
rehabilitation care for SRUs,"'^
we were interested in determining
whether similar variation existed in
acute care rehabilitation services and,
if so, whether geographic variation in
care receipt was ameliorated after
guideline implementation. Therefore,
we also examined the odds of receiving a service in one region compared
witli the odds of receiving services in
another region using separate logistic
regression for services received before
2008 and after 2008.

Results
There were 12,599 veterans with an
incident lower limb amputation
from 2005 to 2010. Characteristics of
these patients are shown in Table 1.
The mean age of the group was 6G
years. The sample was 99% male,
47% were admitted from a hospital,
9% were admitted from a nursing
facility, and 43.9% were admitted
from the community. The average
length of acute care hospital stay was
19.2 days. The most common comorbid conditions were peripheral vascular disease (60%) and diabetes
{66%). Forty percent of the amputation surgeries in our sample
occurred at southern hospitals compared with 18% in the Northeast,
21.4% in the Upper Midwest, and
20.5% in the West.
Factors Associated With Receipt
of Rehabilitation Services
Multivariable analyses. Results
of the logistic regressions modeling
receipt of preoperative and postoperative rehabitation services are
shown in Tables 2 and 3, respectively. For each additional day of hospitalization, the odds of a patient
receiving any preoperative physical
therapy, occupational therapy, or
any therapy were 1.01 to 1.02 times
higher. For each additional comor1202

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bidity, the odds of receipt of any

preoperative physical therapy were
1.06 times higher, the odds of receiving preoperative occupational therapy were 1.15 times higher, and the
odds of receiving any therapy were
1.07 times higher. The odds of
receiving preoperative physical therapy for patients under 45 years of
age were 0.47 compared w^ith
patients aged 55 to 6A years. Hospital
bed size was associated with receipt
of all types of services, but the pattern of relationship was not clear.
Admitting bed section was related to
service receipt, with patients admitted
to neurology, orthopedics, surgery, or
vascular sections having significandy
lower odds of receiving physical tlierapy and those admitted to orthopedic,
podiatry, surgery, or vascular sections
having lower odds of receiving occupational therapy compared with those
admitted to medicine.
Patients who had their surgeries in
the Northeast had 0.67, 0.69, and
0.63 the odds receiving any preoperative physical therapy, occupational
therapy, and any therapy services,
respectively, compared with those
in the South. Patients in hospitals in
the Upper Midwest had 1.21, 1.35,
and 1.17 times the odds of receiving
any preoperative physical therapy,
occupational therapy, and any therapy, respectively, compared with
those in the South. Patients in the
West had 1.32, 1.40, and 1.25 times
the odds of receiving preoperative
physical therapy, occupational therapy, and any therapy, respectively,
compared with those in the South.
For each additional day of hospitalization, patients had 1.01 times
greater odds of receiving any type of
postoperative rehabilitation service.
For each additional comorbidity,
patients had 1.11 times the odds for
receiving postoperative physical
therapy and 1.10 times the odds for
receiving any postoperative therapy.
Patients over 75 to 84 years of age

Number 9

had 0.87 times the odds and those

over age 85 years had 0.77 times the
odds of receiving any postoperative
therapy compared with those aged
55 to 64^ years. Patients admitted
from the community had 1.16 times
the odds of receiving any physical
therapy and 1.11 times the odds of
receiving any therapy compared
with those admitted from a hospital.
Those admitted from nursing homes
had 0.58 times the odds of receiving
any physical therapy, 0.50 times the
odds of receiving occupational therapy, and 0.54 times the odds of receiving any therapy compared with those
admitted from a hospital. Patients with
below-knee amputations or aboveknee amputations had higher odds of
receiving physical therapy and occupational therapy services compared
with those with foot or ankle amputation. Black patients had 1.16 times the
odds of receiving any postoperative
physical therapy, 1.36 times the odds
of receiving occupational therapy, and
1.26 times the odds of receiving
any therapy compared with white
patients. Additionally, patients with
paralysis, diabetes, or renal failure had
lower odds of receiving any postoperative physical therapy, whereas those
with congestive heart failure had
higher odds of receiving occupational
therapy.
Substantial regional variation in
receipt of postoperative rehabilitation services w^as observed. Patients
who had their surgeries in the Northeast had 0.50, 0.42, and 0.43 the
odds of receiving any postoperative physical therapy, occupational
therapy, and any therapy services,
respectively, compared with those
in the South. Patients in hospitals in
the Upper Midwest had 1.28 and
1.24 times the odds of receiving any
preoperative physical therapy and
any therapy, respectively, than those
in the South. Patients in the West
had a similar pattern, with 1.54 and
1.43 times the odds of receiving
postoperative physical therapy and
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Utilization of Rehabilitation Services by Patients With Amputation in the VA System

Table 1.
Characteristics of Patients With Incident Amputations, 2005-2010 (N=12,599)
Continuous Covariates
Length of stay (d)

iVIean (SD) [Median]

19.2 (26.4) [13.0]

Categoricai Covariates

N (%)

Age(y)

Hospital days prior to surgery

7.0 (15.7) [3.0]

<45

Hospital days after surgery

12.3 (17.5) [8.0]

45-54

1,353(10.7)

3.2 (1.5) [3.0]

55-64

4,943 (39.2)

20.7 (32.5) [14.6]

65-74

2,968 (23.6)

75-84

2,489(19.8)

Elixhausen Index
Income (dollars in thousands)

Categoricai Covariates

N C/o)

Amputation level

166(1.3)

s85

680 (5.4)

Admission bed section

Foot/ankle

3,340 (26.5)

Medicine

Below knee

5,032 (39.9)

Cardiology

141 (1.1)

Above or at knee

4,227 (33.6)

Neurology

156(1.2)

Orthopedic

851 (6.8)

Admission source

4,097 (32.5)

Hospital

5,927(47.1)

Other

Nursing

1,136(9.0)

Podiatry

399 (3.2)

Community

5,524 (43.9)

Surgery

3,812(30.3)

Vascular

3,094 (24.6)

Marital status
Single

1,804(14.3)

49 (0.4)

Discharge bed section

Divorced

3,501 (27.8)

Medicine

Married

4,999 (39.7)

Cardiology

3,377 (26.8)
127(1.0)

Unknown

1,006(8.0)

Neurology

182(1.4)

Widowed

1,289(10.2)

Orthopedic

815(6.5)

Sex

Other

Male

12,467(99.0)

Podiatry

Female

Rehabilitation

132(1.1)

Race

3,396 (27.0)

Vascular

3,461 (27.5)

7,492(59.5)

Black

2,928 (23.2)

Preoperative PT

158(1.3)

Preoperative OT

Unknown

2,021 (16.0)

Comorbidities
CHF

1,906(15.1)

PVD

7,472 (59.3)

Paralysis
Other neurological disease

729 (5.8)
573 (4.6)

Diabetes

8,268 (65.6)

Renal failure

2,606 (20.7)

Cerebral vascular disease

142(1.1)

Region

865 (6.9)

Surgery

White

Other

42 (0.3)
334 (2.7)

1,532(12.2)
617(4.9)

Preoperative any therapy

1,710(13.6)

Postoperative PT

6,373 (50.6)

Postoperative OT

4,009(31.8)

Postoperative any therapy

6,936(55.1)

Year.
Before 2008

6,376 (60.4)

After 2008

4,180(39.6)

Bed size
<126

4,087 (32.4)

127-244

4,564 (36.2)

South

5,048(40.1)

245-362

3,243 (25.7)

Northeast

2,279(18.1)

>362

Upper Midwest

2,696(21.4)

West

2,576 (20.5)

705 (5.6)

CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational therapy.

September 201 3

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Table 2.
Logistic Regression Models Predicting Preoperative Rehabilitation Receipt (n=12,587)
Variable

PT, OR (95% CI)

OT, OR (95% CI)

Any Therapy, OR (95% CI)

Length of stay (d)

1.02(1.01-1.02)*

1.01 (1.01-1.01)*

1.02(1.01-1.02)*

Elixhausen Index

1.06(1.00-1.11)*

1.15(1.06-1.24)*

1.07(1.01-1.12)*

Age(y)
55-64 (reO
<45

0.47 (0.23-0.98)*

0.52(0.19-1.43)

0.52(0.27-1.01)

45-54

0.95(0.78-1.16)

0.70(0.50-0.97)*

0.94(0.78-1.14)

65-74

1.12(0.97-1.30)

1.14(0.92-1.41)

1.11 (0.96-1.27)

75-84

1.14(0.98-1.34)

1.14(0.90-1.44)

1.16(1.00-1.35)*

85

1.00(0.76-1.32)

0.89(0.58-1.37)

0.91 (0.27-:1.01)

Admission source
Hospital (ref)
Nursing

0.84 (0.67-1.04)

0.99(0.72-1.34)

0.91 (0.74-1.12)

Community

0.97 (0.86-1.09)

0.96(0.80^1.15)

0.96 (0.85-1.07)

Below knee

1.02(0.88-1.17)

1.19(0.96-1.48)

1.03(0.90-1.18)

Above or at knee

0.98 (0.98-0.84)

1.03(0.81-1.31)

0.99(0.86-1.16)

Amputation level
Foot/ankle (ref)

Marital status
Single (ref)
Divorced

0.93(0.78-1.11)

0.91 (0.70-1.18)

0.95(0.80-1.12)

Married

0.90(0.76-1.06)

0.93(0.72-1.20)

0.93(0.79-1.10)

Unknown

0.41 (0.30-0.56)*

0.46 (0.29-0.73)*

0.39 (0.29-0.52)*

Widowed

0.93(0.74-1.17)

1.00(0.72-1.40)

0.96(0.77-1.19)

0.93(0.51-0.72)

1.47(0.68-3.21)

0.91 (0.51-1.64)

Black

1.02(0.87-1.20)

1.10(0.87-1.39)

1.03(0.88-1.19)

Other

1.01 (0.58-1.76)

1.54(0.78-3.02)

1.02(0.60-1.73)

Unknown

1.07(0.94-1.21)

0.90(0.73-1.09)

1.06(0.94-1.19)

HF

1.00(0.85-0.17)

0.80(0.63-1.01)

0.95(0.81-1.11)

PVD

1.09 (0.96-1.25)

1.00(0.82-1.22)

1.08(0.95-1.23)

Paralysis

1.10(0.85-1.17)

1.22(0.85-1.74)

1.05(0.81-1.35)

Other neurological disease

0.74 (0.55-0.99)*

0.79(0.52-1.19)

0.83 (0.63-1.08)

Diabetes

0.91 (0.80-1.04)

0.88(0.72-1.08)

0.94 (0.82-1.06)

Renal failure

0.98(0.84-1.14)

0.89(0.71-1.11)

0.92(0.79-1.06)

Northeast

0.67 (0.56-0.80)*

0.69 (0.52-0.92)^

0.63 (0.53-0.74)*

Upper Midwest

1.21 (1.04-1.42)*

1.35(1.07-1.71)*

1.17(1.00-1.35)*

West

1.32(1.13-1.54)*

1.40(1.12-1.77)+

1.25(1.07-1.45)t

Sex
Male (ref)
Female
Race
White (reO

Comorbidities

Region
South (ref)

(Continued)

1204

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utilization of Rehabilitation Services by Patients With Amputation in the VA System

Table 2.
Continued
Variable

PT, OR (9SO/O Ci)

OT, OR (95% Ci)

Any Tiierapy, OR (95% Ci)

Bed size
sl26(ref)
127-244

1.11 (0.98-1.27)

1.49(1.22-1.82)*

1.20(1.06-1.36)'

245-362

0.52 (0.43-0.62)*

0.79(0.60-1.02)

0.53 (0.44-0.62)*

>362

0.92(0.70-1.21)

0.80(0.50-1.28)

0.98(0.75-1.26)

Cardiology

0.82(0.50-1.36)

0.38(0.14-1.05)

0.81 (0.50-1.30)

Neurology

0.31 (0.17-0.58)*

0.47(0.22-1.01)

0.35(0.19-0.63)

Orthopedic

0.44 (0.32-0.60)*

0.57 (0.38-0.86)+

0.44 (0.33-0.59)*

Admission bed section

Medicine (ref)

Other

1.17(0.57-2.39)

3.20(1.56-6.57)'

1.62(0.84-3.10)*

Podiatry

0.75(0.55-1.03)

0.59 (0.36-0.97)*

0.71 (0.52-0.96)*

Surgery

0.65 (0.56-0.75)*

0.55 (0.44-0.68)*

0.62(0.54-0.71)*

Vascular

0.63 (0.54-0.74)*

0.47 (0.37-0.60)*

0.61 (0.52-0.70)*

0.08

0.07

0.09

Max-rescaled R^ (Nagelkerke)

OR=odds ratio, 95% Cl=95% confidence interval, CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational
therapy, ref=reference. *P<.05, 'P<.01, *P<.001.

any therapy, respeetively, compared

with those in the South.
Discharge bed section was associated with postoperative rehabilitation service receipt. Those patients
discharged from neurology had 0.37,
0.40, and 0.35 the odds of receiving
physical therapy, occupational therapy, and any therapy, respectively,
than those discharged from medicine. Patients discharged from orthopedics had 2.08, 1.67, and 1.95
times the odds of receiving physical therapy, occupational therapy,
and any therapy, respectively, compared with those discharged from
medicine. Patients discharged from
rehabilitation had 0.32, 2.92, and
2.35 times the odds to receive physical therapy, occupational therapy,
and any therapy, respectively, compared with those discharged from
medicine.

(Tab. 4) shows that patients with

incident amputation after 2008
(as opposed to those with amputations before 2008) had 1.45, 1.73,
and 1.43 the odds of receiving preoperative physical therapy, occupational therapy, and any therapy,
respectively. Patients in the later
time period also had higher odds of
receiving postoperative physical
therapy, occupational therapy, any
therapy (odds ratio=1.68, 1.79, and
1.72, respectively).

Despite the increased prevalence

of physical therapy and occupational
therapy service receipt after guideline implementation, the regional
variations in prevalence of care
receipt persisted, as shown in
Table 5. After guideline implementation, patients who had amputations
in the West and Northeast regions
had 1.43 and 1.33 times, respectively, the odds of receiving physical
Rehabilitation services before therapy compared with patients
and after guideline implemen- from the South. Similarly, after guidetation. Examination of receipt of line implementation, patients in the
rehabilitation services by year West and Northeast regions had
September 2013

1.69 and 0.36 times, respectively,

the odds of receiving postoperative
physical therapy services compared
with patients from the South. Those
in the Northeast also had 0.35 times
the odds of receiving postoperative
occupational therapy services.

Discussion
Our study described the use of rehabilitation services following lower
limb amputation surgery at VA Medical Centers in the years 2005 to
2010. Although prior research has
examined factors associated with
the use of inpatient rehabilitation,
our study is the first to examine
change in prevalence of receipt of
rehabilitation services after the introduction of the VA/DoD Clinical Practice Guideline for Rehabilitation of
Lower Limb Amputation,' a publication meant to improve qualit)' of care
throughout the VA and DoD. Our
study examined factors associated
with receipt of both preoperative
and postoperative rehabilitation services in the acute care setting and is
the first to examine prevalence of

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Table 3.
Logistic Regression Models Predicting Postoperative Rehabilitation Receipt (n=12,587)
Variable

PT, OR (95% CI)

OT, OR (95% CI)

Any Therapy, OR (95% CI)

Length of stay (d)

1.01 (1.00-1.01)*

1.01 (1.00-1.01)*

1.01 (1.01-1.01)*

Elixhausen Index

1.11 (1.07-1.50)*

1.04 (1.00-1.08)*

1.10(1.06-1.14)*

<45

0.99(0.70-1.38)

0.86 (0.60-1.22)

1.07(0.76-1.51)

45-54

1.03(0.90-1.17)

0.88(0.77-1.01)

1.01 (0.89-1.15)

65-74

0.97(0.88-1.07)

0.94(0.85-1.04)

0.97 (0.88-1.08)

75-84

0.91 (0.81-1.01)

0.82 (0.73-0.92)*

0.87(0.78-0.97)*

85

0.83 (0.70-0.99)*

0.71 (0.58-0.86)*

0.77(0.64-0.91)+

Nursing

0.58 (0.50-0.66)*

0.50 (0.43-0.59)*

0.54 (0.48-0.63)*

Community

1.16(1.07-1.26)*

1.01 (0.92-1.09)

1.11 (1.02-1.20)*

Below knee

1.59(1.44-1.75)*

2.13(1.92-2.38)*

1.74(1.58-1.92)*

Above or at knee

1.24(1.12-1.38)*

1.67(1.48-1.88)*

1.34(1.20-1.49)*

Age(y)
55-64 (reO

Admission source
Hospital (ref)

Amputation level
Foot/ankle (ref)

Marital status
Single (reO
Divorced

0.96 (0.85-1.08)

0.93(0.81-1.05)

0.96 (0.85-1.08)

Married

0.96 (0.86-1.08)

0.98(0.87-1.11)

0.96 (0.85-1.08)

Unknown

0.31 (0.26-0.37)*

0.34 (0.28-0.42)*

0.27 (0.22-0.32)*

Widowed

0.87(0.74-1.02)

0.85(0.71-1.00)

0.87(0.75-1.03)

0.74(0.51-1.08)

0.85 (0.56-1.27)

0.80(0.55-1.16)

Sex
Male (ref)
Female
Race
White (ref)
Black

1.16(1.04-1.29)+

1.36(1.21-1.51)*

1.26(1.14-1.41)*

Other

0.72(0.49-1.06)

0.96(0.64-1.44)

0.89(0.60-1.30)

Unknown

1.11 (1.02-1.21)*

0.98 (0.89-1.07)

1.05(0.96-1.14)

CHF

0.89 (0.79-0.99)*

1.18(1.05-1.32)*

0.94 (0.84-1.05)

PVD

1.10(1.00-1.20)*

1.09(0.99-1.20)

1.07(0.98-1.18)

Paralysis

0.75(0.62-0.91)+

0.92(0.75-1.12)

0.77(0.64-0.93)+

Other neurological disease

0.82 (0.68-0.99)*

0.91 (0.75-1.11)

0.90(0.75-1.09)

Diabetes

0.92(0.84-1.01)

0.96 (0.87-1.05)

0.91 (0.83-0.99)

Renal failure

0.81 (0.74-0.90)*

0.93 (0.83-1.04)

0.81 (0.73-0.91)*

Northeast

0.50 (0.45-.56)*

0.42 (0.37-0.48)*

0.43 (0.38-0.48)*

Upper Midwest

1.28(1.15-1.43)*

1.05(0.94-1.18)

1.24(1.11-1.39)*

West

1.54(1.38-1.71)*

1.05(0.94-1.18)

1.43(1.28-1.59)*

Comorbidities

Region
South (ref)

(Continued)

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utilization of Rehabilitation Services by Patients With Amputation in the VA System

Table 3.
Continued
Variabie

PT, OR ( 9 5 % Ci)

OT, OR ( 9 5 % Ci)

Any Tiierapy, OR ( 9 5 % Ci)

Bed size
s i 26 (reO
127-244

1.38(1.26-1.52)*

1.16(1.05-1.28)f

1.41 (1.28-1.54)*

245-362

0.64 (0.67-0.72)*

1.03(0.91-1.16)

0.76 (0.68-0.85)*

>362

2.10(1.74-2.54)*

0.63(0.51-0.78)*

2.02 (1.66-2.45)*

Cardiology

0.84(0.58-1.23)

0.86(0.57-1.30)

0.83(0.57-1.20)

Neurology

0.37 (0.24-0.57)*

0.40 (0.25-0.64)*

0.35 (0.23-0.53)*

Orthopedic

2.08(1.75-2.48)*

1.67 (1.40-1.99)*

1.95(1.63-2.32)*

Discharge bed section

Medicine (ref)

Other

1.00(0.53-1.91)

1.31 (0.67-2.53)

1.14(0.59-2.20)

Podiatry

0.80 (0.62-1.02)

0.47 (0.32-0.68)*

0.78(0.61-1.01)

Rehabilitation

2.32(1.95-2.76)*

2.92 (2.47-3.45)*

2.35(1.97-2.82)*

Surgery

1.48(1.33-1.65)*

1.37(1.22-1.54)*

1.52(1.36-1.69)*

Vascular

1.28(1.15-1.42)*

1.21 (1.08-1.35)'

1.31 (1.18-1.45)*

0.15

0.13

0.16

Max-rescaled R^ (Nagelkerke)

OR=odds ratio, 95% Cl=95% confidence interval, CHF=congestive heart failure, PVD=peripheral vascular disease, PT=physical therapy, OT=occupational
therapy, ref = reference. *P<.05, 'P<.01, *P<.001.

receipt of specific rehabilitation services, including physical therapy and

occupational therapy services.
Overall, we found that receipt of
any postoperative rehabilitation
was much more prevalent than preoperative rehabilitation, with 13.6%
of patients receiving some type of
service preoperatively and 54.7%
receiving services postoperatively.
Physical therapy was the most common type of service provided preoperatively and postoperatively.
Our findings suggest that patients
aged 75 to 84 years and those who
were sicker were more likely to
receive preoperative rehabilitation
services than patients 55 to 64 years
old, controlling for all other factors.
However, patients over the age of
85 years were no more likely to
receive services than those 55 to 64
years of age. It is unclear why these
differences in service receipt exist,
given that the guidelines recommend that physical therapy and
September 201 3

occupational therapy professionals

be involved in preoperative patient
assessment of ROM, strength, mobility, and function, regardless of age or
comorbidity.
Our findings suggest that patients
who were less independent (admit-

ted from nursing facilities) and were

over age 75 years were less likely to
receive postoperative rehabilitation
in the acute care setting. Our results
are similar to those reported by Zhou
et al,^ who found that older people
and those who were admitted from
extended care facilities were less

Table 4.
Logistic Regression Models Predicting Likelihood of Receipt of Preoperative and
Postoperative Rehabilitation After 2008, After VA/DoD Clinical Practice Guideline
Publication (n=6,376). Compared With Before 2008, Before Guideline Publication
(n=4,180)
OR ( 9 5 % Ci)

Services
Preoperative PT

1.45(1.27-1.65)**

Preoperative OT

1.72(1.41-2.10)**

Preoperative any therapy

1.45 (1.28-1.65)* *

Postoperative PT

1.68(1.53-1.84)*-*

Postoperative OT

1.79(1.63-1.97)**

Postoperative any therapy

1.72(1.57-1.89)*-*

OR=odds ratio, 95% Cl=95% confidence interval, PT=physical therapy, OT=occupational therapy.
* Results of separate models controlling for length of stay, Elixhausen Index, inconne, age, amputation
level, admission source before hospitalization, marital status, sex, race, congestive heart failure,
peripheral vascular disease, paralysis, other neurological disorders, diabetes, renal failure, hospital
region, and hospital bed size. Admitting bed section was included in models predicting preoperative
service receipt, and discharge bed section was included In the models predicting postoperative service
receipt. * P<.001.
i

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Table 5.
Logistic Regression Models Predicting Rehabilitation Receipt: Results of Separate Models"
Preoperative Services
PT

OT

Any Tiierapy

Before 2008

After 2008

Before 2008

After 2008

Before 2008

After 2008

OR (95% CI)

OR (95% Cl)

OR (95% CI)

OR (95% CI)

OR (95% CI)

OR (95% Ci)

Northeast

0.76(0.58-0.99)*

0.67 (0.50-0.90)+

0.74(0.48-1.14)

0.68(0.43-1.07)

0.72 (0.55-0.92)*

0.61 (0.46-0.81)*

Upper Midwest

1.58(1.25-2.01)*

1.11 (0.86-1.43)

1.52(1.04-2.23)*

1.36(0.95-1.95)

1.51 (1.20-1.90)*

1.04(0.82-1.33)

West

1.38(1.09-1.76)+

1.43(1.11-1.84)+

1.78(1.25-2.55)+

1.32(0.92-1.90)

1.36(1.09-1.72)+

1.28(1.01-1.64)*

Region
South (reO

Postoperative Services
PT

Region

OT

PT/OT

Before 2008

After 2008

Before 2008

After 2008

Before 2008

After 2008

OR (95% Ci)

OR (95% CI)

OR (95% CI)

OR (95% Ci)

OR (95% Ci)

OR (95% Ci)

South (ref)
Northeast

0.69(0.59-0.81)*

0.36 (0.30-0.45)*

0.57 (0.48-0.68)*

0.35 (0.28-0.43)*

0.62 (0.53-0.72)*

0.30 (0.24-0.36)*

Upper Midwest

1.72(1.47-2.01)*

0.94(0.77-1.15)

1.16(0.98-1.38)

0.96(0.79-1.16)

1.65(1.41-1.94)*

0.88(0.72-1.07)

West

1.53(1.31-1.78)*

1.69(1.39-2.06)*

1.07(0.90-1.26)

1.20(0.99-1.45)

1.37(1.17-1.59)*

1.57(1.28-1.93)*

'OR=odds ratio, 95% Cl=95% confidence interval, PT=physical therapy, OT=occupational therapy. *P<.05, +P<.01, *P<.001.

likely to receive outpatient therapy ple who had serious comorbidities

services after lower limb amputa- in the acute setting were less likely
tion. However, a study of rehabilita- to receive outpatient services. Fretion receipt in the acute care setting burger et al"* also reported that
in North Carolina showed that the greater illness severity, as indicated
relationship of age to service receipt by the presence of conditions such
varied by condition, with older age as hemorrhagic stroke and congesassociated with an increased likeli- tive heart failure, was associated
hood of receipt of rehabilitation ser- with a lower likelihood of receiving
vices poststroke, but not after hip physical therapy in the acute care
replacement."* That study did not setting.
examine living location prior to
admission and did not assess receipt We found that people who were
of care after lower limb amputation. discharged from acute care more
quickly were less likely to have
We found that having more comor- received postoperative rehabilitation
bid conditions (as measured by the services. Our results suggest that
Elixhausen Index) was associated for each 10 additional days in the
with increased likelihood of receiv- hospital, patients would have a l6%
ing therapy (preoperatively and post- and 9% increased likelihood of
operatively), but that having con- receiving preoperative physical
ditions with greater severity, such therapy and occupational therapy,
as congestive heart failure, paraly- respectively, and a 6% increased likesis, and renal failure, was associated lihood of receiving postoperative
with a decreased likelihood of physical therapy or occupational
receiving physical therapy. Zhou et therapy. Consistent with our findal^ did not report an association ings regarding length of stay, Frebetween total Elixhausen Index and burger et al"* also reported that lonlikelihood of receipt of outpatient ger hospital length of stay was
therapy, but they did find that peo- associated with a greater likelihood
1208

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Number 9

of receiving physical therapy after

stroke and joint replacement surgery. It is possible that some patients
had been referred for therapy services but that those services were
not delivered prior to discharge due
to a short time frame, scheduling, or
staffing issues.
We found considerable variation in
receipt of preoperative rehabilitation that was associated with region
of the country, even after controlling
for patient characteristics, comorbidities, and admission source prior
to hospitalization. Patients in the
Northeast had the lowest likelihood
of receiving any preoperative services (all categories), whereas
patients in the West had th highest likelihood of receiving any preoperative services compared with
patients in the South. This pattern
was largely repeated for most postoperative rehabilitation services,
with patients in the Northeast having approximately 0.50 lower odds
of receiving postoperative services
(all categories) and patients in the
West having 1.54 the odds of receivSeptember 201 3

Utilization of Rehabilitation Services by Patients With Amputation in the VA System

ing postoperative physical therapy
compared with patients in the South.
We do not know for certain what
amount of service utilization is too
little, too much, or just the clinically
indicated amount. How^ever, in an
ideal health system and assuming
that patient preferences are the
same, wide variations in health care
utilization should not occur.

hospitals may not have occupational

therapists and may use physical therapists to perform functional rehabilitation, we did not observe a
decreased likelihood of occupational
therapy utilization for smaller hospitals. Instead, smaller hospitals of
127 to 244 beds were more likely to
provide the most preoperative occupational therapy, as well as postoperative physical therapy and occupaThe reasons for variation of care in tional therapy. This finding suggests
this national VA sample are not clear, larger hospitals may have lower
and w^e have no way of determin- therapist-to-hospital bed ratios and
ing whether rehabilitation treatment more unfilled vacancies. This finding
delivered was clinically indicated or contrasts with that of Freburger et al, ' ''
whether clinically indicated treat- who reported that patients at larger
ment was not delivered. Given that hospitals were more likely to receive
the guidelines suggest that physical acute care physical therapy after hip
therapy and occupational therapy joint replacement or stroke. However,
providers should be consulted for Freburger and colleagues' study
postoperative patient assessment included only hospitals in a single
and should play a role in develop- state, whereas our study included aU
ment of a treatment plan, we suspect VA medical centers in the country.
the latter.
In summary, the reasons for geoAlthough previous investigators graphic variation in receipt of rehareported variation in receipt of reha- bilitation services in the acute care
bilitation in an SRU associated with setting are unclear, but could be due
region and bed size,"'^ ^ e did not to regional and hospital level differexpect to see similar variations in ences in practice patterns as well as
rehabilitation service delivery in the hospital staffing levels.
acute care setting. Access to specialized rehabilitative care varies, in Our study did not examine data after
part, due to supply and co-location discharge from the acute hospital
within the hospital or area, whereas stay, and thus we are unable to deteraccess to rehabilitation in the acute mine whether these patients, with
care setting should be more uni- apparently greater need for rehabiliformly available because acute care tation, did ultimately receive rehabilhospitals typically have physical itation services, albeit in a delayed
therapists and occupational thera- time frame. However, Zhou et al''
pists on site to provide services. Our reported that older veterans and
findings, together with those of those admitted from long-term care
Zhou et al,** suggest that there may facilities were less likely to receive
be regional trends across the contin- outpatient rehabilitation, perhaps
uum of rehabilitation services post- because of a perceived lack of rehaamputation, with prevalence of use bilitation potential.
the lowest in the Northeast and highest in the Midwest and West.
We found that the likelihood of
receiving preoperative and postThe pattern of relationship between operative physical therapy and occuhospital bed size and receipt of reha- pational therapy services was signifbilitation services was less clear. icantly greater after the introduction
Although we expected that smaller of the guidelines. Although this
September 2013

increase in receipt of physical therapy and occupational therapy services was expected, we are unable
to state with any certainty that the
relationship between introduction of
the guidelines and prevalence of
rehabilitation receipt was causal
because the study design was observational. Instead, any observed associations may have been due to
changing practice patterns over this
time period and were not directly
related to guideline introduction.
We are unaware of any similar studies that would provide historical
comparisons for non-VA hospitals.
Because this was an observational
study and w^e had no relationship to
the w^ork group that developed the
guidelines, we had limited information on how they were disseminated.
The VA has an office of quality management that disseminates evidencebased guidelines for all types of conditions.' Although regional variation
in dissemination of the guidelines
may have existed, we have no information on the methods used to disseminate the guidelines or whether
these methods differed across VA
medical centers.
Another study limitation is that the
sample included only those veterans
who had amputation surgeries
within the VA system. No attempt
was made to identify veterans who
had their surgeries at other facilities.
Therefore, the findings cannot be
generalized to veterans who had
their surgeries outside the VA or to
nonveteran patients and settings.
We encountered known problems
with missing race information in our
VA secondary data sources. Race
information was recaptured for more
than half of those patients missing
it by using VA MedSAS outpatient
data. Nevertheless, l6% of patients
had this information missing, threatening the validity of the findings
about the relationship between

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utilization of Rehabilitation Services by Patients With Amputation in the VA System

being black and likelihood of rehabilitation service receipt.

VAA)oD Clinical Practice Guideline

for Rehabilitation of Lower Limb
Amputation.' We found that prevaThe sample was limited to veterans lence of receipt of preoperative
with new amputations by using a and postoperative therapy services
12-month look-back period, similar (physical therapy and occupational
to the one used by prior research- therapy) in the acute care setting
5-5.4.8-10 However, it is possible that increased after the introduction of
some patients had revisions of ampu- the guidelines. The analyses identitations performed prior to that date, fied variations in receipt of rehaor outside of the VA. It is possible bilitation by geographic regin and
that rehabilitation receipt varied hospital bed size that were not
for bilateral amputees; however, we explained by patient characteriswere not able to examine this issue tics. These findings suggest that ftirbecause there is no way to identify ther quality improvement efforts
whether patients had bilateral ampu- are needed to standardize delivery of
tations, as side of amputation surgery rehabilitation services for veterans
is not coded in the data.
with amputations in the acute care
setting.
Although we attempted to control
for patient characteristics that w^e Both authors provided concept/idea/
believed might influence receipt of research design, writing, and data analysis.
rehabilitation and included key vari- Dr Resnik provided project management.
ables reported in prior literature,
DOI: 10.2522/ptj.20120415
we had no measures of wound healing, functional status, or cognitive
function prior to amputation, which References
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we could expect would be associDoD Clinical Practice Guideline for Rehaated with service receipt. Thus,
bilitation of Lower Limb Amputation.
Available at: http://www.healthqualit)'.
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va.gov/Lower_Limb_Amputation.asp. Acconfounders.
cessed March 30, 2011.
Lastly, the study was largely descriptive; we did not attempt to examine
the impact of rehabilitation receipt
on outcomes, such asftmctionalstatus, health care costs, discharge destination, or use of rehabilitation services outside of the acute hospital
stay. Further research is needed to
link additional data sources to examine these types of questions.

Conclusions and
Implications
This study described the use of rehabilitation services prior to and following lower Umb amputation surgery at VA medical centers in the
years 2005 to 2010 and compared
rates of utilization of services prior to
and after the introduction of the

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Volume 93

2 Esquenazi A, Meier RH Jr. Rehabilitation in

limb deficiency, 4: limb amputation. Arch
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3 Stineman MG, Kwong PL, Xie D, et aL
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232-243.

7 Dillingham TR, Pezzin LE, Mackenzie EJ.

Discharge destination after dysvascular
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Rehabii. 2003;84:l662-l668.
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12 Kurichi JE, Xie D, Kwong PL, et al.factors
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Available at: http://www.virec.research.va.
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4 Zhou J, Bates BE, Kurichi JE, et al. Factors

influencing receipt of outpatient rehabilitation services among veterans following
lower extremit)' amputation. Arch Phys
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17 HCUP Comorbidity Software. Healthcare

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18 Konety BR, Dhawan V, Allareddy V, Joslyn

SA. Impact of hospital and surgeon volume
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6 Dillingham TR, Pezzin LE, MacKenzie

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Number 9

September 2013

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