HEALTH SERVICE RESEARCH CSIRO PUBLISHING

Australian Health Review, 2015, 39, 76–84 http://dx.doi.org/10.1071/AH14042

Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: a 7-year series Heather R. Batten1,2,9 B Phty, Physiotherapist Advanced, MPhil Candidate Suzanne S. Kuys3,4 PhD, BPhty(Hons), PGDip Pub Hlth, BEdSt, BHMS (Ed), Principal Research Fellow Steven M. McPhail5,6 PhD, BPhty, Principal Research Fellow Paulose N. Varghese7,8 MBBS PG Dip PH FRACP, Director of Geriatric Medicine Jennifer C. Nitz2 PhD, MPhty, BPhty, FACP, Senior Lecturer, Leader Ageing Research Team 1

Physiotherapy Department, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia. Division of Physiotherapy, School of Health & Rehabilitation Sciences, The University of Queensland, St Lucia, Qld 4072, Australia. Email: [email protected] 3 Allied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Rode Road, Chermside, Qld 4032, Australia. Email: [email protected] 4 Griffith Health Institute, Griffith University, Gold Coast, Qld 4222, Australia. 5 Centre for Functioning and Health Research, Buranda Village, Corner Ipswich Road and Cornwall Streets, Buranda, Qld 4102, Australia. Email: [email protected] 6 Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Qld 4059, Australia. 7 Department of Geriatric Medicine, Princess Alexandra Hospital, Ispwich Road, Woolloongabba, Qld 4102, Australia. 8 School of Medicine, The University of Queensland, St Lucia, Qld 4072, Australia. Email: [email protected] 9 Corresponding author. Email: [email protected] 2

Abstract Objective. To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. Methods. In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. Results. Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25–76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P < 0.001) and recorded lower functional independence measure – motor scores at admission (z = 3.61, P < 0.001) and discharge (z = 4.52, P < 0.001). More nonvascular amputees worked before amputation (43% vs 11%; P < 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P < 0.001) and had a shorter length of stay (7 days, 95% confidence interval: –3 to 17), although this was not statistically significant. Conclusions. Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees. What is known about the topic? Lower limb amputation occurs due to various aetiologies. What does this paper add? Lower limb amputee rehabilitation over 7 years was investigated, comprising 425 admissions, 80% due to dysvascular aetiology. Personal and social demographics, and discharge outcomes are compared by aetiology. What are the implications for practitioners? Demographic and discharge outcome differences exist between dysvascular and non-vascular lower limb amputees. Twenty-one percent were required to change residence and 28% required additional social supports. Discharge planning should begin as soon as possible to limit time spent waiting for new Journal compilation  AHHA 2015

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Demographics and outcomes of lower limb amputees

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accommodation or major modifications for current homes. Lower limb amputees are not homogeneous, so care should be taken if extrapolating from combined amputee aetiologies or from one aetiology to another. Additional keywords: amputation, prosthesis, rehabilitation. Received 25 February 2014, accepted 21 September 2014, published online 5 January 2015

Introduction Lower limb amputation is a severe complication of vascular disease.1 Although causes of lower limb amputation include trauma, cancer and infection, dysvascular causes, such as diabetes, peripheral vascular disease and venous conditions, traditionally have the largest representation in the amputee population in the western world.2 In Australia, there is likely to be an increased demand on services required after amputation due to increasing rates of diabetes and the aging population.3 Amputation is a catastrophic event with severe consequences for the individual and healthcare system. Losing a limb, particularly a lower limb, has been shown to negatively affect physical ability4 and quality of life,5 and is associated with a deterioration of functional ability affecting residential status,6 with a significant number of amputees requiring long-term care.7 However, there is limited evidence as to whether the aetiology of amputation influences outcomes following subacute inpatient rehabilitation. Some differences have been found been between dysvascular and non-vascular amputees in terms of age,8 mobility,9,10 activities of daily living, cognition, memory and communication.11 Recently, no difference in rehabilitation length of stay was reported between dysvascular amputees and other aetiologies.12 However, further investigation is required to examine the influence of personal and social demographics, and outcomes such as length of stay, residential status, employment and prosthetic prescription between dysvascular and non-vascular lower limb amputees. Princess Alexandra Hospital is the largest tertiary hospital in the Metro South Hospital and Health Service (Metro South Health), situated in the south-east corner of Queensland, Australia.13 It services 1.5 million people across the Metro South, Darling Downs–West Moreton and South West Queensland Health Services. The Princess Alexandra Hospital performed 21% of all lower limb amputations in Queensland during 2006–07,14 with the majority receiving subacute inpatient rehabilitation on site. Consequently, the patient sample receiving rehabilitation at this facility represents a substantial proportion of this clinical population, so examining their outcomes may be informative for guiding future service improvements in this and other comparable subacute inpatient rehabilitation services. At Princess Alexandra Hospital, following a lower limb amputation, amputees are cared for in the acute orthopaedic or vascular wards for 5–7 days. The multidisciplinary team determines the appropriate acute care discharge destination, including on-site speciality amputee inpatient rehabilitation, home with or without outpatient rehabilitation or to a long-term care facility. Rigid removable dressings are used with transtibial amputees once admitted to rehabilitation. Prosthetic services are provided on site. Those admitted for inpatient rehabilitation directly from acute care will undergo interim prosthetic fitting (from ~6 weeks

postoperatively) and prosthetic training during their inpatient rehabilitation stay. Other amputees undergo prosthetic rehabilitation as outpatients or can be readmitted to inpatient rehabilitation for an intensive block of prosthetic training. The inpatient amputee rehabilitation program is patient-focussed and goaldirected, with physiotherapists designing individualised exercise programs as well as providing group education sessions. This study examined the personal and social demographics of people with new lower limb amputations admitted for subacute inpatient rehabilitation at Princess Alexandra Hospital between 2005 and 2011. A secondary aim was to describe the rehabilitation discharge outcomes, including length of stay, change of residential status and prosthetic prescription. Comparisons were made between patients whose primary reason for lower limb amputation was attributable to dysvascular or non-vascular aetiology. Methods Design A retrospective cohort investigation was undertaken. Setting and participants Participants included amputees admitted to a subacute inpatient rehabilitation unit at Princess Alexandra Hospital. Patients admitted for rehabilitation following a new lower limb amputation (consecutive admissions meeting inclusion criteria) between January 2005 and December 2011 were eligible for inclusion. The inclusion criterion for participation was a new primary diagnosis of major lower limb amputation, consisting of transtibial, knee disarticulation, transfemoral or hip disarticulation. There were no exclusion criteria. Institutional Human Research Ethics Committees approved this study. Procedures A purpose-designed database had been previously developed for unit staff to record demographic, clinical and functional outcome measures for patients admitted to this unit. Staff from the multidisciplinary team recorded demographic and clinical information for all patients in this database following routine clinical assessments at admission and before discharge from the unit. Records of patients that met the inclusion criteria were identified from the database. Demographic and outcome variables that were relevant to this investigation were extracted to a separate research database. These variables were checked for completeness and any missing data were retrieved from the patient’s medical record by a member of the staff from the rehabilitation unit. Where multiple amputations occurred on the same limb within the same acute hospital episode, the higher level of amputation was recorded. Similarly, if a contralateral lower limb amputation occurred within the same acute

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hospital admission, this was recorded as bilateral amputation. If a patient was transferred back to the acute hospital on site, they were considered to be discharged and the length of stay was determined at that date. If the patient was later readmitted back to the rehabilitation unit, this was considered a new admission and the rehabilitation length of stay recommenced. All patients who required a second admission for rehabilitation following discharge home were classified as a new admission. This included patients readmitted from home specifically for prosthetic training or those who underwent a new amputation (on either a more proximal or contralateral limb). Personally identifiable patient information (for example, patient names) was not included in the research database, which was subsequently analysed to address the research aims. The total number of patients who had received a lower limb amputation during the study period (including those not admitted for rehabilitation) was obtained from the hospital’s Activity Based Funding and Clinical Costing Unit. Outcomes Personal demographic information included gender, age, aetiology of amputation, level of amputation and use of walking aid before hospital admission (if any). Comorbidities identified and reported included cardiovascular conditions (atrial fibrillation, hypertension, ischaemic heart disease, diabetes, peripheral vascular disease, hypercholesterolemia, obesity and, congestive cardiac failure), respiratory disease (chronic obstructive pulmonary disease and asthma), neurological conditions (cerebrovascular accident, transient ischaemic attack), cancer, cognitive impairment, visual impairment, renal impairment or dialysis, and previous amputations. The total number of these comorbidities for each individual was also recorded. Social demographic information included place of birth, marital status, employment status, type of residence before hospital admission, social supports (living situation, use of community services) and indigenous status. Discharge outcomes recorded included the proportion of patients who had a further admission to the same rehabilitation unit during the study period (and who met the inclusion criteria), whole-of-episode inpatient rehabilitation length of stay (time from admission until discharge from inpatient rehabilitation unit), functional independence measure – motor (FIM-M)15 scores, deaths while an inpatient in rehabilitation unit, prosthetic prescription rates, walking aids used at discharge from rehabilitation, discharge destination, discharge supports (living situation, use of community services) and those who had to change residence (i.e. they were discharged to an alternate residence at discharge from inpatient rehabilitation compared to their residence before amputation). Analysis Descriptive statistics (frequency and percentages) were calculated for all variables at admission and discharge from inpatient rehabilitation. Tests for normality (Shapiro–Wilk) and homogeneity of variance (Levene) were performed for all outcomes. Age was the only normally distributed variable; non-parametric analyses were conducted for all other variables. Participants were grouped according to aetiology: dysvascular or non-vascular. Conventional unpaired tests of hypotheses were then used to

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examine potential differences between patients with amputations attributable to dysvascular or non-vascular causes. This included a t-test for age, Wilcoxon rank-sum tests for total number of comorbidities, length of stay, and FIM-M score at admission and discharge, and chi-square tests for previous walking aid use, employment status, residential status, social supports, prosthetic prescription and discharge walking aid. Alpha was set at 0.05 for these analyses, which were performed with StataSE ver. 12 (StataCorp LP, College Station, TX, USA). Results Amputee demographics A total of 601 people underwent a new major lower limb amputation at Princess Alexandra Hospital. This resulted in 425 (71%) admissions to the amputee rehabilitation unit of 335 individuals with 90 readmissions during the study period. Ten readmissions occurred following a transfer to the acute hospital for additional treatment; these were recorded as a separate admission. Thirty-two readmissions occurred following a further amputation (24 had an amputation on the contralateral leg, 8 had a more proximal amputation on the ipsilateral leg) and 48 were for prosthetic training. Thirty-five people were discharged to an acute hospital for further treatment or management, and were considered to have been discharged for the purposes of data analysis. Personal demographic information is displayed in Table 1. The mean (s.d.) age of people admitted for amputee rehabilitation was 65 (14) years; 314 (74%) were male. Dysvascular causes accounted for 342 (80%) of the amputees admitted for rehabilitation. Cardiovascular risk factors were common within the dysvascular group, particularly hypertension, diabetes and peripheral vascular disease, which were each present in more than 50% of amputees. Approximately half (n = 226, 53%) used a walking aid indoors before amputation. The median FIM-M score at admission to inpatient rehabilitation was 70 (interquartile range (IQR): 54.5–76). Social demographics are displayed in Table 2. Approximately half of the amputees (n = 208, 49%), reported having a partner (married or de facto); 132 (31%) lived alone before their admission. Community domestic or personal care services were required for 70 (16%) of the amputees before their admission. The majority (n = 350, 82%) were not in paid employment. Australia was the birthplace for 305 (72%) of the amputees, with 6 (1.8%) identifying as indigenous Australian. Discharge outcomes Outcomes for patients discharged from subacute inpatient rehabilitation are presented in Table 3. Median length of stay in rehabilitation was 48 days (IQR: 25–76), although there was a large variation across patients, ranging from 2 days to 273 days. Few people (n = 15, 4%) died during the period of their subacute inpatient rehabilitation. Median FIM-M scores at discharge was 79 (IQR: 74–84). Lower limb amputation resulted in a change of residence for 89 (21%) of the admissions, with 25 (6%) requiring long-term residential care. Community domestic or personal care services were required for 116 (28%) of amputees following discharge from subacute rehabilitation. Approximately half (56%) of the group received

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Table 1. Personal demographics of lower limb amputee admissions to rehabilitation from 2005 to 2011 *Significant difference between dysvascular and non-vascular amputees, P < 0.05. TTA, transtibial amputation; TFA, transfemoral amputation; IQR, interquartile range; FIM-M, functional independence measure – motor Personal demographic Total rehabilitation admissions n (%) Gender n (%) Males Females Admission age (years) Mean (s.d.)* Range Aetiology of amputation n (%) Dysvascular Diabetes or peripheral vascular disease Venous Non-vascular Trauma Tumour Infection OtherA Amputation level n (%) TTA: unilateral TFA: unilateral Bilateral TTA Bilateral TFA TTA and TFA OtherB Previous walking aid indoors n (%)* Nil Stick Walker (four-wheeled walker or hopper) Wheelchair Others (including crutches, rollator) Comorbidities n (%) Cardiovascular conditions Atrial fibrillation Hypertension Ischaemic heart disease Diabetes Peripheral vascular disease Hypercholesterolaemia Obesity Congestive cardiac failure Respiratory disease Chronic obstructive pulmonary disease Asthma Neurological conditions Cerebrovascular accident Transient ischaemic attack Cancer Cognitive impairment Visual impairment Renal impairment Dialysis Previous amputation Total number comorbidities n (%)* 0 1–3 >3 Median (IQR) Range FIM-M score at admission* Median (IQR) A B

Total

Dysvascular

Non-vascular

425 (100)

342 (80)

83 (20)

314 (74) 111 (26)

252 (74) 90 (26)

62 (75) 21 (25)

65 (14) 19–93

67 (12) 26–93

54 (16) 19–82

342 (80) 83 (20) – – – – –

342 (100) 334 (98) 8 (2) – – – – –

83 (100) – – 25 (30) 14 (17) 29 (35) 15 (18) –

184 (43) 147 (35) 38 (9) 27 (6) 16 (4) 13 (3)

144 (42) 119 (35) 35 (10) 25 (7) 15 (4) 4 (1)

40 (48) 28 (34) 3 (4) 2 (2) 1 (1) 9 (11)

199 (47) 63 (15) 54 (13) 79 (19) 30 (7)

150 (44) 53 (15) 48 (14) 69 (20) 22 (6)

49 (59) 10 (12) 6 (7) 10 (12) 8 (10)

76 (18) 254 (60) 162 (38) 234 (55) 222 (52) 142 (33) 47 (11) 52 (12) 81 (20) 67 (16) 12 (3)

69 (20) 225 (66) 153 (45) 209 (61) 212 (62) 130 (38) 36 (11) 52 (15) 70 (20) 59 (17) 9 (3)

7 (8) 29 (32) 9 (10) 25 (27) 10 (11) 12 (13) 11 (12) 0 (0) 11 (12) 8 (9) 3 (3)

66 (16) 17 (4) 47 (11) 14 (3) 73 (17) 116 (27) 32 (8) 65 (15)

63 (18) 16 (5) 30 (9) 14 (4) 64 (19) 101 (30) 24 (7) 63 (18)

3 (3) 1 (1) 17 (19) 0 (0) 9 (10) 14 (15) 7 (8) 2 (2)

42 (10) 135 (32) 248 (58) 4 (3–6) 0–12

10 (3) 94 (27) 238 (70) 4 (3–6) 0–12

33 (36) 33 (40) 20 (24) 2 (0–3) 0–9

70 (54.5–76)

67 (53–75)

73 (68–78)

Other causes of amputation include burns, compartment syndrome and rhabdomyolysis. Other levels of amputation include foot amputation on other leg, knee or hip disarticulation, and hemipelvectomy.

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Table 2. Social demographics of lower limb amputee admissions to rehabilitation from 2005 to 2011 *Significant difference between dysvascular and non-vascular amputees, P < 0.05 Social demographic Place of birth n (%) Australia United Kingdom Other Marital status n (%) Partner (married, de facto) No partner (never married, separated, divorced, widowed) Not stated Employment status n (%) Employed* Not employed (unemployed, pension, retired, home duties, student)* Pension (aged, disability or carer) Previous residence n (%) Community Owned (including caravan) Other owned Rental (including public housing, boarding house) Retirement village Supported community Residential care Social support n (%) Lived alone Lived alone with services Lived with another Lived with another and services

Total n = 425

Dysvascular n = 342

Non-vascular n = 83

305 (72) 45 (11) 75 (17)

239 (70) 38 (11) 65 (19)

66 (80) 7 (8) 10 (12)

208 (49) 212 (50) 5 (1)

168 (49) 170 (50) 4 (1)

40 (48) 42 (51) 1 (1)

75 (18) 350 (82) 294 (69)

38 (11) 304 (88) 260 (76)

36 (43) 47 (57) 35 (42)

422 (99) 213 (50) 40 (9) 152 (36) 14 (3) 3 (1) 3 (1)

339 (99) 171 (50) 30 (9) 121 (35) 14 (4) 3 (1) 3 (1)

83 (100) 42 (51) 10 (12) 31 (37) 0 (0) 0 (0) 0 (0)

88 (21) 44 (10) 264 (62) 26 (6)

70 (20) 39 (11) 208 (61) 22 (6)

18 (22) 5 (6) 56 (67) 4 (5)

Table 3. Discharge outcomes of lower limb amputee admissions to rehabilitation from 2005 to 2011 *Significant difference between dysvascular and non-vascular amputees, P < 0.05. IQR, interquartile range; FIM-M, functional independence measure – motor Discharge outcomes Length of stay (days) Median (IQR) Range FIM-M score on discharge* Median (IQR) Received a prosthesis n (%)* Discharge walking aid n (%) Nil Stick(s) Walker (four-wheeled walker, hopper) Wheelchair* Other (including crutches) Discharge destination n (%) Community Hospital transfer Residential care facility Death Changed residence Discharge support n (%) Living alone Living alone with services Living with another Living with another and services Readmissions n (%)

Total n = 425

Dysvascular n = 342

Non-vascular n = 83

48 (25–76) 2–273

48.5 (26–77) 2–273

44 (23–71.5) 3–160

79 (74–84) 238 (56)

78 (70–83) 177 (52)

82 (79–85) 61 (73)

6 (1) 96 (23) 49 (12) 229 (54) 23 (5)

2 (1) 63 (18) 43 (13) 196 (57) 16 (5)

4 (5) 33 (40) 6 (7) 33 (40) 7 (8)

340 (80) 45 (11) 25 (6) 15 (4) 89 (21)

266 (78) 38 (11) 23 (7) 15 (4) 74 (22)

74 (89) 7 (8) 2 (2) 0 (0) 15 (18)

36 (8) 58 (14) 188 (44) 58 (14) 90 (21)

29 (8) 49 (14) 136 (40) 52 (15) 77 (23)

7 (8) 9 (11) 52 (62) 6 (7) 13 (16)

Demographics and outcomes of lower limb amputees

a prosthesis for mobility; however, a wheelchair was the discharge mobility aid for 229 (54%) of the admissions. Ten percent of the group who were prescribed a prosthesis for mobility were not mobilising with it at discharge from subacute inpatient rehabilitation. Dysvascular versus non-vascular amputees Dysvascular amputees were older (d.f. = 423, t = 8.27, P < 0.001), had more comorbidities (n1 = 342, n2 = 83, z = 7.80, P < 0.001), recorded a lower FIM-M score on admission (n1 = 342, n2 = 83, z = 3.61, P < 0.001) and more frequently used a walking aid before the current amputation (d.f. = 1, c2 = 6.18, P = 0.013; Table 1). More non-vascular amputees were employed (d.f. = 1, c2 = 19.11, P < 0.001). Both clinical groups had similar residences and social supports before amputation (Table 2). There was no statistically significant difference in length of stay between dysvascular and non-vascular amputees (n1 = 342, n2 = 83, z = 0.996, P = 0.32). Dysvascular amputees recorded a lower FIM-M score on discharge (n1 = 342, n2 = 83, z = 4.52, P < 0.001), fewer were prescribed a prosthesis (d.f. = 1, c2 = 12.81, P < 0.001) and a greater proportion were discharged using a wheelchair for mobility (d.f. = 1, c2 = 11.07, P = 0.001) in comparison to the non-vascular amputee group. There were no deaths in the non-vascular group whilst undertaking subacute inpatient rehabilitation (Table 3). Discussion This study successfully addressed the research aims, demonstrating that the majority of admissions were male and elderly, and the need for amputation was attributable to dysvascular causes. The investigation also indicated that non-vascular amputees were younger, more frequently employed, had less comorbidities, had a higher FIM-M score at admission and less frequently used a walking aid before amputation. Following lengthy subacute inpatient rehabilitation, a very high proportion of patients were able to return to living in the community rather than residential care facilities. However, many were required to change residence and needed more community services. Amputees admitted for rehabilitation at Princess Alexandra Hospital had similar characteristics to previously published studies of lower limb amputations in Australia with respect to age, gender and aetiology.12,13,16,17 Differences were apparent for the reported level of amputation, percentage receiving a prosthesis and rehabilitation length of stay. A substantial proportion of the sample had transfemoral or bilateral amputations, which are more likely than transtibial amputations to be due to advanced vascular disease and occur in the presence of comorbidities.18 Additionally, the people with these types of amputations have more complex needs that often require institutionalisation after amputation.19 It is possible that this illustrates the potential frailty and complexity present among this cohort in comparison to previous studies that have reported higher proportions of transtibial (55–68%)12,16,20 and lower proportions of transfemoral (22–28%)12,16 and bilateral amputees (8–15%).12,16 The higher proportion of transfemoral and bilateral amputees in the present study may also have contributed to the lower prosthetic prescription rates (56%) than those previously reported (81%).16 Proximal amputation

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has previously been associated with low prosthetic success rate21 due to the increased energy requirements of prosthetic walking22 and increased mortality.7,23 Inpatient rehabilitation length of stay (median: 48 days) was higher in the current study than that previously reported for Australian amputee cohorts (median: 17–44 days).12,16,17 It would have been reasonable to hypothesise that the length of stay in this study could have been shorter compared to other Australian amputee cohorts,12,16,17 given that patients were considered to be discharged (and the length of stay determined at that date) if transferred back to the acute hospital on site. However, this was not the case. Previous studies were conducted in a prosthetic rehabilitation unit12 or reported on a national database,17,24 and were therefore not necessarily inclusive of all amputees or may reflect differences in service delivery models, such as ambulatory models, across Australia. Additionally, our longer inpatient rehabilitation length of stay may be due to our lower prosthetic prescription rates. A previous study16 had a higher proportion of prosthetic users (81%), which could indicate a higher functioning amputee group and subsequently contribute to a shorter inpatient rehabilitation length of stay. Amputees who receive a prosthesis are known to have shorter length of stays than amputees who are wheelchair-dependent.25 Amputees require a long length of stay in subacute rehabilitation units due to the importance of restoring independent mobility and community integration.26 Historically, one suggested contributing factor for long length of stay in rehabilitation units is people waiting for transfer to a residential care facility.27,28 This, however, does not appear to be the case in the current study, as only 6% of patients were discharged to a residential aged care facility. Locating suitable accommodation and waiting for financial funding and then completion of home modifications have been identified as barriers for discharge from inpatient rehabilitation.28 A substantial proportion of the present cohort required a change in residence (21%) or major modifications made to their previous residence before discharge from inpatient rehabilitation. The majority of these relocations or modifications were due to the new amputees requiring wheelchair accessible accommodation. It is possible that many amputees lived in residences with stair access, either internal such as units or external such as the ‘Queenslander’ (high-set home), which may have contributed to the need for housing modification. The low socioeconomic status (69% received the pension) of the cohort also highlights the vulnerability of the postamputation population, as low socioeconomic status has been shown to increase the risk of perceived environmental barriers.29 Other factors that are likely to have contributed to the long rehabilitation length of stay in this study were the social isolation of the group and the need for increased support after amputation. Within this group, approximately half of the cohort did not have a partner; a factor known to negatively influence ability to return home after amputation.7,30 Additionally increased supports at home were required after discharge in our amputee inpatient rehabilitation group, either from community services or from living with another person. The loss of a limb has been shown to be associated with a deterioration of functional ability,31 while regaining independence in mobility and activities of daily living has been shown to influence residential status after amputation. The main goal of amputee rehabilitation should be to restore

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and preserve maximum independence for as long as possible, particularly independence with activities of daily living,32 since performing these activities is an important predictor for wellbeing and quality of life.33 Differences in length of stay between this and previous studies may be difficult to compare due to potential differences in reporting methodology. For example, in Australia, there is no nationally consistent process for determining inpatient rehabilitation length of stay.34 In this study, inpatient rehabilitation length of stay was reported for the entire period that patients remained in the rehabilitation unit (i.e. from date of admission to inpatient rehabilitation to date discharged to the community). This whole-of-episode approach includes statistical separations or discharges (including maintenance episodes)34 under the Australian National Subacute and Non-Acute Patient classification.35 This may have inflated the rehabilitation length of stay in this investigation. In contrast, Hordacre,24 for example, used the Australasian Rehabilitation Outcomes Centre data, which reports the length of stay as time from admission to rehabilitation until patients were classified as having completed rehabilitation (rehabilitation subacute and non-acute patient classification), which meant patients still occupying beds in a rehabilitation unit may have been considered to have been discharged from inpatient rehabilitation. Reporting the whole-of-episode length of stay is relevant for several reasons. Statistical separations34 can be based on an administrative decision and may therefore be subject to variation in business rules of rehabilitation units and the rigour in which these business rules are applied. These business rules may lack formal definition and are not subject to audit. In addition, differences in the application of these business rules cannot be controlled for and may vary over time. Whole-of-episode length of stay is based on two discrete events (admission and discharge from the rehabilitation unit) that are not subject to interpretation. Whole-of-episode length of stay is reflective of resource use by clinical units, and can be used to accurately gauge the flow of patients into and out of the rehabilitation unit. This is of relevance for both service planning and to help estimate waiting times to enter the unit. It is also of particular interest to the individual patient as it allows a more realistic prediction of expected hospital stay that takes into account the many potential barriers to discharge. It is also noteworthy that international comparisons are difficult due to different healthcare delivery and funding models.36 The majority of amputations (71%) performed at the facility in this study resulted in an inpatient rehabilitation admission. This is in contrast to American studies,30,37 which have reported between 9% and 55% undergoing inpatient rehabilitation. Reasons for these differences are unclear but may include differences in patient selection, funding and service delivery models including ambulatory models of amputee rehabilitation compared to that used in Australia. Even within Australia, the model of service delivery is not always well defined to enable informed comparisons. Inpatient rehabilitation has been shown to have better outcomes, with reduced mortality, fewer subsequent amputations, better prosthetic acquisition and greater medical stability than if patients are discharged home immediately following acute care.38 At the facility in the present study, some amputees stay

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in rehabilitation for interim prosthetic fitting and initial prosthetic training, whereas others undergo prosthetic rehabilitation as outpatients or can be readmitted to rehabilitation for an intensive period of prosthetic training. An inpatient model of care potentially works well for the patient population being serviced by this unit, as there are patients with multiple comorbidities, including complex chronic diseases, who can also be from small and regional towns and cities with limited access to support and appropriate local care due to the broad geographical region that this facility services.14 This model potentially benefits the amputee by enabling rehabilitation with people in a similar situation to them, including benefits such as peer education, camaraderie and motivation. The 80% that returned to live in the community and the very low in-hospital mortality rate of 4% is indicative of a successful rehabilitation model. In the future, other factors should be examined, including 6- and 12-month mortality, prosthetic usage at discharge and follow-up and costing data to inform comparisons across different funding and service models; both in Australia and internationally. The differences between dysvascular and non-vascular lower limb amputees observed also have implications for the design of lower limb amputee rehabilitation programs. As non-vascular amputees were more likely to be employed, it is recommended that employment requirements be addressed and consideration given to the individuals’ vocation goals when prescribing prostheses for this group.39 For amputees of working age, vocational rehabilitation and counselling should be part of their rehabilitation program.40 Inpatient rehabilitation can have a negative impact on returning to work.41 Outpatient rehabilitation, therefore, may be more beneficial to reduce the time to returning to work. Reducing the time between amputation and return to work is important for an amputee’s mental wellbeing, as well as for economic reasons.42 Dysvascular amputees had lower prosthetic prescription rates and lower FIM-M scores at discharge compared to the nonvascular amputees. The functional outcome of diabetic amputees has been shown to be lower than that of non-diabetics11, which could be due to the higher number of comorbidities and the poorer pre-amputation walking status of the dysvascular amputees. Higher numbers of comorbidities can affect the likelihood of successful prosthetic rehabilitation.43,44 Elderly dysvascular amputees tend to have very poor physical fitness due to their comorbidities.43 If wheelchair mobility is a more appropriate goal, rehabilitation programs should focus on maximising independence in transfers and learning wheelchair skills,45 and also addressing issues caused by comorbidities, such as poor endurance and balance. Limitations This was an audit of a facility database and, as such, relied upon the accuracy and completeness of the documentation by the multidisciplinary team. There is potential for missing data when analysing a previously collected dataset;46 however, ward administration staff checked files for completeness before finalising each patient admission to minimise this. In addition, missing data were retrieved from medical charts to ensure the completeness of the dataset. This study only examined lower limb amputees admitted to a rehabilitation unit, and did not include those

Demographics and outcomes of lower limb amputees

discharged after amputation from acute care to home or a residential care facility, so these findings may not be generalisable to amputee patients discharged directly to the community or a long-term care facility. The study included consecutive admissions to rehabilitation related to a primary diagnosis of lower limb amputation. This meant some patients were included more than once. This study also reported whole-of-episode length of stay, which differs in reporting methodology from previous studies, which may make between-study comparisons difficult. Additionally, as there is considerable variation in the admission criteria to rehabilitation units16 and this study was based at a single hospital rehabilitation unit, the results may not be generalisable to other populations or to dissimilar societies. Conclusions In summary, differences in social demographic and discharge outcomes exist between dysvascular and non-vascular lower limb amputees. Rehabilitation programs should be designed with these differences in mind. Given the potential vulnerability and clinical complexity of patients in this clinical group, discharge planning should ideally begin as soon as possible to minimise time spent waiting in hospital for new accommodation or major modifications for their current homes. People with lower limb amputations are not a homogeneous group, so extrapolating results from combined amputee groups or from a non-vascular group to a dysvascular group should be avoided.

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Competing interests None declared. Acknowledgements Some aspects of these data were presented at the Australian Physiotherapy Conference, Melbourne 2013. Funding was provided by a Health Practitioner Research Grant 2011/12.

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Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: a 7-year series.

To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees...
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