Prognostic differences for functional recovery after major lower limb amputation: effects of the timing and type of inpatient rehabilitation services in the Veterans Health Administration.
OBJECTIVE
To compare the recovery of mobility and self-care functions among veteran amputees according to the timing and type of rehabilitation services received.


METHODS
Observational study of inpatient rehabilitation care patterns of 2 types (specialized and consultative) with 2 timings (early and late).


METHODS
Data from inpatient specialized rehabilitation units (SRUs) and consultative services within 95 Veterans Affairs Medical Centers across the United States during fiscal years 2003 to 2004.


METHODS
Medical records of 1502 patients who received early or late consultative or specialized rehabilitation.


METHODS
Hypotheses were established and general categories of negative and positive risk factors specified a priori from available clinical characteristics. Linear mixed effects models were used to model motor Functional Independence Measure (FIM) gain scores on patient-level variables accounting for the correlation within the same facility.


METHODS
Recovery of activities of daily living (ADLs) and mobility (physical functioning) expressed as the magnitudes of gains in motor FIM scores achieved by rehabilitation discharge.


RESULTS
After adjustment, amputees who received specialized rehabilitation had motor FIM gains that were on average 8.0 points greater than those for amputees who received consultative rehabilitation. Although patients whose rehabilitation was delayed until after discharge from the index surgical stay tended to be more clinically complex, they had gains comparable to those of patients who received early rehabilitation. Advanced age, transfemoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower motor FIM gains. The variance for the random effect for facility was statistically significant, suggesting extraneous variation within facility that was not explainable by observed patient-level variables.


CONCLUSIONS
On the basis of this analysis, those patients who receive specialized rehabilitation can be expected to make comparatively greater gains than patients who receive consultative services, regardless of timing and clinical complexity. Findings highlight the need for clinicians to adjust prognostic expectations to both clinical severity and the type of rehabilitation that patients receive.
Stineman
Margaret G
MG
Department of Physical Medicine and Rehabilitation and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104-6021, USA. mstinema@exchange.upenn.edu
Kwong
Pui L
PL
Xie
Dawei
D
Kurichi
Jibby E
JE
Ripley
Diane Cowper
DC
Brooks
David M
DM
Bidelspach
Douglas E
DE
Bates
Barbara E
BE
D000203:Activities of Daily Living; D000368:Aged; D000671:Amputation, Surgical / Q000534:rehabilitation*; D015331:Cohort Studies; D005260:Female; D006760:Hospitalization; D006787:Hospitals, Veterans; D006801:Humans; D035002:Lower Extremity; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology; D020127:Recovery of Function / Q000502:physiology*; D012017:Referral and Consultation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome