Patients who underwent lower limb dysvascular amputations and were released to an inpatient rehabilitation facility experienced a reduction in depressive symptoms and improved physical function compared with patients released to a skilled nursing facility or to home, according to recent study results.

Timothy R. Dillingham, MD, MS, of the department of physical medicine and rehabilitation at the University of Pennsylvania, and senior author of the recent papers, said the assessment of the physical and emotional functioning of patients after amputation is the most important aspect of the study.

“The study, funded by the National Institution of Health, has looked at several different outcomes, but these were two that I think are very important,” Dillingham told O&P Business News. “We’re also examining prosthetic use and satisfaction, as well as pain, but the most important outcomes are physical and emotional functioning for persons who have lost a limb.”

Depressive symptoms

Dillingham and colleagues conducted a prospective study of approximately 300 patients with lower limb amputation to assess whether an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF) or home care provided the best outcomes. In a substudy, the researchers focused on mental and emotional health.

“When we put together this study, I wanted to make sure psychosocial mental health function was evaluated, not just disposition at home or other kinds of outcomes,” Dillingham said. “I think it adds to the literature dealing with persons who have suffered an amputation.”

Researchers obtained information from acute care medical charts, in-person baseline patient interviews and follow-up telephone interviews conducted 6 months after acute care discharge among 297 patients undergoing major lower limb dysvascular amputations. Inclusion criteria were based on age, amputation level and etiology of amputation — as a result of diabetes or peripheral vascular disease.

Overall, 43.4% of patients received most of their inpatient postacute care at an IRF, 32% at an SNF and 24.6% were discharged home with no inpatient rehabilitation. After adjustments for preamputation characteristics and potential selection bias regarding the postacute care setting, study results showed that patients who received postacute care at an IRF were significantly less likely to experience depressive symptoms. Patients receiving postamputation care at IRFs also experienced better social functioning and were less likely to report low emotional functioning vs. patients receiving postamputation care at home or in an SNF.

“For the first time, this study assesses in a prospective, large sample of amputees the effects of rehabilitation care on mental health. Going to rehabilitation was positive and significant at improving the mental health, ie, depression, emotional and social functioning, of amputees compared with receiving postoperative rehabilitation in a nursing home or through home care,” Dillingham said.

Functional outcomes

In another substudy with the same patients, the researchers analyzed the same settings on physical function outcomes.

“The purpose of this substudy was to determine which venue led to the best outcomes in terms of functional gains in physical functioning and the ability to function in the environment,” Dillingham said.

Study results showed patients receiving postacute care at an IRF had improved physical function and better role physical and physical component summary scores on a standard outcome scale the SF36, compared with patients cared for at an SNF. Patients receiving postacute care at IRFs also experienced better role physical and physical component summary score outcomes compared with patients discharged directly home.

Patients were more likely to score in the top quartile for general health and less likely to score in the lowest quartile for physical function, role physical and physical component summary scores if they were being treated in an IRF. According to study results, lower activity of daily living impairment was also observed in an IRF compared with an SNF.

“The results were surprising in that there was a very robust positive outcome if you went to inpatient rehabilitation over many of the outcome measures, particularly when we compared inpatient rehabilitation facility to a skilled nursing facility,” Dillingham said. “Even after controlling for variables, such as whether sicker patients go to one venue or another, going to inpatient rehabilitation yielded better results in function mobility than going to a skilled nursing facility or home.”

Variations in patient care

According to Dillingham, patient care varied considerably across the three venues. Patients generally received closer medical supervision, more attention to active medical problems, more attention to the surgical wound and greater preparation for disposition home in rehabilitation units compared with skilled nursing facility.

“In a skilled nursing facility the amount of therapy a patient receives may be an hour a day compared with 3 hours a day for rehabilitation,” he said. “There is much less medical oversight at a skilled nursing facility. Presumably patients who go home have a home environment and support systems that can accommodate their discharge needs. Those patients discharged home are presumably at a little better functional level, but even with that, patients who went to rehabilitation were better off than those who went home.

“Inpatient rehabilitation should be considered for amputees as the best venue for receiving rehabilitative and medical care and third party payers should support these admissions,” Dillingham said. — by Casey Murphy

Disclosure: The researchers received financial support from the National Institutes of Health, the National Institute of Child Health and Human Development and the National Center for Medical Rehabilitation Research.