Dysvascular lower limb amputation: incidence, survival and pathways of care
Fard, Behrouz
DOI:
10.33612/diss.134440454
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47
C
HAPTER4
– Return to home after dysvascular major lower limb amputation:
a multicentre observational study in the Netherlands.
Behrouz Fard1,3
Jan H. B. Geertzen1
Pieter U. Dijkstra1,2
From the 1Department of Rehabilitation Medicine and the 2Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, and 3Roessingh Center for Rehabilitation, Enschede, the Netherlands.
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Abstract
Objective: The aim of this study was to report the rates of persons returning home within 1 year
following dysvascular major lower limb amputation (LLA) in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after discharge to care facilities.
Design: Retrospective cohort study.
Patients: Dysvascular major LLA, N=382, mean age (SD) 71.9 (12.5) years, 65% male.
Methods: Medical records of all persons undergoing major LLA in 2012-2013 in 12 hospitals in
Northern Netherlands were reviewed. Odds ratios (OR) were calculated using multivariate logistic regression.
Results: Among persons admitted from home and surviving the hospital admission, 21% returned
home, higher odds were associated with living with a partner (OR = 2.8, p=0.006) and younger age (<65 years). Among those discharged to care and surviving the first year, 77% returned home within 1 year after amputation, with higher odds being associated with younger age (<75 years) and admission to inpatient rehabilitation (OR = 10.6, p=0.004) or geriatric rehabilitation in skilled nursing facilities (SNF) (OR = 3.5, p=0.030).
Conclusion: Four out of five persons surviving dysvascular major LLA will return to home within 1
year, although a majority requires care in either inpatient rehabilitation or SNF setting.
Keywords: Amputation; Skilled Nursing Facilities; Rehabilitation Centers; Frail Elderly.
Abbreviations: DM: diabetes mellitus; KD: knee disarticulation; LLA: lower limb amputation; OR:
odds ratio; PAD: peripheral arterial disease; PM&R: physical medicine & rehabilitation; SNF: skilled nursing facility; TF: transfemoral; TT: transtibial.
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Introduction
Over 90% of lower limb amputations (LLA) in Western European countries are secondary to peripheral arterial disease (PAD) and diabetes mellitus (DM)1, and may be referred to as ‘dysvascular’
amputations. LLA are categorised as minor or major, the latter defined as through the ankle joint and more proximal levels2–5. Major LLA are associated with more disability6 and high mortality rates3
compared to minor LLA. On average 47%5 of patients do not survive the first year after major LLA,
though the reported 1 year mortality ranges greatly: between 16-48%5. A majority of persons with LLA
live independently at home prior to amputation7–9. Successful rehabilitation may be defined as
regaining ambulation and/or prosthesis use7,10–13. However, being able to return home is also an
important goal for patients, their families and health care professionals 9,14,15, even more so considering
the limited life expectancy of persons undergoing amputation16. Resumption of independent living
directly after hospital admission for LLA is oftentimes not feasible, and patients are discharged to inpatient care facilities17,18. Traditionally, high intensity treatment for persons undergoing amputation
has been provided in inpatient rehabilitation centres. Considering the typically older age of dysvascular LLA patients19 and high comorbidity rates20, skilled nursing facilities (SNF) have seen growth in the past
decades in order to accommodate this population14,15.
The current research on the effectiveness of SNFs is conflicting to a large extent: several studies have reported that more comprehensive rehabilitation programs are associated with better survival 11,21,22
and functional outcomes 11,18,21,23, while others did not find these differences 12,24 and observed
benefits of rehabilitation programs offered in SNFs 14. To our knowledge, few studies have focused
specifically on analysing return to home among persons undergoing dysvascular LLA, taking into account factors such as mortality rates at different stages and the patient’s eventual residential situation9,22. Most prior research has focused on populations from a single (rehabilitation) centre7,8,25,
hospitals for military veterans13,18,23 or SNFs only14,26, and has excluded patients with prior LLA9,12,27 or
bilateral/proximal level of LLA24,28,29 or included those with traumatic aetiology12,22,23, which may be
regarded as a separate population which include typically younger patients, with lower incidence of comorbidity and higher life expectancy30.
The aim of the present study is to report the rates of persons returning home within the first year following dysvascular major LLA in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after being discharged to care facilities. The findings of this study will provide insight into the pathways of care for surgeons, Physical & Rehabilitation Medicine (PRM) specialists and geriatric specialists who are involved in the multidisciplinary treatment of persons undergoing dysvascular amputation, who constitute a small but frail population.
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Methods
Setting and population
Data of all major LLA performed from January 1, 2012 through December 31, 2013 in the 3 northern provinces of the Netherlands were examined for eligibility. Data collection was performed in 12 hospitals –11 general hospitals and 1 university hospital– from January 1, 2015 through April 1, 2017, for which patients’ medical records were accessed directly. Prior to data collection, the regional Medical Ethics Committee (M15.176087), local Medical Ethics Committees of hospitals and Board of Directors approved the study. Dysvascular LLA was defined as any major amputation (i.e., ankle disarticulation and more proximal) among patients with a recorded diagnosis of PAD and/or DM at the time of, or prior to, the amputation. Amputation due to trauma, cancer, Complex Regional Pain Syndrome type-1, iatrogenic complications, lymphedema, fulminant infection in otherwise healthy adults, and congenital syndromes were excluded. No patients were excluded based on age. Additional information pertaining to the healthcare system in the Netherlands, differences in care facilities and the study population is provided in S1.
Variables
The outcomes were discharge directly to home following hospital admission and return to home within 1 year, among persons surviving the first year after major LLA, as identified from their medical records. Data regarding age, gender, presence of comorbidities, vascular surgical history, including percutaneous transluminal angioplasty, arterial bypass grafting, endarterectomy and previous minor or major LLA, were also extracted from the medical records, specified for having been performed either ipsilateral, contralateral or bilateral to the side of first major LLA in the study period (i.e., the index amputation). For every performed amputation –both during and prior to the study period– etiology, date, level and anatomic side were recorded. Because the aim of this study was to assess a functional outcome, anatomic levels of amputation were subsequently recoded as either: ‘unilateral high’ (knee disarticulation (KD) or transfemoral (TF) amputation), ‘unilateral low’ (transtibial (TT) amputation) or ‘bilateral’ (TF, KD or TT). When multiple amputations had been performed on the ipsilateral or contralateral limb –either prior to or within the study period– the most proximal level was used to determine the level of amputation, since this level may determine discharge destination through level of ambulation. For example, TF performed within the study period and contralateral TT prior to the study resulted in the amputation level being coded as ‘bilateral’, whereas TT followed by an ipsilateral TF within the study period resulted in the amputation level being coded as ‘unilateral high’. A primary LLA was defined as no recorded history of any revascularisation, minor or major LLA on the side of index amputation. Because social support has been reported to influence outcome after amputation31, status
of patients living with a partner at the time of index amputation was recorded and analysed. Marital status was recorded (not presented), because many ‘unmarried’ and ‘widowed’ individuals do in fact have a life partner with whom they share a household, marital status by itself provides insufficient
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information in assessing social support. Further details pertaining to data collection and variables are provided in the supplemental information (S2).
Statistical analyses
Age as a potential predictor of the outcomes was analysed both as a continuous variable (presented in supplemental information S3 and S4) and recoded into age categories in order to facilitate clinical interpretation. Univariate associations between patient characteristics and the outcome variables were explored using χ2 tests. Variables with p < 0.2 were included in the multiple logistic regression analyses
with backward stepwise elimination. Odds ratios (OR) with 95% Confidence Intervals (CI) were calculated for the identified associations between the predictor and outcome variables. For the main analyses, statistical significance was set at α = 0.05. Microsoft Excel 2016 and IBM SPSS Statistics 24 were used for analyses.
Table I. Patient characteristics.
Total LLA N=382
Personal characteristics, n (%)
Age, years, mean (SD) 71.9 (12.5)
Age 27-54 42 (11) 55-64 66 (17) 65-74 96 (25) 75-85 122 (32) >85 56 (15) Gender, men 247 (65)
Living with partner 196 (51)
Clinical characteristics, n (%)
Prior major LLA (either side) 39 (10)
Primary LLA 100 (26) Level of amputation Unilateral higher (TF or KD) 138 (36) Unilateral lower (TT) 210 (55) Bilateral (TF or KD) 31 (8) Comorbidity, n (%)
Peripheral arterial disease 336 (88)
Diabetes mellitus 216 (57)
Cerebrovascular disease 81 (21)
Myocardial infarction 101 (26)
Heart failure 102 (27)
Chronic pulmonary disease 112 (29)
Renal disease 128 (34)
Hemodialysis 28 (7)
Alcohol abuse 65 (17)
Note. Ankle disarticulation (n=2) and hip disarticulation (n=1) not
shown. KD: knee disarticulation; LLA: lower limb amputation; TF: transfemoral amputation; TT: transtibial amputation.
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Figure 1. Pathways of care at admission, hospital discharge and 1 year after amputation. Eligible for return
to home directly after hospital admission: N=382 excluding persons admitted from nursing home (n=45), residential care (n=33) and those died in hospital (n=38); and eligible for return to home within 1 year: additionally, excluding persons discharged to residential care (n=2), home (n=56), those who returned home but died (n=9) and those who died after discharge without returning home (n=41). In total 130 (34%) died within 1 year after amputation: 49 during hospital admission and 81 after discharge. For 18 (5%) persons, outcome data were unavailable at 1 year after amputation. * Returned home, but died before 1 year after amputation
Home n=304 (79%) Nursing home n=45 (12%) Residential care n=33 (9%) Home n=56 (15%) Inpatient Rehabilitation n=55 (14%) Skilled nursing facillity n=120 (31%) Died in hospital n=49 (13%) Residential care n=17 (5%) Nursing home n=85 (22%) Returned home n=169 (47%) Returned home* n=17 (5%)
Did not return home n=38 (10%) Died n=113 (31%) Remained in care n=27 (7%) Admitted from N=382
Status after 1 year
N=364
Discharge destination
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Results
A total of 382 persons undergoing dysvascular major LLA in 2012 and 2013 were identified, 65% of whom were male (Table I). The mean age (SD) at the time index amputation was 71.9 (12.5) years, the youngest person was 27 and oldest 95 years old. The mean ages (SD) of persons discharged to home, inpatient rehabilitation, SNF and nursing home were respectively 62.3 (11.9), 64.3 (9.4), 73.7 (11.0) and 77.6 (12.3) years. The clinical course after hospital admission showed a high level of complexity with regard to discharge destinations, mortality rates at different stages and eventual outcomes at 1 year after amputation (Fig. 1). The aim of the study being rates of return to independent living, persons already residing in nursing homes or residential care prior to amputation and those who died during hospital admission or after discharge did not qualify for return to home (Fig 1.). With the exception of one person who was admitted from a nursing home (which was a temporary admission unrelated to amputation) and was observed to reside in independent living within 1 year of amputation.
Table II. Univariate and multivariate analyses of discharge to home following hospital admission for amputation.
Univariate Multivariate logistic regression Discharge
to home Discharge to care p* β SE OR (95% CI) p**
Personal characteristics n (%) n=56 (21) n=210 (79) Age <0.001 <0.001 27-54 13 (23) 23 (11) 2.03 0.82 7.6 (1.5-7.8) 0.013 55-64 21 (39) 34 (16) 2.08 0.79 7.9 (1.7-7.5) 0.009 65-74 14 (25) 65 (31) 0.95 0.79 2.6 (0.5-2.3) 0.235 75-84 6 (11) 60 (29) 0.33 0.85 1.4 (0.3-7.4) 0.260 >85 2 (4) 28 (13) Ref. Gender, men 44 (79) 139 (66) 0.076
Living with partner 44 (79) 118 (56) 0.002 1.01 0.37 2.8 (1.3-5.7) 0.006
Amputation characteristics, n (%)
Prior major LLA (either side) 7 (13) 14 (7) 0.150
Primary LLA 11 (20) 52 (25) 0.423 Level of amputation 0.170 Unilateral high (TF/KD) 12 (22) 72 (34) Unilateral low (TT) 38 (69) 125 (60) Bilateral (TF/KD/TT) 5 (9) 12 (6) Comorbidity
Peripheral arterial disease 47 (84) 185 (88) 0.407 Diabetes mellitus 39 (70) 114 (54) 0.039 Cerebrovascular disease 7 (13) 39 (19) 0.286 Myocardial infarction 11 (20) 58 (28) 0.226
Heart failure 9 (16) 51 (24) 0.191
Chronic pulmonary disease 8 (14) 63 (30) 0.018
Renal disease 17 (30) 70 (33) 0.673
Hemodialysis 3 (5) 16 (8) 0.559
Alcohol abuse 14 (25) 35 (17) 0.153
Note. Numbers (%) unless stated otherwise. * p-values for univariate Χ2 tests. ** Logistic regression model with
backwards elimination, Nagelkerke R2 for model fit = 0.18. CI: confidence interval; KD: knee disarticulation; LLA: lower
limb amputation; OR: odds ratio; Ref.: reference category; SE: standard error of the mean; TF: transfemoral; TT: transtibial.
Discharge to home following hospital admission
Among persons who were admitted from home and had survived the hospital admission (n=266), 56 (21%) returned home and 210 (79%) were discharged to either care in a nursing home, inpatient rehabilitation centre or SNF (Table II). Univariate and subsequent multivariate analyses of discharge to home are presented in Table II. Compared to those aged >85 years, persons in the age categories 0-54
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and 55-64 had respectively 7.6 (p=0.013) and 7.9 (p=0.009) times higher odds of being discharged to home directly. The rates of discharge to home for persons aged 65-74, 75-84 and >85 were similar. Independently of age, living with a partner at the time of hospital admission was associated with higher odds of being discharged to home (OR = 2.8, 95% CI: 1.3 to 5.7, p=0.006).
Table III. Univariate and multivariate analyses of return to home within 1 year of amputation.
Univariate Multivariate logistic regression Did
return Did not return home p* β SE OR (95% CI) p**
Personal characteristics (%) n=122 (77) n=36 (23) Age <0.001 <0.001 27-54 17 (14) 2 (5) 2.44 0.98 11.5 (1.7-8.7) 0.013 55-64 30 (25) 2 (5) 2.54 0.96 12.6 (1.9-2.6) 0.008 65-74 49 (40) 8 (22) 1.93 0.71 6.9 (1.7-27.9) 0.007 75-84 21 (17) 15 (42) 0.77 0.68 2.2 (0.6-8.1) 0.256 >85 5 (4) 9 (25) Ref. Gender, men 83 (68) 24 (67) 0.878
Living with partner 75 (62) 17 (47) 0.128
Amputation characteristics, n (%)
Prior major LLA (either side) 10 (8) 2 (5) 0.599
Primary LLA 23 (19) 10 (28) 0.247 Level of amputation 0.093 Unilateral high (TF/KD) 36 (30) 17 (49) Unilateral low (TT) 77 (63) 17 (49) Bilateral (TF/KD/TT) 9 (7) 1 (2) Comorbidity
Peripheral arterial disease 108 (89) 31 (86) 0.696
Diabetes mellitus 69 (57) 17 (47) 0.323
Cerebrovascular disease 14 (12) 10 (28) 0.017 Myocardial infarction 27 (22) 11 (31) 0.299
Heart failure 20 (16) 8 (22) 0.421
Chronic pulmonary disease 33 (27) 15 (42) 0.094
Renal disease 31 (25) 17 (47) 0.012
Hemodialysis 6 (5) 3 (8) 0.437
Alcohol abuse 24 (20) 4 (11) 0.237
Discharge destination <0.001 0.012
Inpatient rehabilitation 50 (41) 3 (8) 2.47 0.81 10.6 (2.2-2.3) 0.004 Skilled nursing facility 64 (53) 22 (61) 1.27 0.58 3.5 (1.1-11.1) 0.030
Nursing home 8 (7) 11 (31) Ref.
Prosthesis procurement 92 (76) 15 (42) <0.001
Note. Numbers (%) unless stated otherwise. * p-values for univariate Χ2 tests. ** Logistic regression model with
backwards elimination, Nagelkerke R2 for model fit = 0.33. CI: confidence interval; KD: knee disarticulation; LLA: lower
limb amputation; OR: odds ratio; Ref.: reference category; SE: standard error of the mean; TF: transfemoral; TT: transtibial.
Return to home within 1 year of amputation
Among persons who could not be discharged to home after hospital admission and survived the first year after amputation (n=158), 122 (77%) returned home within 1 year, whereas 36 (23%) did not (22 resided in a SNF, 11 in a nursing home and 3 were still admitted for inpatient rehabilitation) (Table III, Fig. 1). Univariate and subsequent multivariate analyses of return to home within 1 year of the amputation are presented in Table III. Respectively 50 out of 53 persons referred to inpatient rehabilitation, 64 out of 86 those discharged to SNFs and 8 out of 19 for those discharged to nursing homes, returned home within 1 year. Compared to those aged >85 years, ORs of returning home within 1 year were 11.5 (p=0.013) for persons aged 0-54 years, 12.6 (p=0.008) for those aged 55-64 years and 6.9 (p=0.007) for those aged 65-74 years. Compared to discharge to a nursing home after hospital
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admission, both inpatient rehabilitation and SNF were associated with higher odds of return to home within 1 year, with ORs of 10.6 (95% CI: 2.2 to 52.3, p=0.004) and 3.5 (95% CI: 1.1 to 11.1, p=0.030) respectively.
Discussion
The main findings of this study are that 21% of persons surviving hospital admission for dysvascular major LLA in the Netherlands are discharged home; among those who cannot be discharged home directly and survive the first year, 77% return home within 1 year of amputation. In our study, 4 out of 5 persons undergoing major LLA were admitted from independent living at home, similar to previous studies7–9,22. Direct comparison of the outcomes with previous research is challenging because of
inherent differences in health care systems and study populations (e.g., inclusion of minor LLA and exclusion of patients with prior or bilateral LLA). Our finding that 21% were discharged home directly following hospitalisation has been similarly reported in a study conducted in the United States17,
whereas other studies have observed about 50% of persons being discharged home following LLA9,21.
These disparities may be explained to some extent by the inclusion of foot amputations21 and patients
with first ever LLA after revascularisation only9. Previous studies report that between 42 and
84%14,22,23,26,32 of persons eventually return home in the first year of amputation. The relatively large
variation observed across studies is likely due to the aforementioned differences in health care systems, study samples and study designs.
Most previous research has focused solely on persons undergoing their first ever LLA. These persons may be expected to have less severe vascular disease and to be in a better physical condition, compared to those who have undergone dysvascular amputation(s) in the past3. We chose to include these
persons in order to test the assumption that having undergone a major LLA in the past would predispose one to lower odds of returning home after major LLA. A small minority of persons (10%) in our study had a prior major LLA on either side, but they were no better or worse off than those undergoing their first LLA, in terms of returning home after hospitalisation or within 1 year of amputation. There is an ongoing discussion in the literature whether persons undergoing major LLA after ‘failed’ attempts of revascularisation have worse clinical outcomes compared to those for whom the decision to amputate (i.e., ‘primary’) is reached earlier on10,13,33. In this study, one-fourth
underwent primary LLA (i.e., no ipsilateral revascularisation or minor/major LLA prior to the eventual major LLA), but this was not associated with different odds of returning home10,11,13. Previous studies
state that comorbidities such as cerebrovascular disease27,34, (congestive) heart disease5, chronic
pulmonary disease31,34 and end-stage renal disease9,10,27 are associated with poorer outcomes of
survival, ambulation or prosthesis use. Therefore, we expected persons with these conditions to show lower rates of being able to return to home, which was not the case in this study. Several authors note that persons with dysvascular amputation –especially the geriatric subpopulation– are medically frail
56
and that multi-morbidity is common5,20. However, the extent of the role of different comorbidities on
clinical outcomes such as walking ability remains unclear, as concluded by a systematic review35. It is
surprising that proximal or bilateral levels of amputation were not associated with less favourable odds of returning home directly after hospital admission or within 1 year, as distal and unilateral LLA have been found be to associated with better physical functional outcomes and prosthesis use in previous research10,13,18,26. However, a distal unilateral amputation might not be a requisite for achieving
ambulation (with or without a prosthesis)12,35 at the level needed for returning to independent living.
Strengths and limitations
The main strength of this study is that by including persons from 12 hospitals, we were able to avoid selection bias to a large extent, as the population was not restricted to persons from inpatient rehabilitation, geriatric or single hospital settings only. Also, by analysing the clinical course from the moment of amputation up to 1 year, we were able to illustrate the intricacies of care pathways at different stages. A limitation is that we encountered difficulties in determining the cumulative length of hospital stay related to the amputation, because many persons had multiple admissions prior and after the index amputation, some related to the amputation and others (potentially) not. Unfortunately, for most persons we were unable to assess the pre-amputation cognitive, nutritional and ambulatory status based on hospital records. Because these factors have been reported as being predictive of functional outcomes after LLA by some studies35, their omission in this study should be
taken into account. The relatively small sample size may have contributed to limited power in the multivariate analyses. The medical ethical permissions only allowed storage of data relevant to the study population (i.e., dysvascular LLA), because of which we are unable to provide specific details pertaining to excluded persons (i.e., LLA due to other causes). As extensively described previously, differences of incidence rates, mortality rates, patients characteristics and outcomes are reported between nations as well as between regions in certain countries5,16,36, we therefore caution
generalising our results to other countries. The design of the present study does not allow us to ascertain whether inpatient rehabilitation or treatment in SNFs is better in terms of functional outcomes. Although the age of persons receiving SNF care is considerably higher than those in inpatient rehabilitation, a majority of persons discharged to SNFs were nonetheless able to return home within one year of amputation. Although analysis of survival rates was not within the scope of this study, we should note that the 1-year mortality rate was 34%, which is within the lower range of previously reported research5, and that conclusions regarding return to home should be prefaced by ‘among those
who did survive the amputation’. Clinical implications
Our finding that relatively younger age and having a partner in the home situation are beneficial for the odds of persons returning directly to independent living10,17 are in line with clinical experience.
57
Clinicians and researchers might assume that the extent of comorbidity determines whether patients require additional high or low intensity inpatient care before being able to resume independent living. However, no single comorbidity was identified as being predictive of odds of returning home. In the Netherlands, PM&R specialists determine the indication for inpatient rehabilitation, for which they analyse the overall level of function and make an individual assessment of a person’s biological and psychosocial capacities. The association of admission to inpatient rehabilitation with considerably higher odds of return to home compared to admission to a nursing home might therefore be regarded as a proxy of assessing a person’s overall functional status at the time of major LLA, in which factors such as comorbidity are nested. Some studies have suggested that treatment in SNF is associated with worse survival and functional outcomes compared to inpatient rehabilitation11,18,21. However,
systematic reviews of 1- and 5-year mortality rates did not identify type of treatment facility as being associated with survival rates5,16. A person’s physical condition is expected to greatly influence whether
they are able to adhere to high intensity treatment in an inpatient rehabilitation setting. With this mind, it is likely that in the aforementioned studies11,18,21, persons with more deconditioning and more severe
comorbidity were discharged to SNFs instead of inpatient rehabilitation, and that the poorer outcomes were not necessarily attributable to the SNF treatment by itself. Interestingly, a systematic review concludes that there are likely benefits of geriatric rehabilitation programs in general, in terms of mortality rates, discharge destinations and functional status37. Similarly, a recent study of geriatric
rehabilitation in the Netherlands stated that between 2007-2015, the intensity of treatment in SNFs increased, while mortality rates decreased and rates of patients returning home improved significantly in the same period38. The rationale behind this being that dedicated rehabilitation therapy and
goal-oriented efforts in optimising functional recovery are more likely to improve the physical condition and motor skills of the affected persons compared to traditional ‘rest and nursing’ regimes in the geriatric population. Given this rationale, the results of the current study suggest that –within the Dutch healthcare system– dedicated geriatric rehabilitation may be effective in facilitating return to independent living among more elderly persons after major LLA, in conjunction with clinical rehabilitation provided for younger physically more fit persons. As we have observed in review of the contemporary literature, rehabilitation programs tailored for the elderly do not exist in many countries. The findings of the current study may provide incentive for future prospective research in the Netherlands and internationally, with more in depth analysis of functional outcomes for elderly and non-elderly persons undergoing major LLA in different rehabilitation settings.
Conclusion
In the Netherlands, most persons undergoing major dysvascular LLA are admitted from independent living. Among those surviving the hospital admission, 21% is discharged directly to home, with higher rates being associated with younger age (<65 years) and having a partner at home. Among those who are unable to return to home after hospital admission and survive the first year, 77% returns home
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within 1 year of amputation. For these persons, younger age (<75) and care in either inpatient rehabilitation or SNF is associated with higher odds of returning to home eventually. These results suggest that high intensity inpatient rehabilitation for younger persons and low intensity geriatric rehabilitation for elderly persons may be effective in optimising the odds of return to independent living after major LLA.
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Supplemental information
S1. Health care system in the Netherlands and study setting
In the Netherlands, medical insurance is mandatory for all citizens, ensuring universal medical access for both primary and specialist care. This study was performed in the northern region of the Netherlands consisting of the provinces of Groningen, Friesland and Drenthe, containing 1.7 of the 16.8 million inhabitants in the Netherlands in 2013[1]. The region is relatively less densely populated (on average 207 persons per km2) compared to the Netherlands in general (on average 498 persons per km2). In the study region, 18.3% of the population was aged >65 years, compared to 16.8% in the total Dutch population in 2013. For the total Dutch population aged 75-84 years the annual year risk of death was estimated as 2.5-7.3% in 2013[1]. A comprehensive study of regional mortality rates in the Netherlands, notes that the provinces of Groningen and Friesland seem to show slightly lower mortality rates compared to the other parts of the Netherlands. Whereas, in Groningen and Drenthe there are a few municipalities that are relatively lower in socio-economic development, which is associated with a lower average life expectancy compared to the rest of the Netherlands[2]. A majority of the population in the study region resides in cities with a general hospital (within 5 km radius), the median distance to a general hospital is 9.4 km (compared to 6.5 km nationwide)[1], the maximum distance from the most rural town in the region to a general hospital is 38 km.
In the study region, there are 2 inpatient rehabilitation centers and 34 Skilled Nursing Facilities (SNF) offering ‘geriatric rehabilitation’. In the Netherlands, inpatient rehabilitation programs are aimed at regaining ambulation, prosthesis procurement and facilitating return to independent living and comprise:
multidisciplinary treatment (including physiotherapy, occupational therapy, social work and psychology); high intensity therapy (at least 1.5-2 hours per day, excluding nursing);
certified prosthetist (on site);
coordination by Physical Medicine & Rehabilitation (PM&R) specialist (on site).
Geriatric rehabilitation takes place in dedicated wards in selected nursing homes (i.e., SNFs) aimed at facilitating return to independent or semi-independent living and comprises:
multidisciplinary treatment (mostly physiotherapy and nursing, to a lesser extent occupational therapy, social work and psychology)[3,4];
low intensity therapy (on average 4-5 hours per week, including nursing)[4]; certified prosthetist and PM&R specialist (consultation);
coordination by elderly care physician.
The SNFs are distinct from nursing homes, which provide long stay care for patients (i.e., nursing and assistance with daily activities). Residential care homes provide semi-independent living, typically located in close approximation of nursing homes in order to provide home nursing up to 3-4 times a day. During acute care in hospitals, PM&R specialists are consulted and advise whether patients are to be discharged to home (with outpatient rehabilitation), admitted to inpatient rehabilitation, SNF or nursing home. In the Netherlands, all citizens are entitled to receive home care when prescribed by the general physician or medical specialist and approved by the central governing body. Temporary home care may be initiated after hospital admissions, which is often provided by registered home nurses and is more focused on dedicated activities such as wound care or administering medication. On the long term, there may be need for home care for assistance with daily activities (e.g., bathing or clothing) and household shores (e.g., cleaning and groceries), which is often provided by caretaker professionals and organised on a municipality level. The government policy aims to enable the elderly population to remain in their respective homes as long as possible. There are limits however, in what home care services are expected to provide: typically, when more than 3 times a day 15-30 minutes of care is required, it is deemed unfeasible for individuals to remain home. Home adaptations for physically challenged persons are financed through municipality funds. With the aim of rendering residents’ homes accessible from the outside (e.g., level entrance) and inside (e.g., stairs lift chair), given that the total costs of adaptations do not exceed a certain percentage of the estimated worth of the individual’s home (either private homeowners or tenants).
[References]
1. Central Bureau for Statistics (CBS). StatLine. [Internet] https://www.cbs.nl/en-gb/figures [Accessed: 25-09-2017] 2. Loke R, De Jong A. Regionale verschillen in sterfte verklaard. 2013. [Internet]
https://www.cbs.nl/nl-nl/achtergrond/2013/07/regionale-verschillen-in-sterfte-verklaard [Accessed: 25-09-2017]
3. Eijk MS, van der Linde H, Buijck BI, Zuidema SU, Koopmans RTCM. Geriatric rehabilitation of lower limb amputees: a multicenter study. Disabil Rehabil 2012;34: 145–150.
4. Fortington LV, Rommers GM, Wind-Kral A, Dijkstra PU, Geertzen JHB. Rehabilitation in skilled nursing centres for elderly people with lower limb amputations: a mixed-methods, descriptive study. J Rehabil Med 2013; 45: 1065–1070.
62 S 2 . D et ai ls f or sear ch s tr at eg y, i n cl u si on /e xc lu si on an d d ef in it io n o f co m or b id it y var iab le s. In clu sio n ICD -9 co d e C o mo rbidity ICD -9 co d e A m p u tat io n M yo car d ia l In far ct io n 410 D isar ti cu la ti on o f an kl e 8 4 .1 3 H ear t fa ilu re 4 2 8 .x x D isar ti cu la ti on o f an kl e th ro u g h m al le ol i of t ib ia an d f ib u la 8 4 .1 4 Ce re b ro vasc u lar d is ease c O th er am p u ta ti on b el ow k n ee 8 4 .1 5 S u b ar ach n oi d al h em or rh ag e 430 D isar ti cu la ti on o f kn ee 8 4 .1 6 In tr acer eb ral h em or rh ag e 431 A m p u tat io n ab ov e kn ee 8 4 .1 7 O th er i n tr acr an ia l h em or rh ag e 432 D isar ti cu la ti on o f h ip 8 4 .1 8 O ccl u si on an d s te n os is of p re cer eb ral ar te ri es 433 Lo we r lim b a m p u tat io n , n ot sp ec if ie d 8 4 .1 0 O ccl u si on o f cer eb ra l ar te ri es 434 Per ip h er al ar te ri al d isease ( PA D ) R en al d isease c A th er oscl er os is of t h e ex tr em it ie s, n ot s p eci fi ed 4 4 0 .2 0 A cu te g lo m er u lo n ep h ri ti s 580 A th er oscl er os is of t h e ex tr em it ie s w it h c la u di cat io n 4 4 0 .2 1 N ep h ro ti c sy n d ro m e 581 A th er oscl er os is of t h e ex tr em it ie s w it h r est p ai n 4 4 0 .2 2 Ch ro n ic g lo m er u lo n ep h ri ti s 582 A th er oscl er os is of t h e ex tr em it ie s w it h u lcer at io n 4 4 0 .2 3 N ep h ri ti s an d n ep h ro p at h y, n ot sp ec if ie d 583 A th er oscl er os is of t h e ex tr em it ie s w it h g an g re n e 440 .2 4 A cu te r en al f ai lu re 584 O th er p er ip h er al v asc u lar d is ease 4 4 3 .x x Ch ro n ic r en al f ai lu re 585 D iab et es M el lit u s 250 R en al f ai lu re , u n sp ec if ie d 586 E x clu sio n H em od ia ly si s a,b M al ig n an t n eo pl asm o f b on e an d ar ti cu la r car ti lag e 1 7 0 .x x Pu lm on ar y di se a se c M al ig n an t n eo pl asm o f co n n ect iv e an d o th er so ft t iss u e 1 7 1 .x x Ch ro n ic o b st ru ct iv e p u lm on ar y di se ase 491 M al ig n an t m el an om a of sk in 1 7 2 .x x A st h m a 493 T rau m at ic am p u ta ti on o f le g (s ) 8 9 7 .x x E m p h ys em a 492 Cr u sh in g i n ju ry o f lo we r lim b 9 2 8 .x x A lco h ol ab u se 3 5 0 .0 -3 R ef le x sy m p at h et ic d yst ro p h y of t h e lo w er l im b 3 3 7 .2 2 Ce rt ai n co n g en it al m u scu lo sk el et al d ef or m it ie s 7 5 4 .x x O th er co n g en it al m u scu lo sk el et al an om al ie s 7 5 6 .x x N ot e. F ir st , ex te n si ve s ear ch t er m s we re ap p lie d i n cl u di n g IC D -9 co d es, l o cal ly u sed op er at io n /p ro cedu re co d es an d f re e te xt t o id en ti fy a ll am p u tat io n s w it h in t h e ti m e fr am e 2 0 1 2 , Jan u ar y – 2 0 1 3 , D ece m b er . S eco n d , th e ex cl u si on cr it er ia we re ap pl ie d . T h ir d, sp or ad ic cas es cl ear ly n ot r el at ed t o PA D o r D M ( e. g ., f u lm in an t in fe ct io n i n o th er w ise h ea lt h y ad u lt s) we re ad di ti on al ly e xc lu d ed . a N o ICD co d es, u si n g f re e te xt i n p at ie n ts’ r eco rd s on ly . b A t th e ti m e of i n d ex am pu tat io n . c D ich ot om iz ed as y es /n o if an y of t h e u n d er ly in g di ag n oses we re p re sen t.
63
S3. Multivariate analyses of discharge to home following hospital admission for amputation,
with age as a continuous variable.
Multivariate logistic regression
β SE OR (95% CI) p
Constant 2.137 0.93 0.022
Age (continuous) -0.062 0.01 0.94 (0.92 to 0.97) <0.001 Living with partner 0.995 0.37 2.71 (1.31 to 5.59) 0.007
Note. Logistic regression model with backwards elimination, Nagelkerke R2 for model fit =
0.18. CI: confidence interval; OR: odds ratio.
Logistic regression equation: 𝐿𝑜𝑔(𝑌) = 𝛽0+ 𝛽1𝑋1+ ⋯ 𝛽𝑘𝑋𝑘 . Example: for a 60 year old person: 𝐿𝑜𝑔 (𝑌) = 2.137 + (−0.062 × 60) = −1.583 ; 𝑒−1.583= 0.21 . That is, independently of living with partner, a 60 year old person has OR of 0.21 of discharge to home compared to the youngest person.
S4. Multivariate analyses of return to home within 1 year of amputation, with age as a
continuous variable.
Multivariate logistic regression
β SE OR (95% CI) p
Constant 4.834 1.75 0.006
Age (continuous) -0.070 0.02 0.93 (0.89 to 0.97) 0.002
Discharge destination 0.003
Inpatient rehabilitation 2.641 0.79 14.02 (2.94 to 66.67) 0.001 Skilled nursing facility 1.326 0.57 3.77 (1.24 to 11.49) 0.020
Nursing home Ref.
Note. Logistic regression model with backwards elimination, Nagelkerke R2 for model fit =
0.29. CI: confidence interval; OR: odds ratio.
Logistic regression equation: 𝐿𝑜𝑔(𝑌) = 𝛽0+ 𝛽1𝑋1+ ⋯ 𝛽𝑘𝑋𝑘. Example: for a 75 year old person: 𝐿𝑜𝑔 (𝑌) = 4.834 + (−0.070 × 75) = −0.416 ; 𝑒−0.416= 0.66 . That is, independently of discharge to inpatient rehabilitation, skilled nursing facility or nursing home, a 75 year old person has OR of 0.66 of return to home within 1 year compared to the youngest person.
