Predictors of hospital readmissions after lower extremity amputations in Canada

Reporting of Rehabilitation Outcomes in the Traumatic Lower Limb Amputation Literature: A Systematic Review

OBJECTIVE

To synthesize the outcomes reported in the rehabilitation and community literature for adults with traumatic lower limb amputation (LLA).

DATA SOURCES

The search strategy was conducted in 3 databases (Medline, EMBASE, and CINAHL) from inception to April 2022.

STUDY SELECTION

To be eligible, articles could be of any design but were required to have at least 50% adult individuals with traumatic LLA and had to report on interventions and outcomes in either a rehabilitation or community setting.

DATA EXTRACTION

The extracted outcomes were classified using Dodd's framework, which is designed for organizing research outcomes. Heterogeneity was observed in the outcome measures (OMs) used for evaluation. Two reviewers independently conducted the data extraction, which was verified by a third reviewer.

DATA SYNTHESIS

Of the 7,834 articles screened, 47 articles reporting data on 692 individuals with traumatic LLA, met our inclusion criteria. Four core areas encompassing 355 OMs/indicators were identified: life effect (63.4%), physiological/clinical (30.1%), resource use (5.1%), and adverse events (1.4%). Physical functioning (eg, gait, mobility) was the most frequently reported outcome domain across studies, followed by nervous system outcomes (eg, pain) and psychiatric outcomes (eg, depression, anxiety). Domains such as global quality of life and role/emotional functioning were seldomly reported.

CONCLUSION

The study provides a list of outcome indicators explicitly published for adults with traumatic LLA, highlighting inconsistent reporting of outcome indicators. The lack of a standardized set of OMs is a barrier to performing meta-analyses on interventions, preventing the identification of effective care models and clinical pathways. Developing a core outcome set that includes OMs relevant to the needs of the traumatic LLA population may address these issues.

Barriers and Facilitators to Cardiovascular Rehabilitation Programmes for People with Lower Limb Amputation: A Survey of Clinical Practice in Canada

Purpose

This study determines barriers and facilitators to including people with lower limb amputation (LLA) in cardiovascular rehabilitation programmes (CRPs).

Method

Canadian CRP managers and exercise therapists were invited to complete a questionnaire.

Results

There were 87 respondents. Of the 32 CRP managers, 65.6% reported that people with LLA were eligible for referral, but of these, 61.9% only accepted people with LLA and cardiac disease, and 38.1% only accepted them with ≥ 1 cardiovascular risk factor. CRP eligibility progressively decreased as mobility severity increased, with 94% of programmes accepting those with mild mobility deficits but only 48% accepting those with severe deficits. Among therapists in CRPs that accepted LLAs, 54.3% reported not having an LLA participant within the past three years. Among all responding therapists and managers who were also therapists (n = 58), 43% lacked confidence in managing safety concerns, and 45%, 16%, and 7% lacked confidence in prescribing aerobic exercise to LLA with severe, moderate, and no mobility deficits respectively. There was a similar finding with prescribing resistance training. LLA-specific education had not been provided to any respondent within the past three years. The top barriers were lack of referrals (52.6%; 30) and lack of knowledge of the contraindications to exercise specific for LLA (43.1%; 31). Facilitators included the provision of a resistance-training tool kit (63.4%; 45), education on exercise safety (63.4%; 45), and indications for physician intervention/inspection (63.6%; 42).

Conclusion

Most of the CRPs surveyed only accept people with LLA if they have co-existing cardiac disease or cardiovascular risk factors. Few people with LLA participate. Education on CRP delivery for LLAs is needed to improve therapists' confidence and exercise safety.

Impact of Care Fragmentation after Major Lower Extremity Amputation

BACKGROUND

Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease.

METHODS

Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges.

RESULTS

We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4 years old vs. 69.7 years old, P = 0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P < 0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P < 0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P < 0.001 and 54.7% vs. 42.0%, P < 0.001, respectively). On their first postamputation readmission, LOS (16.3 days vs. 14.7 days, P = 0.004) and hospital charge ($48,964 vs. $44,388, P = 0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P < 0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P < 0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P = 0.36).

CONCLUSIONS

CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.

Understanding transitions in care for persons with limb loss: a qualitative study exploring health care providers' perspectives

PURPOSE

To explore health care providers' (HCP) experiences related to transitions in care from inpatient rehabilitation to the community for patients with limb loss.

MATERIALS AND METHODS

A qualitative study was conducted using semi-structured interviews. Participants were eligible if they were HCPs currently working in amputation rehabilitation at a rehabilitation hospital in Ontario, Canada, with at least 1-year experience in this setting, and could speak and understand English. Data were analyzed thematically using the six-step process of the DEPICT model dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analyzing and translating.

RESULTS

Fourteen HCPs from a variety of health care professions participated in this study. Five key themes describe participants' perspectives on the factors impacting patients' transition in care following limb loss. Specifically, participants emphasized patient preparedness, HCP follow-up, finances and funding, patient self-management skills, and psychosocial support as factors that could influence the transition in care.

CONCLUSION

This study identified challenges to transitions in care for people with limb loss. Future research is needed to evaluate solutions to address these challenges in transitions in care.

Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients

OBJECTIVE

Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation.

METHODS

Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses.

RESULTS

A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all).

CONCLUSIONS

Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.

Percutaneous deep venous arterialization at femoropopliteal segment for unhealed amputated stump ulcer after below the knee amputation

Efficacy of percutaneous deep venous arterialization (pDVA) has been reported for patients with no-option chronic limb threatening ischemia. To date, the procedure has been limited for below the knee/below the ankle occlusive disease. The present report describes the pDVA performed at a femoropopliteal segment for a patient with a stump complication after below the knee amputation. The patient was a 70-year-old male who had a history of endovascular treatment in the right superficial femoral artery (SFA) and below knee amputation 6 years before. He had an unhealed ulcer at the amputated stump for 3 years. Computed tomography angiography demonstrated occluded right SFA, with a stenotic popliteal artery. Revascularization was considered unfeasible due to the absence of run off vessels. In order to improve the perfusion at the ulcer, pDVA was performed at the distal SFA level, bridging SFA and femoral vein using stent grafts. The final angiogram demonstrated the revascularized SFA connecting to popliteal vein with a brisk flow. After pDVA, the stump ulcer improved and the stent grafts were kept patent after 6 months of the procedure. pDVA at the SFA level was technically feasible and could be a useful approach for stump complication after below knee amputation.

Understanding transitions in care for people with major lower limb amputations from inpatient rehabilitation to home: a descriptive qualitative study

PURPOSE

To understand how people with major limb amputation experience the transition in care from inpatient rehabilitation to the community.

METHOD

A qualitative study was conducted using semi-structured interviews. Individuals were eligible if they had undergone a major lower limb amputation and had been discharged from inpatient rehabilitation to the community within one to twelve months. Interviews explored participants' experiences and factors associated with the transition in care. The interviews were audio-recorded, transcribed, and thematically analyzed.

RESULTS

Nine individuals with major lower limb amputation participated. Five themes were identified to describe the transition in care experience: (a) Preparedness: differing experiences during inpatient rehabilitation; (b) Challenges with everyday tasks: "everything has to be thought out"; (c) Importance of coping strategies; "gradually you accept it more and more" (d) Importance of support and feeling connected; "if I needed anything, they're right there" and (e) Not everyone has access to the same resources: "left to your own devices".

CONCLUSIONS

The identified themes concurrently influenced the transition from inpatient rehabilitation to the community. Common challenges during the initial transition were identified. Areas of improvement within inpatient rehabilitation included individualized care, discussions surrounding expectations, and better access to ongoing community support.Implication for rehabilitationTransition in care are difficult and vulnerable times for people with major lower limb amputation, especially when transitioning home following inpatient rehabilitation.Rehabilitation should prepare individuals for completing meaningful tasks in the home and community.Access to ongoing support in the community in the form of practical and emotional support can ease the challenges of transitioning home.

The Role of Earlier Receipt of a Lower Limb Prosthesis on Emergency Department Utilization

Introduction

Adverse events after a lower limb amputation (LLA) can negatively affect the rehabilitation process and may lead to emergency department (ED) visits. Earlier receipt of a prosthesis, as compared to delayed or not receiving a prosthesis, may decrease or moderate the risk of increased ED utilization. In addition, adverse events (ie, fall‐related injury [FRI]) may be associated with increased health care utilization as measured by ED use. The implication of the timing of prosthesis provision after amputation and reduced ED use is not well established. Obtaining data about ED utilization early post‐LLA could assist the rehabilitation team in ensuring timely and appropriate access to improve outcomes.

Objective

To determine the role that timing of prosthesis receipt has in ED utilization and the association of fall/FRI with health care utilization.

Design

Retrospective observational cohort using commercial claims data. A logistic regression model was used to assess factors that influence ED utilization post‐LLA.

Setting

Watson/Truven administrative database 2014 to 2016.

Participants

The study sample consisted of 510 adults age 18 to 64 years with continuous enrollment for 3 years.

Interventions

Independent variables included age, sex, diabetes status, amputation level, fall diagnosis, and prosthesis receipt. Fall was defined as presence of a diagnosis code in any outpatient procedure after the amputation date.

Main Outcome Measure

ED use after amputation was defined as the presence of procedure codes that billed for ED services (99281 to 99285).

Results

Individuals who receive a prosthesis early, within 0 to 3 months, post‐LLA were 48% (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.97) less likely to use the ED compared to those who did not receive a prosthesis. Individuals who experienced a fall/FRI had 2.8 (OR 2.86, 95% CI 1.23 to 6.66) times the odds of ED utilization.

Conclusion

Receipt of a prosthesis reduces the risk of ED use. The current study underscores the value of prostheses during the rehabilitation process after LLA.

Postoperative negative pressure wound therapy is associated with decreased surgical site infections in all lower extremity amputations

Introduction

We hypothesize that Negative Pressure Wound Therapy (NPWT) is associated with a lower incidence of surgical site infection (SSI) in lower extremity amputations (LEAs), a potentially devastating complication.

Methods

NSQIP database from 2011 to 2018 was queried to identify all-level LEAs. Cases using NPWT were identified. One-to-one nearest-neighbor propensity score matching was performed using a binary logistic regression on NPWT status controlling for patient comorbidities.

Results

NPWT was used in 133 of 5237 total LEAs (2.54%). Compared to propensity score-matched controls, they had significantly fewer SSIs (1.50% vs. 8.27%).

Conclusions

NPWT was associated with lower incidence of SSI.

Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes

BACKGROUND

Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes.

MATERIALS AND METHODS

Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences.

RESULTS

A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001).

CONCLUSIONS

Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.

Incidence and Factors Associated With Major Amputation in Patients With Peripheral Artery Disease

Background:

Peripheral artery disease (PAD) is associated with increased risk of mortality, cardiovascular morbidity, and major amputation. Data on major amputation from a large randomized trial that included a substantial cohort of patients without critical limb ischemia (CLI) have not been described. The objective was to describe the incidence and types of amputations in the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease) population, subcategorize amputations in the CLI versus no CLI cohorts, and describe the events surrounding major amputation.

Methods and Results:

Postrandomization major amputation was analyzed in the EUCLID trial. Patients were stratified by baseline CLI status. The occurrence of major amputation was ascertained and defined as the highest level. Perioperative events surrounding major amputation were obtained including acute limb ischemia, revascularization, and all-cause mortality. All variables were assessed for significance in univariable and multivariable models. The rate of major amputation during the course of the trial was 1.6% overall, 8.4% in the CLI at baseline group, and 1.2% in the no CLI at baseline group. The annualized rate of major amputation was 0.6% in PAD overall, 3.9% in the CLI at baseline group, and 0.5% in the no CLI at baseline group. Several factors were associated with increased risk of major amputation, including history of amputation, the presence of diabetes mellitus, baseline Rutherford category 4 to 6, and an ankle-brachial index <0.8. Factors associated with a lower risk for major amputation included prior statin use. The 30-day mortality rate after major amputation was 6.5% overall, 5.6% in the CLI at baseline group, and 6.8% in the no CLI at baseline group. The annual mortality rate following major amputation was 22.8% in the CLI at baseline group and 16.0% in the no CLI at baseline group.

Conclusions:

The risk factors for major amputation in EUCLID patients are similar to previous large registries’ reports except for diabetes mellitus in patients with CLI. The mortality following major amputation is lower in the EUCLID trial compared with registry data.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01732822.

Population-based secular trends in lower-extremity amputation for diabetes and peripheral artery disease

BACKGROUND

The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both.

METHODS

We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time.

RESULTS

A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both.

INTERPRETATION

Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.

Identifying priorities and developing strategies for building capacity in amputation research in Canada

BACKGROUND

Compared to other patient population groups, the field of amputation research in Canada lacks cohesion largely due to limited funding sources, lack of connection among research scientists, and loose ties among geographically dispersed healthcare centres, research institutes and advocacy groups. As a result, advances in clinical care are hampered and ultimately negatively influence outcomes of persons living with limb loss.

OBJECTIVE

To stimulate a national strategy on advancing amputation research in Canada, a consensus-workshop was organized with an expert panel of stakeholders to identify key research priorities and potential strategies to build researcher and funding capacity in the field.

METHODS

A modified Delphi approach was used to gain consensus on identifying and selecting an initial set of priorities for building research capacity in the field of amputation. This included an anonymous pre-meeting survey (N = 31 respondents) followed by an in-person consensus-workshop meeting that hosted 38 stakeholders (researchers, physiatrists, surgeons, prosthetists, occupational and physical therapists, community advocates, and people with limb loss).

RESULTS

The top three identified research priorities were: (1) developing a national dataset; (2) obtaining health economic data to illustrate the burden of amputation to the healthcare system and to patients; and (3) improving strategies related to outcome measurement in patients with limb loss (e.g. identifying, validating, and/or developing outcome measures). Strategies for moving these priorities into action were also developed.

CONCLUSIONS

The consensus-workshop provided an initial roadmap for limb loss research in Canada, and the event served as an important catalyst for stakeholders to initiate collaborations for moving identified priorities into action. Given the increasing number of people undergoing an amputation, there needs to be a stronger Canadian collaborative approach to generate the necessary research to enhance evidence-based clinical care and policy decision-making.IMPLICATIONS FOR REHABILITATIONLimb loss is a growing concern across North America, with lower-extremity amputations occurring due to complications arising from diabetes being a major cause.To advance knowledge about limb loss and to improve clinical care for this population, stronger connections are needed across the continuum of care (acute, rehabilitation, community) and across sectors (clinical, advocacy, industry and research).There are new surgical techniques, technologies, and rehabilitation approaches being explored to improve the health, mobility and community participation of people with limb loss, but further research evidence is needed to demonstrate efficacy and to better integrate them into standard clinical care.

Rigid dressings versus soft dressings for transtibial amputations

BACKGROUND

Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump.

OBJECTIVES

To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations.

SEARCH METHODS

In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments.

MAIN RESULTS

We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I² = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I² = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost.

AUTHORS' CONCLUSIONS

We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).

Risk Factors for Thirty-Day Readmissions After Lower Extremity Amputation in Patients With Vascular Disease

BACKGROUND

Understanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission.

OBJECTIVE

To evaluate factors associated with all-cause 30-day readmission after lower extremity amputation procedures.

DESIGN

Retrospective cohort study.

SETTING

Inpatient.

PATIENTS

A total of 2480 patients who had lower extremity amputations between 2008 and 2014 were selected from national electronic medical record database, Cerner Health Facts.

METHODS

Univariate analysis of demographics, diagnoses, postoperative medications, and laboratory results were examined. Multivariate logistic regression models were used to identify characteristics independently associated with readmission overall and by amputation location-above the knee (AKA) or below the knee (BKA).

MAIN OUTCOME MEASUREMENT

Readmission within 30 days of discharge.

RESULTS

More than one half of patients (1403, 57%) underwent BKA and 1077 (43%) underwent AKA. Readmission within 30 days was 22% (24.1% BKA versus 19.4% AKA, P = .005). In multivariable logistic regression, factors associated with 30-day readmission after any amputation included BKA (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.15-1.74, P = .001), hypertension (OR 1.70, 95% CI 1.33-2.16), surgical-site infections (OR 1.44, 95% CI 1.02-2.04), heart failure (OR 1.39, 95% CI 1.10-1.75), discharge to a skilled nursing facility (OR 1.88, 95% CI 1.41-2.51), and emergency/urgent procedures (OR 1.32, 95% CI 1.04-1.67). At readmission, 13.3% of patients with a BKA required an AKA revision, and 21.3% had a diagnosis of surgical-site infection.

CONCLUSIONS

Risk factors for readmission after any amputation included cardiac comorbidities, associated postoperative medications, and discharge to a skilled nursing facility. The finding that acute arterial embolism or thrombosis and a BKA during the index admission was highly associated with readmission, combined with the high rates of 30-day conversion to an AKA when readmitted, suggests these patients more often develop stump complications or may be undertreated during the initial hospitalization.

LEVEL OF EVIDENCE

III.

Risk factors and direct medical cost of early versus late unplanned readmissions among diabetes patients at a tertiary hospital in Singapore

OBJECTIVE

To examine the risk factors and direct medical costs associated with early (≤30 days) versus late (31-180 days) unplanned readmissions among patients with type 2 diabetes in Singapore.

METHODS

Risk factors and associated costs among diabetes patients were investigated using electronic medical records from a local tertiary care hospital from 2010 to 2012. Multivariable logistic regression was used to identify risk factors associated with early and late unplanned readmissions while a generalized linear model was used to estimate the direct medical cost. Sensitivity analysis was also performed.

RESULTS

A total of 1729 diabetes patients had unplanned readmissions within 180 days of an index discharge. Length of index stay (a marker of acute illness burden) was one of the risk factors associated with early unplanned readmission while patient behavior-related factors, like diabetes-related medication adherence, were associated with late unplanned readmission. Adjusted mean cost of index admission was higher among patients with unplanned readmission. Sensitivity analysis yielded similar results.

CONCLUSIONS

Existing routinely captured data can be used to develop prediction models that flag high risk patients during their index admission, potentially helping to support clinical decisions and prevent such readmissions.

Risk factors for unplanned readmission and stump complications after major lower extremity amputation

OBJECTIVE

The unplanned 30-day readmission rate is a marker of quality of patient care across many disciplines. Data regarding risk factors for unplanned readmission after major lower extremity amputation (LEA) are limited. We evaluated predictors of readmission at our institution after major LEA.

METHODS

We conducted a retrospective review of all patients undergoing above-knee amputation (AKA) or below-knee amputation (BKA) between November 2009 and November 2014. Patient demographic variables were collected. Predictors of unplanned 30-day readmission and stump complications were determined by multivariable logistic regression.

RESULTS

A total of 811 patients were identified (AKA, 325; BKA, 486). Of these, 739 patients were included in the final analysis after excluding 30-day decedents without readmission. The overall 30-day readmission rate was 28.8% (AKA 27.9%; BKA 29.4%; P = .730). Stump complications accounted for 28.6% of readmissions (16.5% of AKA; 35.8% of BKA; P = .004). Other common diagnoses included nonsurgical site infection (33.8%), exacerbation of congestive heart failure (7.0%), and diabetes-related complications (6.1%). Surgical intervention was performed on 61% of stump complications (35.9% of AKA readmitted with stump complications; 68.7% of BKA readmitted with stump complications). BKA stump complications were converted to AKAs in 34.1% of cases (3.2% of the total BKA). None of the AKA stump complications required a higher level of amputation (ie, hip disarticulation). Independent predictors of all 30-day readmission included coronary artery disease and end-stage renal disease. American Society of Anesthesiologists class 3 as compared with class 4 was protective. Independent predictors of 30-day readmission for stump complications included rest pain and BKA. Patients who underwent BKA, rest pain as an indication for amputation, and having an occluded bypass graft were predictors of having a stump complication requiring surgery.

CONCLUSIONS

The 30-day readmission rate after major LEA is high, with wound infections accounting for a significant proportion of these readmissions. There was no difference in readmission rates based on level of amputation. Those undergoing BKA were more likely to present with stump complications requiring a surgical intervention, and often a higher level of amputation. Identification of high-risk patients may play a role in reducing postoperative readmissions and stump complications.

[Lower limb amputations and rehabilitation]

BACKGROUND We wished to study the therapy for lower limb amputees at Sørlandet Hospital Kristiansand after restructuring of activities in 2004.MATERIAL AND METHOD All lower limb amputees hospitalised in the Department of Physical Medicine and Rehabilitation between March 2012 and July 2015 were followed up prospectively.RESULTS A total of 50 patients with 54 amputations were followed up for at least three months. Altogether 31 transtibial amputations, 22 transfemoral amputations and one knee disarticulation were performed. The median age of the patients was 66 years, 36 of whom were men, median Charlson comorbidity index was 1.5, 14 smoked, 8 were substance abusers, 9 were able to walk at least 2 km preoperatively, 44 of the amputations were performed with myodesis, and 41 patients were transferred directly to the Department of Physical Medicine and Rehabilitation. At the three-month check-up, 48 patients used their custom-made prostheses, average walk-test time was 21 seconds, and 45 lived in their own home. At the one-year check-up, 32 of 35 patients who attended used prostheses, and average walk-test time was 18 seconds. Use of painkillers declined during the period. Advanced age, transfemoral amputation and substance abuse were associated with longer walk-test time at the three-month check-up.INTERPRETATION Most patients achieved a good level of function, and the therapy appears to be functioning satisfactorily.

Rehabilitation Trends After Lower Extremity Amputations in Canada

BACKGROUND

The heterogeneity of medical complications that lead to amputation has resulted in a diverse patient population with differing rehabilitation needs; however, the rehabilitation trends for patients with lower extremity amputations across Canada have not been studied previously.

OBJECTIVE

To describe trends in rehabilitation after lower extremity amputations and the factors affecting rehabilitation length of stay in Canada.

DESIGN

Retrospective cohort analysis.

SETTING

Canadian inpatient rehabilitation facilities that received persons with lower extremity amputations discharged from academic or community hospitals.

PARTICIPANTS

Patients underwent lower extremity amputations between 2006 and 2009 for nontraumatic indications and were then discharged to a rehabilitation facility. Patients were identified from the Canadian Institute for Health Information's Discharge Abstract Database that includes hospital admissions across Canada except Quebec.

INTERVENTIONS

Inpatient rehabilitation after lower extremity amputations.

MAIN OUTCOME MEASURES

Length of stay, discharge destination, and change in total and motor function scores.

RESULTS

The analysis included 5342 persons who underwent lower extremity amputations, 1904 of whom were transferred to a rehabilitation facility (36%). Patients most commonly underwent single below-knee (74%) and above-knee (17%) amputations. The duration of rehabilitation varied by whether the amputation was performed by a vascular (median = 36 days), orthopedic (median = 38 days), or general surgeon (median = 35 days). The overall median length of stay was 36 days. Most patients (72%) subsequently were discharged home and 9% were readmitted to hospital. Predictors of longer rehabilitation included amputation by an orthopedic surgeon (beta = 5.0, P ≤ .01), older age (beta = 0.2, P ≤ .01), and a history of ischemic heart disease (beta = 3.8, P = .03) or congestive heart failure (beta = 5, P = .04). Patients who spent <7 days in hospital were significantly more likely to have a shorter rehabilitation stay (beta = -4, P = .03). Advanced patient age was the only predictor for hospital readmission (odds ratio = 1.03, P ≤ .01).

CONCLUSIONS

Rehabilitation length of stay in Canada after lower extremity amputation varies by the type of surgeon performing the amputation. Advanced age, undergoing surgery in the province of Manitoba, and having a history of ischemic heart disease or congestive heart failure predict a longer rehabilitation stay. A shorter perioperative hospitalization period (<7 days) predicts a shorter rehabilitation duration. Future studies are needed to explore these issues and to optimize the delivery of rehabilitation services to Canadians after lower extremity amputation.

LEVEL OF EVIDENCE

II.