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Shutze W, Gable D, Ogola G, Eidt J. Prosthetic outcomes after amputation and the impact of mobility level on survival. J Vasc Surg 2024; 80:873-881. [PMID: 38670323 DOI: 10.1016/j.jvs.2024.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5-year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis, and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation. METHODS This was a retrospective analysis of all patients that underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to December 31, 2019. Abstracted data included: age, sex, race, body mass index, comorbidities, American Society of Anesthesiologists score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level, also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries, and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. RESULTS A total of 464 patients were included in this study. The mean age was 65 years, and mean body mass index was 27 kg/m2. The majority of patients were male (68%), White (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis, age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95% confidence interval [CI], 37.6%-46.6%) (below-the-knee amputation, 47.7% [95% CI, 42.5%-53.5%]; above-the-knee amputation, 28.7% [95% CI, 22.1%-37.2%]). On multivariable analysis, age >60 years, congestive heart failure, above-the-knee amputation, and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival. CONCLUSIONS This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The Medicare Functional Classification Level K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival.
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Affiliation(s)
- William Shutze
- Heart Hospital Baylor Plano, Plano, TX; Texas Vascular Associates, Plano, TX.
| | - Dennis Gable
- Heart Hospital Baylor Plano, Plano, TX; Texas Vascular Associates, Plano, TX
| | - Gerald Ogola
- Baylor Scott and White Research Institute, Dallas, TX
| | - John Eidt
- Texas Vascular Associates, Plano, TX; Baylor University Medical Center, Dallas, TX
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Kaufman KR, Bernhardt K, Murphy S, Archer M, Brandt JM, Bowman L, Phillips B. Creation of a Limb Loss and Preservation Registry for Improving the Quality of Patient Care in the United States. Arch Rehabil Res Clin Transl 2024; 6:100356. [PMID: 39372245 PMCID: PMC11447551 DOI: 10.1016/j.arrct.2024.100356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024] Open
Abstract
Objective To describe the development of a national Limb Loss and Preservation Registry (LLPR) designed to collect, standardize, and report patient outcomes data on limb loss and limb difference in the United States. Design Clinical Data Registry. Setting The LLPR was developed through consensus of key stakeholders from academia, industry, patient advocacy, and payers as well as the available scientific evidence. Data are collected from multiple sources, including hospitals, providers, and patients. Participants Data are collected from all 50 states. Interventions Not applicable. Main Outcome Measures More than 1100 trigger codes are used to identify patients who have limb difference or have received a limb preservation or amputation procedure. Once a patient is identified, all subsequent episodes of care are collected for the life of the patient. An integrated model is used for collecting, validating, cleaning, transforming, aggregating, and storing the data received from all sources. The information contained is then provided in a thorough and easily comprehensible manner. Results To date, the LLPR has captured data from >435,000 patients and >11.5 million episodes of care. Conclusions The LLPR creates opportunities to apply large-data analytical methodologies to provides caregivers, researchers, manufacturers, payers, and policy makers the tools needed to improve the quality of clinical care, quantify patient-centric outcomes, develop clinical practice guidelines, assess patient quality of life, identify appropriate technology, and guide creation of national policies to allocate scarce sources appropriately.
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Affiliation(s)
- Kenton R. Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Kathie Bernhardt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Shawn Murphy
- Thought Leadership and Innovation Foundation, McLean, VA, United States
| | - Marah Archer
- Thought Leadership and Innovation Foundation, McLean, VA, United States
| | | | | | | | - Registry External Advisory Board
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
- Thought Leadership and Innovation Foundation, McLean, VA, United States
- Brandt Ventures, Chester Springs, PA, United States
- BData, Inc., Minneapolis, MN, United States
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O'Meara R, Chawla K, Gorantla A, Kelly R, DeJong M, Babrowski T, Halandras P, Blecha M. The Impact of Sociodemographic Variables on Functional Recovery following Lower Extremity Amputation. Ann Vasc Surg 2024:S0890-5096(24)00492-8. [PMID: 39096953 DOI: 10.1016/j.avsg.2024.07.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND We hypothesize that sociodemographic variables, particularly disadvantaged financial environments, impact both rate of prosthetic utilization and the achievement of ambulation post major amputation. METHODS All cases in the Vascular Quality Initiative amputation module were queried between April 2013 and January 2024. Inclusion was limited to patients who underwent below knee, through knee, and above knee amputation. Two primary outcomes were investigated: Nonambulatory status after amputation (minimum of 120 days follow-up); and, not having obtained a prosthetic limb (minimum of 90 days follow-up). The ambulation status and prosthetic status analyses had 6,984 and 6,793 patients meet inclusion, respectively. Multivariable binary logistic regression analysis was performed utilizing variables which achieved univariable significance (P < 0.05) for the outcomes. RESULTS Mean follow-up for those meeting inclusion was 432 days. Among all patients meeting inclusion, 46.7% of patients did not acquire a prosthetic limb and 44.1% were nonambulatory. Sociodemographic factors with significant multivariable association for the outcome of no prosthetic limb acquisition in follow-up were as follows: advancing age (adjusted odds ratio [aOR] 1.011/year (1.006-1.016), P < 0.001); female sex (aOR 1.43 (1.28-1.61), P < 0.001); top 20% area deprivation index representing highest deprivation (aOR 1.24 (1.09-1.41) P = 0.001); race (P = 0.002) insurance status (P = 0.028) with protective status for commercial insurance (39% rate of no prosthetic) and non-US insurance (33%) versus Medicare (51%), Medicaid (48%), Veterans Affairs insurance (49%), Self-pay (42%), and Medicare Advantage (51%). There were numerous comorbidities which also had association with lack of prosthetic limb acquisition. Sociodemographic variables which achieved multivariable significance (P < 0.05) for the outcome of nonambulatory status after major amputation were as follows: female sex (aOR 1.37 (1.23-1.54), P < 0.001); Medicare insurance (P = 0.016); advancing age (aOR 1.009/year (1.004-1.014), P < 0.001); congestive heart failure (aOR 1.15 (1.02-1.31), P = 0.028); and, not living at home in follow-up (aOR (3.53 (2.99-4.17) P < 0.001). Physical therapy at any point after surgery (aOR 0.742 (0.662-0.832), P < 0.001) and commercial insurance (aOR 0.839 (0.737-0.956), P = 0.008) were protective. There were numerous comorbidities which also had association with nonambulatory status in follow-up. CONCLUSIONS Living within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic limb acquisition following major amputation. Black, Native American, and Pacific Islander demographic patients experience lack of acquisition at a higher rate than White and Asian patients independent of comorbidities and socioeconomic covariables. Female patients obtain a prosthetic limb and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Comorbidities and not socioeconomic variables are the leading drivers of nonambulation.
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Affiliation(s)
- Rylie O'Meara
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Karan Chawla
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Akshita Gorantla
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Robert Kelly
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Matthew DeJong
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Trissa Babrowski
- Section of Vascular Surgery and Endovascular Therapy, University of Chicago Medical Center, Maywood, IL
| | - Pegge Halandras
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Stritch School of Medicine, Loyola University Health System, Loyola University Chicago, Maywood, IL.
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McGinnis A, Weber Z, Zuhaili B, Garrett HE. Mobility Rates After Lower-Limb Amputation for Patients Treated with Physician-Led Collaborative Care Model. Ann Vasc Surg 2024; 105:99-105. [PMID: 38599488 DOI: 10.1016/j.avsg.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Clinical outcomes after major lower-limb amputation have been historically poor. The current care provided to most amputees is often disorganized and without physician supervision. The primary purpose of this study is to examine rates of postamputation mobility achieved with a prosthesis by patients with chronic limb-threatening ischemia and/or diabetes who required major lower-limb amputation and were treated under an established physician-led collaborative care pathway. The secondary purpose is to describe the structure and utilization of the care pathway by multiple independent vascular surgery practices in the United States to enable future exploration of its impact on key clinical outcomes within this patient population. METHODS Clinical records of 2,475 patients from 6 vascular practices that adopted this collaborative care pathway between 2017 and 2020 were retrospectively reviewed. Only records with sufficient documented histories of amputation surgeries, prosthetic services, and mobility status were included. RESULTS Of 2,475 patient records reviewed, 1,787 patients (2,157 major amputations) were eligible for analysis. Sixty-two-point 2 percent (n = 1,111) of patients achieved mobility with the collaborative care pathway. Mobility rate varied by amputation level in the study. Prosthetic mobility was achieved in 73.5% of transtibial amputations, 40.4% of transfemoral amputations, and 35.7% of through-knee amputations, regardless of patient laterality, which is superior or equivalent to the best published rates of mobility. CONCLUSIONS The study describes the structure and utilization of a physician-led collaborative care pathway for treating patients who require lower-limb amputation that meets 5 of the 7 recommendations from the 2019 Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischemia. Internal data analysis results suggest that patients treated via this care pathway can potentially achieve improved mobility rates with a prosthesis following amputation. This collaborative care pathway should be further evaluated for its ability to directly improve mobility and other clinically relevant amputation outcomes.
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Affiliation(s)
| | | | - Bara Zuhaili
- Michigan Vascular Center, Michigan State University, Flint, MI
| | - H Edward Garrett
- Division of Vascular Surgery, University of Tennessee-Memphis, Memphis, TN.
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Forrester N, Donzo MW, Hu C, Mize BM, Hui KH, Duwayri Y, Brewster L, Alabi O. Prosthetic fitting and mortality after major lower extremity amputation. J Vasc Surg 2024; 80:529-536. [PMID: 38777159 DOI: 10.1016/j.jvs.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit; however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality. METHODS We reviewed all patients who underwent LEA between 2015 and 2022 at two academic health care systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1 and 3 years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1 and 3 years of follow-up. RESULTS Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n = 488, 69.5%), predominantly non-Hispanic Black (n = 410, 58.4%), and nearly one-fifth were non-ambulatory before LEA (n = 139 [19.8%]). Of note, 14.3% of all subjects who were nonambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow-up; among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1 and 3 years of follow-up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post- coronavirus disease 2019 pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio, 0.24; 95% confidence interval, 0.14-0.40) as well as within 3 years (adjusted hazard ratio, 0.40; 95% confidence interval, 0.29-0.55). CONCLUSIONS Prosthetic fitting is associated with improved survival, and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the Department of Veterans Affairs, such as prosthetic department evaluation of all amputees, may represent a best practice.
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Affiliation(s)
| | | | - Chengcheng Hu
- Health Sciences Research Collaborative, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Brandi M Mize
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical and Perioperative Care, Atlanta VA Healthcare System, Atlanta, GA
| | - Ka Hoi Hui
- Physical Medicine & Rehabilitation, Atlanta VA Healthcare System, Atlanta, GA
| | - Yazan Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Luke Brewster
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical and Perioperative Care, Atlanta VA Healthcare System, Atlanta, GA
| | - Olamide Alabi
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Surgical and Perioperative Care, Atlanta VA Healthcare System, Atlanta, GA
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Farber E, Zhu M, McNamara T, Cheng TW, Alonso A, Siracuse JJ. Patients Experience Significant Long-Term Social and Health Challenges After Major Lower Extremity Amputation. Ann Vasc Surg 2024; 109:291-296. [PMID: 39069122 DOI: 10.1016/j.avsg.2024.07.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Major lower extremity amputation is a significant life-changing event that can have long-term implications. The goal of this study was to assess long-term medical outcomes and social determinants of health (SDH) challenges in this population. METHODS A retrospective review of major lower extremity (previously mentioned ankle) amputations (2018-2022) was performed at a safety-net tertiary care center. Patients who participated in an SDH survey between 6 months and 1.5 years postoperatively were included for survey analysis. Patient demographics, comorbidities, and perioperative and long-term outcomes were analyzed. RESULTS There were 100 patients included. Mean age was 61.5 years and 23% were of female gender. The majority (57%) were Black race, 20% White race, and 21% Hispanic ethnicity. Comorbidities included diabetes (78%), chronic kidney disease (51%), coronary artery disease (31%), congestive heart failure (23%), previous cerebrovascular events (19%), and 37% used opioids preadmission. At baseline, the majority (62%) lived at home. Guillotine amputation was performed in 24%, with definitive amputation in the following and previously mentioned knee in 67% and 33%, respectively. Median length of stay was 7 days. Readmission at 30 days, 90 days, and 1 year was 13%, 30%, and 43% respectively. The average follow up was 839 days. At long-term follow up, 55% lived at home, 25% used opioids, and only 25% were independently ambulatory. In the SDH survey at follow up, 32% identified at least one SDH challenge, with younger patients more often affected (58 vs. 63 years, P = 0.031). SDH challenges consisted of food insecurity (17%), housing insecurity (13%), transportation challenges (13%), seeking employment (8%), difficulty paying for utilities (5%) and medications (4%), seeking further education (5%), and difficulty caring for family/friends (4%). On multivariable analysis, having at least one SDH challenge was independently associated with 1-year readmission (odds ratio 6.7, 95% confidence interval 1.3-35.8, P < 0.001). Older age was associated with lower long-term independent ambulation (odds ratio 0.92, 95% confidence interval 0.85-0.99, P = 0.025). CONCLUSIONS After major lower extremity amputation, patients have significant medical and social challenges with fewer living at home, the majority were not independently ambulatory, and one-third having at least one SDH challenge. Improvements in long-term support including medical, social, and rehabilitation services are required for this vulnerable population.
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Affiliation(s)
- Elina Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Max Zhu
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas McNamara
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA.
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Norvell DC, Turner AP, Morgenroth DC, Henderson AW, Halsne EG, Hurwitz M, Czerniecki JM. The effect of depression on prosthesis prescription in men and women who have undergone a lower limb amputation. Disabil Rehabil 2024; 46:1204-1211. [PMID: 37035925 DOI: 10.1080/09638288.2023.2192976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/15/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE To determine gender disparities and potential factors that modify prosthesis prescription practices in veteran patients who have undergone their first major unilateral amputation due to diabetes or peripheral arterial disease. MATERIALS AND METHODS A retrospective cohort study using the VA Corporate Data Warehouse to compare prosthesis prescription rates and time to prescription between men and women veterans. The primary exposure was gender. The primary outcome was a qualifying prosthesis prescription within 12 months of the incident amputation. The secondary outcome was time to prosthesis prescription. Multiple logistic and linear regression was used to control for potential confounders and identify potential effect modification. RESULTS 2,862 individuals met study criteria, with 1690 (60%) prescribed a qualifying prosthesis. Men were more likely to receive a prosthesis prescription than women (59% versus 45%, respectively; p = 0.03). This difference was observed primarily among those with a diagnosis of major depressive disorder. In this subgroup, the odds of men receiving a prosthesis over women was over 3 times (adjusted odds ratio = 3.3; 95% Confidence Interval, 1.5, 7.4). Men had a mean shorter time to prescription compared to women (112 ± 72 versus 136 ± 79 days, respectively, p = 0.08). Depression in women negatively impacts their prosthesis prescription rates and time to prescription compared to men. This disparity may have significant impacts on future function and quality of life.Implications for RehabilitationThis study found that men more commonly received a prosthesis prescription and received it earlier than women.This disparity was most extreme among women who had been diagnosed with major depressive disorder.Providers should identify at risk patients early and consider targeted interventions to address depression during the preoperative and immediate postoperative phases.Future research should continue to work to identify gender-specific needs that exacerbate disparity.
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Affiliation(s)
- Daniel C Norvell
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Aaron P Turner
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - David C Morgenroth
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Alison W Henderson
- VA Puget Sound Health Care System, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Elizabeth G Halsne
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Max Hurwitz
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, PA, Pittsburgh
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, WA, Seattle
- Department of Rehabilitation Medicine, University of Washington, WA, Seattle
- Center for Limb Loss and Mobility (CLiMB), Seattle, WA
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McDonald CL, Kahn A, Hafner BJ, Morgan SJ. Prevalence of secondary prosthesis use in lower limb prosthesis users. Disabil Rehabil 2024; 46:1016-1022. [PMID: 36843538 PMCID: PMC11182650 DOI: 10.1080/09638288.2023.2182919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/28/2023]
Abstract
PURPOSE Prostheses designed for daily use are often inappropriate for high-level activities and/or are susceptible to water damage and mechanical failure. Secondary prostheses, such as activity-specific or back-up prostheses, are typically required to facilitate uninterrupted participation in desired life pursuits. This study estimated the prevalence of secondary prosthesis use in a large, national sample of lower limb prosthesis users (LLPUs). METHODS We conducted a secondary analysis of survey data from three cross-sectional studies that assessed mobility in LLPUs. Descriptive statistics were used to determine the percentage of secondary prosthesis users and percentages of LLPUs that used different type(s) of secondary prosthesis(es). Secondary prosthesis users and non-users were compared to identify differences in participant characteristics between groups. RESULTS Of participants in the analysis (n = 1566), most (65.8%) did not use a secondary prosthesis. The most common secondary prosthesis types were back-up (19.2%) and activity-specific prostheses (13.5%). Secondary prosthesis users differed significantly from non-users with respect to gender, race, and other characteristics. CONCLUSIONS Results suggest that secondary prosthesis use for most LLPUs is limited and may differ based on users' demographic and clinical characteristics. Future research should determine how LLPUs' health-related quality-of-life outcomes are affected by access to and use of secondary prostheses.Implications for RehabilitationSecondary prostheses, including activity-specific, back-up, and shower prostheses, have the potential to improve function, mobility, and participation for people who use lower limb prostheses.Most lower limb prosthesis users do not use secondary prostheses, and access to these devices may be related to users' demographic and clinical characteristics.Rehabilitation professionals play a key role in facilitating prosthesis users' access to secondary prostheses and should advocate for those who need them.
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Affiliation(s)
| | | | | | - Sara J. Morgan
- University of Washington, Seattle, WA
- Gillette Children’s, St. Paul, MN
- University of Minnesota, Minneapolis, MN
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Matheny H, Woo K, Siada S, Qumsiyeh Y, Aparicio C, Borashan C, O'Banion LA. Community-wide feasibility of the Lower Extremity Amputation Protocol amongst vascular amputees. J Vasc Surg 2023; 78:1057-1063. [PMID: 37315909 DOI: 10.1016/j.jvs.2023.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The Lower Extremity Amputation Protocol (LEAP) is a multidisciplinary enhanced recovery after surgery pathway for vascular amputees. The objective of this study was to examine feasibility and outcomes of community-wide implementation of LEAP. METHODS LEAP was implemented at three safety net hospitals for patients with peripheral artery disease or diabetes requiring major lower extremity amputation. Patients who underwent LEAP (LEAP) were matched 1:1 with retrospective controls (NOLEAP) on hospital location, need for initial guillotine amputation, and final amputation type (above- vs below-knee). Primary endpoint was postoperative hospital length of stay (PO-LOS). RESULTS A total of 126 amputees (63 LEAP and 63 NOLEAP) were included with no difference between baseline demographics and co-morbidities between the groups. After matching, both groups had the same prevalence of amputation level (76% below-knee vs 24% above-knee). LEAP patients had shorter duration of postamputation bed rest (P = .003) and were more likely to receive limb protectors (100% vs 40%; P ≤ .001), prosthetic counseling (100% vs 14%; P ≤ .001), perioperative nerve blocks (75% vs 25%; P ≤ .001), and postoperative gabapentin (79% vs 50%; P ≤ .001). Compared with NOLEAP, LEAP patients were more likely to be discharged to an acute rehabilitation facility (70% vs 44%; P = .009) and less likely to be discharged to a skilled nursing facility (14% vs 35%; P = .009). The median PO-LOS for the overall cohort was 4 days. LEAP patients had a shorter median PO-LOS (3 [interquartile range, 2-5] vs 5 [interquartile range, 4-9] days; P < .001). On multivariable logistic regression, LEAP decreased the odds of a PO-LOS of ≥4 days by 77% (odds ratio, 0.23; 95% confidence interval, 0.09-0.63). Overall, LEAP patients were significantly less likely to have phantom limb pain (5% vs 21%; P = .02) and were more likely to receive a prosthesis (81% vs 40%; P ≤ .001). In a multivariable Cox proportional hazards model, LEAP was associated with an 84% reduction in time to receipt of prosthesis (hazard ratio, 0.16; 95% confidence interval, 0.085-0.303; P < .001). CONCLUSIONS Community wide implementation of LEAP significantly improved outcomes for vascular amputees demonstrating that utilization of core ERAS principles in vascular patients leads to decreased PO-LOS and improved pain control. LEAP also affords this socioeconomically disadvantaged population a greater opportunity to receive a prosthesis and return to the community as a functional ambulator.
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Affiliation(s)
- Heather Matheny
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Yazen Qumsiyeh
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Carolina Aparicio
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Christian Borashan
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| | - Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA. leighann.o'
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10
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England DL, Miller TA, Stevens PM, Campbell JH, Wurdeman SR. GGEM: Gender, Geography, and EMployment differences based on mobility levels among lower limb prosthesis users living in the United States. Prosthet Orthot Int 2023; 47:265-271. [PMID: 36787381 PMCID: PMC10249601 DOI: 10.1097/pxr.0000000000000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND For individuals with a disability, an increase in functional mobility may improve their quality of life and well-being. Greater understanding is needed on how factors such as gender, geography, and employment may play a role in mobility levels among individuals with lower limb amputation. OBJECTIVES To assess the relationship between gender, geography, and employment status on mobility among lower limb prosthesis users. METHODS A cross-sectional analysis of 7,524 patient mobility outcomes completed across the United States was performed. The regression model included the independent variables, such as age, gender, region, employment status, and amputation level. Mobility was entered as the dependent variable. RESULTS Individuals who were employed had 3.6 times the odds of reaching increased mobility (Prosthetic Limb Users' Survey of Mobility ≥ 50) than those unemployed (odds ratio 3.56, 95% confidence interval 3.10-4.09). Gender and geography were significantly associated with mobility as well. CONCLUSIONS Being employed is associated with greater odds of reaching increased mobility. Addressing factors such as returning to employment may aid in improving mobility levels among prosthesis users.
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Affiliation(s)
- Dwiesha L. England
- Hanger Institute for Clinical Research and Education, Hanger Clinic, Austin, TX
| | - Taavy A. Miller
- Hanger Institute for Clinical Research and Education, Hanger Clinic, Austin, TX
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC
| | - Phillip M. Stevens
- Hanger Institute for Clinical Research and Education, Hanger Clinic, Austin, TX
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT
| | - James H. Campbell
- Hanger Institute for Clinical Research and Education, Hanger Clinic, Austin, TX
| | - Shane R. Wurdeman
- Hanger Institute for Clinical Research and Education, Hanger Clinic, Austin, TX
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE
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11
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Weaver ML, Sorber RA, Holscher CM, Cox ML, Henry BV, Brooke BS, Cooper MA. The measurable impact of a diversity, equity, and inclusion editor on diversifying content, authorship, and peer review participation in the Journal of Vascular Surgery. J Vasc Surg 2023; 77:330-337. [PMID: 36368645 DOI: 10.1016/j.jvs.2022.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content. METHODS The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ2 tests. RESULTS During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001). CONCLUSIONS The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| | - Rebecca A Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Morgan L Cox
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brandon V Henry
- Division of Vascular Surgery and Endovascular Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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