Measuring quality and cost of care: evaluation of an amputation clinical pathway

Lower Extremity Amputation Protocol (LEAP): A pilot enhanced recovery pathway for vascular amputees

Vascular patients, an inherently older, frail population, account for >80% of major lower extremity amputations (transtibial or transfemoral) in the United States. Retrospective data have shown that early physical therapy and discharge to an acute rehabilitation facility decreases the postoperative length of stay (LOS) and expedites ambulation. In the present study, we sought to determine whether patients treated with the lower extremity amputation protocol (LEAP) will have improved outcomes. We performed a nonrandomized prospective study of vascular patients undergoing an amputation from January 2019 to February 2020. Patients who were nonambulatory or had undergone a previous contralateral major amputation were excluded. LEAP is a multidisciplinary team approach to the perioperative care of amputees using an outlined protocol. The prospective patients were compared with historic controls treated before the initiation of LEAP (January 2016 to December 2018). The primary outcomes included the postoperative LOS, time to receipt of a prosthesis, and time to ambulation. Of the 141 included patients, 130 were in the retrospective group and 11 in the LEAP group. The demographics and comorbidities were similar. All 11 LEAP patients had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. Of the 130 retrospective patients, 122 (94%) had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. The LEAP patients were more likely to be discharged to acute rehabilitation (100% vs 27%; P < .001), receive a prosthesis (100% vs 45%; P < .001), and ambulate with the prosthesis (100% vs 43%; P < .001). The LEAP patients had received physical therapy 2 days sooner than had the retrospective controls (P = .006) with a shorter postoperative LOS (3 days vs 6 days; P < .001). Of the patients who had received their prosthesis, the LEAP patients had received their prosthesis, on average, 2 months sooner than had the retrospective cohort (81 ± 39 days vs 137 ± 97 days, respectively; P = .002) and had ambulated with their prosthesis sooner (86 ± 53 days vs 146 ± 104 days, respectively; P = .002). No differences were found in the incidence of surgical site complications or unplanned readmissions between the two groups. The results from the present pilot study have demonstrated that the use of LEAP can significantly decrease postoperative LOS and expedite the time to independent ambulation with a prosthesis for vascular patients undergoing a major lower extremity amputation. These findings suggest a powerful ability to bridge the healthcare gap for this high-risk, underserved, and ethnically diverse population using a disease-specific standardized protocol.

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

An Integrated Care Pathway Appraisal Tool: A ‘Badge of Quality’

Integrated care pathways (ICPs) are being introduced as a tool to improve the quality of health care. Their local development usually involves some consensus-based approach which engages clinical staff in discussions about how to improve services. Whilst this has definite advantages, it also means that ICPs which are developed for ostensibly the same group of patients with a specific disease or condition will vary in content and quality. Many articles have been written expounding the benefits of using ICPs, but recently there have been a number of evaluations of ICPs which report little or no significant improvement in the quality of health care as a result of their introduction. Why is there this divergence of views about the value of ICPs? Could it be connected with the variability in quality of the ICPs being introduced? What is missing from many of the evaluations of ICPs undertaken so far is a consideration of how good those ICPs really are.

This article describes an appraisal instrument for ICPs — the integrated care pathway appraisal tool (ICPAT) — which has been developed within the West Midlands region of the UK and which can provide a framework for assessing the quality of ICPs.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Rehabilitation process and prosthetics. Part 2

BACKGROUND

A structured, multidisciplinary approach in the rehabilitation process after amputation is needed that includes a greater focus on the involvement of both (para)medics and prosthetists. There is considerable variation in prosthetic prescription concerning the moment of initial prosthesis fitting and the use of replacement parts.

OBJECTIVES

To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 2 focuses on rehabilitation process and prosthetics.

STUDY DESIGN

Systematic literature design.

METHODS

Literature search in five databases and quality assessment on the basis of evidence-based guideline development.

RESULTS

An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity.

CONCLUSION

The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for treatment and reintegration of patients undergoing amputation of a lower extremity and can be used to provide patient information.

CLINICAL RELEVANCE

This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Testing the effectiveness of the Amputee Mobility Protocol: a pilot study

We studied prolonged length of stay (LOS) in the acute care setting on a medical-surgical vascular unit, related to loss of functional mobility status after lower extremity amputation, and implementation of the Amputee Mobility Protocol (AMP) as a standard of care for all patients pre- and post-lower extremity amputation who were admitted to the medical-surgical vascular unit. A comparative pre-post observational study evaluated the effect of AMP on level of functional mobility and LOS after lower extremity amputation in the patient population on the medical-surgical vascular unit. Data was collected retrospectively from patient chart reviews from November of 2004 to March of 2005 for the pre-AMP group and through concurrent patient chart reviews from November of 2005 to March of 2006 for the post-AMP group. Dependent variables included functional mobility and LOS, which were evaluated by a modified Functional Independence Measure (FIM) score and the hospital LOS. Forty-four eligible patients were enrolled in the AMP pilot study during a 5-month period. The sample population consisted of 30 patients pre-AMP and 14 patients post-AMP. LOS for transmetatarsal amputations decreased by 0.7 days, whereas functional mobility increased by a minimum of one level in the modified FIM score. Functional mobility increased for transtibial amputations by one level and transfemoral amputations by 2 levels using the modified FIM score. LOS increased for patients undergoing transtibial (7.1 days) and transfemoral (2.7 days) amputations. This quality improvement project heightened staff awareness regarding ambulation and its impact on functional mobility and early discharge. Vascular nurses were able to affect patients' functional mobility and LOS by implementing a standardized AMP. Data showed that using the standardized AMP increased patients' functional mobility but did not significantly decrease acute care setting LOS. The AMP continues to be used for this patient population because of its impact on functional mobility and independence. This pilot study relates to 3 of the top 20 vascular research priorities: 1) an interdisciplinary strategy to improve the patient's level of functional independence and thereby decrease LOS and cost; 2) the nursing intervention of early, predetermined ambulation schedules will increase the nursing knowledge of strategies that facilitate recovery after vascular surgery in this population; and 3) factors that affect patient outcomes after these three major vascular procedures will be addressed in pilot outcomes. Limitations of the AMP pilot study included the small sample size, staff turnover, and lack of a concurrent control group. The next phase of this project will create and implement a similar activity protocol for patients after abdominal aortic aneurysm repair and various types of lower extremity bypass procedures.

Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement

AIM

The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement.

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis.

METHOD

A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005.

FINDINGS

Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study.

CONCLUSION

Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Patients with comorbidities: perceptions of acute care services

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people living with chronic illnesses. Indeed, a significant number of people will experience multiple chronic illnesses (comorbidities) and may require admission to hospital for acute care that is superimposed on their chronic illnesses.

AIM

The aim of this study was to investigate perceptions of quality of care by patients experiencing comorbidities who required an acute hospital stay.

METHOD

A qualitative descriptive design was adopted, informed by Colaizzi's phenomenological method. Single semi-structured interviews were conducted with 12 patients within 14 days of being discharged home after an acute illness episode.

FINDINGS

Data analysis revealed three themes: poor continuity of care for comorbidities, the inevitability of something going wrong during acute care and chronic conditions persisting after discharge. Combinations of chronic illnesses and treatments affected these patients' experiences of acute care and recovery postdischarge. Medicalized conceptualizations of comorbidity failed to capture the underlying health care needs of these patients. Limitations. No generalizations can be drawn because the findings and conclusions were derived from a purposive sample of patients who agreed to participate.

CONCLUSION

These findings have implications for a comprehensive and co-ordinated approach to this group of patients, and inform the body of nursing knowledge about how patients with comorbidities experience nursing care.

Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review

BACKGROUND

Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions.

AIM

To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge.

METHODS

A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge.

FINDINGS

Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people.

CONCLUSION

Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.

Impact of a clinical pathway for elective infrarenal aortic reconstructions

OBJECTIVE

To determine the impact of a clinical pathway for elective infrarenal aortic reconstruction on outcome, resource utilization, and cost in a university medical center.

SUMMARY BACKGROUND DATA

Clinical pathways have been reported to control costs, reduce resource utilization, and maintain or improve the quality of patient care, although their use during elective aortic reconstructions remains unresolved.

METHODS

A clinical pathway was developed for elective infrarenal aortic reconstructions by a multidisciplinary group comprised of representatives from each involved service. The prepathway practice and costs were analyzed and an efficient, cost-effective practice with specific outcome measures was defined. The impact of the pathway was determined by retrospective comparison of outcome, resource utilization, and cost (total and direct variable) between the pathway patients (PATH, n = 45) and a prepathway control group (PRE, n = 20).

RESULTS

There were no significant differences in the patient demographics, comorbid conditions, operative indications, or type of reconstruction between the groups. There were no operative deaths and the overall complication rate (PRE, 35% vs. PATH, 34%) was similar. The pathway resulted in significant decreases in the total length of stay and preoperative length of stay and a trend toward a significant decrease (p = 0.08) in the intensive care length of stay for the admission during which the operation was performed. The pathway also resulted in significant decreases in both direct variable and total hospital costs for this admission, as well as a significant decrease in the overall direct variable and total hospital costs for the operative admission and the preoperative evaluation (< or =30 days before operative admission). Despite these reductions, the discharge disposition, 30-day readmissions, and number of postoperative clinic visits within 90 days of discharge were not different.

CONCLUSIONS

Implementation of a clinical pathway for elective infrarenal aortic reconstructions dramatically decreased resource utilization and hospital costs without affecting the quality of patient care and did not appear to shift the costs to another setting.