A Focus Group- and Patient-Driven Study to Understand Patients' and Health Care Providers' Perspectives on Services for People with Amputation

Care Priorities for Individuals with Lower Extremity Amputations: A Patient Delphi Study

OBJECTIVE

To gather preliminary evidence on short- and long-term care priorities for people with lower extremity amputations.

DESIGN

A three-round modified Delphi study using semi-structured interviews.

PARTICIPANTS

A convenience sample of 20 adult participants who had undergone lower extremity amputations at a tertiary public hospital.

MAIN MEASURE

Consensus on each care priority was defined a priori as an agreement of more than 50%. Semi-structured interviews were conducted to understand the rationales for endorsing the care priorities.

RESULTS

Consensus was reached on 24 short-term care priorities and 12 long-term care priorities in the biomedical, practical and psychological and spiritual domains. The rationales for endorsing each of the care priorities generated three themes: preparedness; mental health, psychological and spiritual well-being; and participating in life, with respect and dignity.

CONCLUSIONS

Our results highlight the substantial need to improve patient access to education and planning support prior to undergoing limb amputation, and optimising post-amputation rehabilitation programmes, enabling people with amputations to participate in meaningful life roles that provide them with purpose, dignity, and self-respect. The knowledge of care priorities revealed in this study may promote effective patient-centred care and improve clinical outcomes.

Transitioning from hospital to home after a major lower extremity amputation: Interview study on patients' and relatives' perspectives

INTRODUCTION

Patients often feel unprepared and concerned about their new life after a major lower extremity amputation (LEA). Therefore, we implemented an integrated care program, Safe Journey, to optimize the quality and continuity of care for patients with LEA due to vascular disease when transitioning from hospital to home. This study aims to illuminate and explore the experiences of patients with LEA and their relatives with the transition from hospital to home after implementing Safe Journey.

MATERIAL AND METHODS

This qualitative, exploratory study individually interviewed six patients with a major LEA and four relatives and jointly interviewed eight patients with their relatives.

RESULTS

The participants' experiences transitioning from hospital to home were centered around two major themes: (1) Going home: mixed emotions and confusion, and (2) bridging the gap. The main themes encompassed six subthemes: (1) simultaneously expectant and worried, (2) a lack of knowledge creating uncertainty, (3) an unexpressed but pending need for psychosocial support, (4) reassurance but safety comes at a price, (5) navigating the system, and (6) lack of involvement.

CONCLUSION

Transitioning from hospital to home after a major LEA creates mixed emotions. Knowledge, feeling involved, and being prepared and cared for were highlighted as important during the transition. The Safe Journey program made patients and relatives feel physically reassured and safe, but all the home visits strained the families. The program's benefits are consistent with existing knowledge on patients with complex needs benefitting from integrated care models. However, a more individualized and person-centered approach is needed.

How do users define success with a lower limb prosthesis? A focus group study

PURPOSE

In this study, we sought to examine how lower limb prosthesis users define success, what constructs they associate with success, and what barriers and facilitators contribute to achieving success.

MATERIALS AND METHODS

Purposively sampled lower limb prosthesis users were recruited to participate in a focus group study. Verbatim transcripts from focus groups were analyzed using inductive thematic analysis. Identified constructs were mapped to existing outcome measures, and a conceptual framework for success with a lower limb prosthesis was proposed.

RESULTS

Thirty-one lower limb prosthesis users participated in one of five focus groups. Five themes were developed: keep moving forward, despite ups and downs; being able to live MY normal life and do the things I want to do with ease; learning what works for me and how to manage my prosthesis; only I can define my success; and what about my mental health? Several constructs that do not align with existing measures were identified, including prosthetic attention, grief/loss after amputation, and trust in prosthesis. Facilitators for success described by participants included peer connection, finding the right prosthetist, and mental health support.

CONCLUSIONS

According to lower limb prosthesis users, success must be patient-driven, individually defined, and continually reassessed.

Utilization and Perception of Peer-Support After Lower Limb Loss in the United States: Potential Benefits on Mobility Outcomes

OBJECTIVE

To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes.

DESIGN

Quantitative and qualitative descriptive study with a cross-sectional design.

SETTING

National survey (distributed to 169 peer-support groups in 44 states in the US).

PARTICIPANTS

The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82).

MAIN OUTCOME MEASURES

A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M).

RESULTS

Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055).

CONCLUSION

Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility.

A qualitative study of clinicians' and individuals' with lower limb loss perspectives on the development of a novel online self-management program

PURPOSE

To explore the rehabilitation preferences and experiences of clinicians and patients for education after lower limb loss to facilitate the development of an online self-management program.

METHODS

A qualitative descriptive approach was used. Thirty-one clinicians (physiotherapists, occupational therapists, and prosthetists), and 26 patients with lower limb loss (transtibial and transfemoral amputation; mean age (SD) of 63.3 (9.1), years) were recruited. We used semi-structured focus groups and one-on-one interviews, and audio recorded the interviews. Data were analyzed using conventional content analysis.

RESULTS

Three themes were identified: (1) Needing education in rehabilitation described the education in current practice as one-on-one discussion and booklets and highlighted the limitations of education such as its length, static nature, and inaccessible for patients living in remote areas. (2) Getting back to activities prior to amputation emphasized how goal setting and social support could assist patients and facilitate self-management. (3) Augmenting learning highlighted the need for an accessible complementary source for education and potential solutions to overcome the barriers of online delivery.

CONCLUSIONS

Our findings underscore the importance of education in the rehabilitation of patients to help them get back to their activities. An online accessible tool may improve education by providing information and peer support.

The Ideal Physical Therapist from the Perspective of Individuals With Limb Loss

BACKGROUND

Effective rehabilitation after limb loss is necessary to maximize function and promote independence. Physical therapists (PT) are one of the primary drivers of the rehabilitation process. While general physical therapy knowledge and abilities have been shown to be important to the rehabilitation process, it is unclear what individuals with limb loss value in their PT's.

OBJECTIVE

The purpose of this study was to understand the elements that define an ideal PT from the perspective of individuals with limb loss.

METHODOLOGY

Mixed-method design consisting of a 20-item web-based survey and semi-structured interviews that were administered to individuals 18 years or older, who spoke English, and had a history of lower limb loss.

FINDINGS

Individuals with limb loss describe an ideal PT as promoting a therapeutic alliance, having specialized knowledge, and collaborating with a prosthetist. Knowledge of the PT as it relates to limb loss was found to be both the greatest facilitator and barrier to the rehabilitation process.

CONCLUSION

From the perspective of those with limb loss, an ideal PT promotes a strong therapeutic alliance through communication, has specialized knowledge when it comes to the limb loss rehabilitation process, and collaborates with the prosthetist to problem-solve throughout the rehabilitation process.

Collaboration and Partnership in a 5-Level Engagement Framework for Diabetic Foot Ulcer Management: A Patient-oriented Scoping Review

OBJECTIVE

The management of diabetic foot ulcers (DFUs) is complex, and patient engagement is essential for DFU healing, but it often comes down to the patient's consultation. Therefore, we sought to document patients' engagement in terms of collaboration and partnership for DFUs in 5 levels (direct care, organizational, policy level, research, and education), as well as strategies for patient engagement using an adapted engagement framework.

METHODS

We conducted a scoping review of the literature from inception to April 2022 using the Joanna Briggs Institute method and a patient-oriented approach. We also consulted DFU stakeholders to obtain feedback on the findings. The data were extracted using PROGRESS+ factors for an equity lens. The effects of engagement were described using Bodenheimer's quadruple aims for value-based care.

RESULTS

Of 4,211 potentially eligible records, 15 studies met our eligibility criteria, including 214 patients involved in engagement initiatives. Most studies were recent (9 of 15 since 2020) and involved patient engagement at the direct medical care level (8 of 15). Self-management (7 of 15) was the principal way to clinically engage the patients. None of the studies sought to define the direct influence of patient engagement on health outcomes.

CONCLUSIONS

Very few studies described patients' characteristics. Engaged patients were typically men from high-income countries, in their 50s, with poorly managed type 2 diabetes. We found little rigorous research of patient engagement at all levels for DFUs. There is an urgent need to improve the reporting of research in this area and to engage a diversity of patients.

Developing a research agenda on exercise and physical activity for people with limb loss in Canada

PURPOSE

There is a lack of high-quality evidence about the effects of exercise or physical activity interventions for adults with lower limb amputations (LLAs). A planning meeting involving stakeholders (i.e., people with LLA, community advocates, health care providers, researchers) was organized to identify key research priorities related to exercise and physical activity for people with LLAs.

METHODS

We used a collaborative prioritized planning process with a pre-meeting survey and 2-day virtual meeting that included: identification and prioritization of challenges or gaps; identification and consolidation of solutions; and action planning. This process integrated a modified Delphi approach, including anonymous feedback in two surveys.

RESULTS

Thirty-five stakeholders participated. Six challenges related to exercise and physical activity for people with LLA were prioritized. One solution was prioritized for each challenge. After consolidation of solutions, participants developed five research action plans for research including: developing an on-line interface; developing and evaluating peer-support programs to support physical activity; examining integration of people with LLA into cardiac rehabilitation; development and evaluation of health provider education; and determining priority outcomes related to physical activity and exercise.

CONCLUSIONS

This collaborative process resulted in an action plan for amputation research and fostered collaborations to move identified priorities into action.IMPLICATIONS FOR REHABILITATIONLower limb amputations impact mobility leading to lower levels of physical activity.There are research gaps in our understanding of the effects of exercise or physical activity interventions for adults with lower limb amputations.Through a collaborative planning process, participants prioritized research directions on physical activity and exercise for people with LLA to advance research in the field.Action plans for research focused on developing online resources, peer support, cardiac rehabilitation for people with LLA, health provider education and determining priority outcomes related to physical activity and exercise.

Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019

BACKGROUND

There is conflicting evidence whether limb amputation (LA) disproportionately affects indigenous populations. To better understand this disparity, we compared the LA incidence rate between First Nations persons registered under the Indian Act of Canada (RI) and the general population (GP) in Saskatchewan.

METHODS

We used Saskatchewan's retrospective administrative data containing hospital discharge LA cases, demographic characteristics (age and sex), and residents population reported in the database stratified by RI and GP from 2006-2019. The LA cases for each stratified group were first disaggregated into three broad categories: overall LA (all reported LA), primary LA (first reported LA), and subsequent LA (revision or contralateral LA), with each category further split into the level of amputation defined as major amputation (through/above the ankle/wrist joint) and minor amputation (below the ankle/wrist joint). LA rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial regressions were performed to explore the trends further.

RESULTS

Overall, there were 1347 RI and 4520 GP LA cases reported in Saskatchewan from 2006-2019. Primary LA made up approximately 64.5% (869) of RI and 74.5% (3369) of GP cases, while subsequent LA constituted 35.5% (478) of RI and 25.5% (1151) of GP cases. The average age-adjusted LA rate was 153.9 ± 17.3 per 100,000 in the RI cohort and 31.1 ± 2.3 per 100,000 in the GP cohort. Overall and primary LA rates for the GP Group declined 0.7% and 1.0%, while subsequent LA increased 0.1%. An increased LA rate for all categories (overall 4.9%, primary 5.1%, and subsequent 4.6%) was identified in the RI group. Overall, minor and major LA increased by 6.2% and 3.3%, respectively, in the RI group compared to a 0.8% rise in minor LA and a 6.3% decline in major LA in the GP group. RI females and males were 1.98-1.66 times higher risk of LA than their GP counterparts likewise, RI aged 0-49 years and 50+ years were 2.04-5.33 times higher risk of LA than their GP cohort. Diabetes mellitus (DM) was the most prevalent amputation predisposing factor in both groups with 81.5% of RI and 54.1% of GP diagnosed with DM. Also, the highest proportion of LA was found in the lowest income quintile for both groups (68.7% for RI and 45.3% for GP).

CONCLUSION

Saskatchewan's indigenous individuals, specifically First Nations persons registered under the Indian Act of Canada, experience LA at a higher rate than the general population. This disparity exists for all variables examined, including overall, primary, and subsequent LA rates, level of amputation, sex, and age. Amplification of the disparities will continue if the rates of change maintain their current trajectories. These results underscore the need for a better understanding of underlying causes to develop a targeted intervention in these groups.