Economic value of orthotic and prosthetic services among medicare beneficiaries: a claims-based retrospective cohort study, 2011–2014

Background

It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we examined the association between transfemoral amputation (TFA) status and the risk of experiencing a major cardiac event for those undergoing either dysvascular or traumatic amputations. The association of receiving a prosthesis with the risk of experiencing a major cardiac event was also examined.

Methods

Study Population: All individuals with TFA (N 162), i.e. knee disarticulation and transfemoral amputation, residing in Olmsted County, MN, between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency.

Data Analysis: A competing risk Cox proportional hazard model was used to estimate the relative likelihood of an individual with a TFA experiencing a major cardiac event in a given time period as compared to the matched controls. The cohort was divided by amputation etiology: dysvascular vs trauma/cancer. Additional analysis was performed by combining all individuals with a TFA to look at the relationship between prosthesis receipt and major cardiac events.

Results

Individuals with a dysvascular TFA had an approximately four-fold increased risk of a cardiac event after undergoing an amputation (HR 3.78, 95%CI: 3.07–4.49). These individuals also had an increased risk for non-cardiac mortality (HR 6.27, 95%CI: 6.11–6.58). The risk of a cardiac event was no higher for those with a trauma/cancer TFA relative to the able-bodied controls (HR 1.30, 95%CI: 0.30–5.85). Finally, there was no difference in risk of experiencing a cardiac event for those with or without prosthesis (HR 1.20, 95%CI: 0.55–2.62).

Conclusion

The high risk of initial mortality stemming from an amputation event may preclude many amputees from cardiovascular disease progression. Amputation etiology is also an important factor: cardiac events appear to be more likely among patients with a dysvascular TFA. Providing a prosthesis does not appear to be associated with a reduced risk of a major cardiac event following amputation.

     

Existential suffering in the palliative care setting: an integrated literature review

ContextExistential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade.ObjectivesTo review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions.MethodsA systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980–2009), MEDLINE (1970–2009), and PsychINFO (1980–2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care.ResultsThe search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood.ConclusionGiven the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.     

Fewer Major Amputations Among Individuals With Diabetes in Finland in 1997�C2007: A population-based study

OBJECTIVE

Complications occur in diabetes despite rigorous efforts to control risk factors. Since 2000, the National Development Programme for the Prevention and Care of Diabetes has worked to halve the incidence of amputations in 10 years. Here we evaluate the impact of the efforts undertaken by analyzing the major amputations done in 1997–2007.

RESEARCH DESIGN AND METHODS

All individuals with diabetes (n = 396,317) were identified from comprehensive national databases. Data on the first major amputations (n = 9,481) performed for diabetic and nondiabetic individuals were obtained from the National Hospital Discharge Register.

RESULTS

The relative risk for the first major amputation was 7.4 (95% CI 7.2–7.7) among the diabetic versus the nondiabetic population. The standardized incidence of the first major amputation decreased among the diabetic and nondiabetic populations (48.8 and 25.2% relative risk reduction, respectively) over 11 years, and the time from the registration of diabetes to the first major amputation was significantly longer, on average 1.2 years more. The cumulative five-year postamputation mortality among diabetic individuals was 78.7%.

CONCLUSIONS

In our nationwide diabetes database, the duration from the registration of diabetes to the first major amputation increased, and the incidence of major amputations decreased almost 50% in 11 years. Approximately half of this change was due to the increasing size of the diabetic population. The risk for major amputation is more than sevenfold that among the nondiabetic population. These results pose a continuous challenge to improve diabetes care.Diabetes is increasing rapidly in Finland (1). For this reason, the National Development Programme for the Prevention and Care of Diabetes (DEHKO) was established for the years 2000–2010 (2). The program has specific goals that aim to reduce the complications of diabetes; one of them is to halve the incidence of lower limb amputations.The majority of amputations are performed for diabetic individuals. In Germany, 66% of lower limb amputations were performed for patients with diabetes; the relative risk was 8.8 for men and 5.7 for women compared with that for the nondiabetic population (3). The incidence of lower limb amputations among diabetic populations has varied from 2.1 to 13.7 per 1,000 person-years (4). In Suffolk, U.K., the incidence of major amputations was as low as 1.62 (5), and, in Sweden, the incidence of the first above-transmetatarsal-level amputation was 1.92 for women and 1.97 for men with diabetes (6). The amputation risk was eightfold (6).Falling amputation trends are described. Among type 1 diabetic patients in Sweden, the relative risk of lower limb amputation was 0.6 during the most recent 5-year period compared against the 5-year period before the year 2000 (7). In Scotland, the incidence of major amputations decreased from 5.1 to 2.9 per 1,000 patients with diabetes in 7 years (8). In Suffolk, U.K., major amputations decreased 82% from 1995 to 2005 (9).A great deal of the improvement in amputation trends is attributed to diabetes control programs. In the U.K., a control program led to a drop in the amputation incidence from 5.6 to 1.76 (10). In South Carolina, an education program brought about a decrease in lower limb amputations that was faster than that in other parts of the U.S. (11). Vascular surgery has an impact: in Denmark, a sevenfold increase in vascular surgical activity was associated with a 75% decrease in major amputations from 1981 to 1995 (12).It is still unclear whether the impact of programs is related to earlier diagnosis of diabetes or reflects a true effect of improved care. Multidisciplinary teamwork focusing on foot care and a continuous prospective audit has been shown to be beneficial (9). A thorough analysis of comprehensive register data may widen the perspective given by figures on amputation incidence among the diabetic population.The aim of our study was to analyze the first major amputations among diabetic individuals identified from comprehensive national databases during 1997–2007 and to evaluate the impact of efforts to improve diabetes care in Finland. Trends in amputation rates, time from the registration of diabetes to the first major amputation, and mortality were compared by sex and age-groups within and between diabetic and nondiabetic populations.     

How ‘preventable’ are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors

Purpose: Clinicians commonly believe that lower extremity amputations are potentially preventable with coordinated care and motivated patient self-management. We used in-depth interviews with recent amputees to assess how patients viewed their initial amputation risk and causes. Method: We interviewed 22 patients at a rehabilitation hospital 2–6 weeks after an incident amputation. We focused on patients’ representations of amputation cause and methods of coping with prior foot and leg symptoms. Results: Patients reported unexpected onset and rapid progression of ulceration, infection, progressive vascular disease, foot trauma and complications of comorbid illness as precipitating events. Fateful delays of care were common. Many had long histories of painful prior treatments. A fatalistic approach to self-management, difficulties with access and communication with providers and poor understanding of medical conditions were common themes. Few patients seemed aware of the role of smoking as an amputation risk factor. Conclusions: Most patients felt out of control and had a poor understanding of the events leading to their initial amputations. Prevention of subsequent amputations will require rehabilitation programs to address low health literacy and psychosocial obstacles to self-management.

Implications for Rehabilitation

• Among amputees, pre-amputation perceptions of decisional and informational control are known to affect rehabilitation and disability adjustment prospects.

• Our findings on patient perceptions of their experiences with an initial lower extremity amputation are salient to rehabilitation specialists working with amputees to avoid a proximal or contralateral amputation.

     

Occupational Therapists' Experience with Assistive Technology in Provision of Service to Clients with Alzheimer's Disease and Related Dementias

ABSTRACT

Aims: The objective of this study was to determine how occupational therapy practitioners use assistive technology (AT) when treating clients who have Alzheimer's disease and related dementia (ADRD). Methods: This study utilized a qualitative phenomenological approach in which occupational therapy practitioners were individually interviewed to explore their use of AT with clients who have ADRD. Results: Findings suggest that some assistive technology devices work better for clients at different stages. Clients in the earlier stages of dementia can use a broader range of assistive technology devices, while those in the later stages may not have the ability to use intricate assistive devices. It was also found that assistive technology is primarily used to address safety concerns with the ADRD population. These concerns include elopement, fall prevention, kitchen safety, and medication management. Three main themes were identified in the current study, including Education (for both the client and their family members/caregivers), Safety, and Selection Process. Conclusions: When using AT, occupational therapy practitioners must consider the stage of dementia their client is in, as well as the client's performance skills. Client safety and education were emphasized as key elements of the occupational therapy process.     

Living with limb loss: everyday experiences of “good” and “bad” days in people with lower limb amputation

Purpose: To provide an understanding of the everyday experiences of individuals with a limb amputation.

Methods: Twenty-two participants (14 female, 8 male) with a mean-age of 42 years (SD?=?10?years) were recruited to take part in two focus groups. The participants reported a range of lower-limb amputations (i.e., congenital, acquired, transfemoral, trantibial, unilateral, and bilateral) and on an average were 5 years post-surgery (SD?=?7 years). Each focus group comprised of 11 participants and was moderated by either the first or second author. The moderator asked participants to discuss their everyday experiences of life with an amputation using Charmaz’s good day/bad day approach. Focus groups were transcribed verbatim and analyzed using an inductive thematic analysis.

Results: Four themes were identified: pain, organization and planning, the embodied experience after amputation, and interactions with others.

Conclusions: These themes provide a key resource for understanding daily fluctuations in physical, social, and psychological functioning.

• Implications for Rehabilitation

• Lower limb amputation can result in daily fluctuations in physical, social, and psychological functioning.

• These fluctuations can be illustrated through experiences of pain, planning and organization, embodied experiences, and interactions with others.

• At a policy level, evaluations of daily living after an amputation should be based on a longitudinal assessment.

     

Prehospital amputation: An experimental comparison of techniques

ObjectivePrehospital limb amputation is a rare but potentially life-saving intervention. When patients cannot be extricated due to limb entrapment or have hemodynamic compromise that precludes a prolonged extrication, they may benefit from an emergent prehospital amputation. The objective was to experimentally compare three prehospital amputation techniques on porcine legs.MethodsThe three techniques studied were a scalpel with a Gigli saw, a hacksaw, and a reciprocating saw. For the first technique, a scalpel was used to make a circumferential incision in the soft tissue and a Gigli wire saw to cut through the bone. The second and third techniques only used a saw and did not require soft tissue incision with a scalpel. Three providers including an emergency medicine physician, a paramedic, and a medical student performed three amputations of each technique, resulting in twenty-seven total amputations. The primary outcome was amputation time. Secondary outcomes were rate of instrument malfunction and cleanliness of cut.ResultsThe primary outcome of amputation time was different between techniques. The Gigli saw technique took 32.86 ± 16.53 s (mean ± SD), hacksaw technique 6.28 ± 0.76 s, and reciprocating saw technique 2.84 ± 0.40 s. There were no differences in amputation time between participants for a given amputation technique. The Gigli saw technique had an instrument malfunction on 3/9 trials which was distinct from the other techniques. Differences in cleanliness of cut were nonsignificant.ConclusionsPrehospital limb amputation with a hacksaw or reciprocating saw may result in faster completion of the time-sensitive procedure with fewer instrument malfunctions.     

The Mental Health Nurse Incentive Program: The Benefits from a Client Perspective

It is now acknowledged that a substantial proportion of the Australian population will experience a mental health condition at some time during their lives. Only a small proportion will access care and treatment for these conditions, and those who do are more likely to access general medical practitioners than specialist mental health providers. The Mental Health Nurse Incentive Program (MHNIP) was introduced by the Commonwealth Government to enhance access to mental health care by engaging mental health nurses in collaboration with general practitioners and private psychiatrists. The aim of the current study was to explore the experiences and opinions of clients utilising these services. A qualitative exploratory approach involving in-depth semi-structured interviews was utilised to enhance understanding of the client perspective. Interviews were conducted with 14 clients. Data were analysed using NVivo to assist with the identification of major themes. The findings revealed the major themes to be: initial reactions; a comfortable setting; flexibility; holistic care; and affordable care. These findings suggest that clients perceive the MHNIP as a valuable intervention that met the mental health needs of clients to a greater extent than had previously been possible.     

Biomechanical risk factors for knee osteoarthritis when using passive and powered ankle–foot prostheses

BackgroundGait compensations following transtibial amputation negatively affect sound limb loading and increase the risk of knee osteoarthritis. Push-off assistance provided by new powered prostheses may decrease the demands on the sound limb. However, their effects in a young population in the early stages of prosthetic use are still unknown. The purpose of this study was to compare limb loading between 1. passive and powered ankle–foot prostheses, 2. sound and amputated limbs, and 3. individuals with amputations in the relatively early stages of prosthetic use and controls.MethodsTen young, active individuals with unilateral transtibial amputation and 10 controls underwent biomechanical gait analysis at three speeds. The peak external knee flexor and adductor moments, adductor moment's angular impulse, peak vertical ground reaction force and loading rate were calculated. Repeated measures ANOVAs compared between limbs, prostheses, and groups.FindingsThe powered prosthesis did not decrease the sound limb's peak adduction moment or its impulse, but did decrease the external flexor moment, peak vertical force and loading rate as speed increased. The powered prosthesis decreased the loading rate from controls. The sound limb did not display a significantly greater risk for knee osteoarthritis than the intact limb or than controls in either device.InterpretationIn the early stages of prosthetic use, young individuals with transtibial amputation display few biomechanical risk factors for knee osteoarthritis development. However, a powered ankle–foot prosthesis still offers some benefits and may be used prophylactically to mitigate potential increases of these variables with continued prosthetic use over time.     

Effects of ethnicity and nephropathy on lower-extremity amputation risk among diabetic veterans

OBJECTIVE: To describe ethnic differences in the risk of amputation in diabetic patients with diabetic nephropathy. RESEARCH DESIGN AND METHODS: A retrospective cohort study was conducted on a national cohort of diabetic patients who received primary care within the Veterans Affairs (VA) Health Care System. Hospitalizations for lower-limb amputations were established by ICD-9-CM procedure codes. Relative risk of amputation in diabetic patients with and without diabetic nephropathy was determined using Cox proportional hazard modeling for unadjusted and adjusted models. RESULTS: Of the 429,918 subjects identified with diabetes (mean age 64 +/- 11 years, 97.4% male), 3,289 individuals were determined to have had a lower-limb amputation during the study period. Compared with diabetic patients without amputations, amputees were on average older, more likely to belong to a minority group, and were more likely to have received treatment for more comorbid conditions. Asians were more likely to have toe amputations compared with whites or other ethnicities, while Native Americans were more likely to have below-the-knee amputations. Native Americans had the highest risk of amputation (RR 1.74, 95% CI 1.39-2.18), followed by African Americans (RR 1.41, 95% CI 1.34-1.48) and Hispanics (RR 1.28, 95% CI 1.20-1.38) compared with whites. The presence of diabetic nephropathy increased the risk of amputation threefold in all groups. Asian subjects with diabetes had the lowest adjusted relative risk of amputation (RR 0.31, 95% CI 0.19-0.50). CONCLUSIONS: Among diabetic patients, certain ethnic minority individuals have an increased risk of lower-extremity amputation compared with whites. Presence of diabetic nephropathy further increases this risk.     

Impact of Chronic Kidney Disease on Survival After Amputation in Individuals With Diabetes

OBJECTIVE

To identify factors that influence survival after diabetes-related amputations.

RESEARCH DESIGN AND METHODS

We abstracted medical records of 1,043 hospitalized subjects with diabetes and a lower-extremity amputation from 1 January to 31 December 1993 in six metropolitan statistical areas in south Texas. We identified mortality in the 10-year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11–84.18 and categorized as foot, below-knee amputation, and above-knee amputation and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate <60 ml/min and hemodialysis from Current Procedural Terminology (CPT) codes (90921, 90925, 90935, and 90937). We used χ² for trend and Cox regression analysis to evaluate risk factors for survival after amputation.

RESULTS

Patients with CKD and dialysis had more below-knee amputations and above-knee amputations than patients with no renal disease (P < 0.01). Survival was significantly higher in patients with no renal impairment (P < 0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (hazard ratio [HR] 3.9, 95% CI 3.07–5.0) and a 46% increase for CKD (HR 1.46, 95% CI 1.21–1.77). Subjects with an above-knee amputation had a 167% increase in hazard (HR 2.67, 95% CI 2.14–3.34), and below-knee amputation patients had a 67% increase in hazard for death.

CONCLUSIONS

Survival after amputation is lower in diabetic patients with CKD, dialysis, and high-level amputations.Diabetes is the most common underlying cause of nontraumatic amputation in the U.S. and Europe (1–4). Of the 120,000 amputations performed in the U.S. every year, 40–70% are in individuals with diabetes. Among individuals with end-stage renal disease receiving dialysis, the incidence of amputation is about 10 times higher than in the general diabetic population (5).The in-hospital and 30-day mortality after amputation in people with diabetes is higher than in people with coronary artery bypass graft surgery, breast cancer, or stroke (6–8). However, there is little published data that report the long-term survival after amputation and even less data regarding patients with chronic kidney disease (CKD). The purpose of this study was to identify differences in the proportion of amputations and survival after lower-extremity amputation in individuals with diabetes and CKD and to identify risk factors for survival after an amputation.     

Agency behind bars: Advance care planning with aging and dying offenders

ABSTRACT

Aging and terminally ill individuals in U.S. prisons are increasing, making critical the need for appropriate end-of-life (EOL) care and advance care planning (ACP). Applying Bandura’s agentic perspective, the authors examined 20 aging/dying offenders’ EOL preferences and ACP. Findings include 6 themes: decisions in the shadow of the past, what works best for me, feeling blessed, what is really going on, can anyone be trusted, and turning agency over to someone else. This study provides critical information that will assist professionals who work with dying offenders, as it presents a vivid illustration of their dying process.     

Massage therapy utilisation by Australian women: Prevalence and determinants

ObjectivesMassage is a popular form of health care used among women, yet little is known about the characteristics of women who use massage therapy and the rationale for its use. This study reports the prevalence and characteristics of young and middle-aged Australian women who consulted a massage therapist.DesignThe study analysed data from the Australian Longitudinal Study on Women's Health; a nationally-representative sample of Australian women. The data from 7,993 young, and 9,102 middle-aged women were included in the analyses and massage use was compared against measures of health status, health care utilisation, and demographics.ResultsPrevalence of consultation with a massage therapist in the previous 12 months was 42.4% in young women and 25.2% in middle-aged women. Women who consulted a massage therapist were more likely to consult other complementary medicine practitioners and/or use self-prescribed complementary medicine. Both young and middle-aged women were more likely to consult a massage therapist if they experienced musculoskeletal problems; however less likely, with chronic disease such as diabetes and hypertension.ConclusionDespite large numbers of young and middle-aged Australian women consulting a massage therapist, no Australian studies investigate the prevalence of massage consultations and report correlations with characteristics relevant to demographic, health status and health service data. Our findings highlight the need for further investigation of women's choices relevant to the use of massage therapy. Such research could shape the future of women's health care by providing insight into women's decision making around massage therapy, conventional treatment and healthcare utilisation.