Journal of Rehabilitation Medicine 51-5 | Page 53

J Rehabil Med 2019; 51: 369–375 ORIGINAL REPORT COMORBIDITY HAS NO IMPACT ON UNPLANNED DISCHARGE OR FUNCTIONAL GAINS IN PERSONS WITH DYSVASCULAR AMPUTATION Raymond CHENG, MD, Sean R. SMITH, MD and Claire Z. KALPAKJIAN, PhD, MS From the University of Michigan Medical School, Department of Physical Medicine and Rehabilitation, Ann Arbor, MI, USA Objective: To examine how factors associated with infection, organ failure, poor wound healing, or indi- ces of chronic vascular disease are associated with unplanned transfers and functional gains in a popu- lation of dysvascular amputees during inpatient re- habilitation. Design: Cross-sectional. Setting: Inpatient rehabilitation unit at an academic medical centre. Patients: A total of 118 patients with new, dysvas- cular, lower-extremity, amputation participating in inpatient rehabilitation. Methods: Logistic regression and indices of change (minimal detectable change; MDC90), standardized response mean and effect size were used to exa- mine the risks of unplanned transfer and functional change. Main outcome measurements: Rate of unplanned transfers from rehabilitation, and Functional Inde- pendence Measure (FIM). Results: Out of the total of 118 patients 19 had un- planned transfers due to medical complications. Age, creatinine, haemoglobin, white blood cell count, haemodialysis, wound vacuum device use, intrave- nous antibiotic use, or previous amputations were not independently associated with unplanned trans- fers, motor FIM change or efficiency. The MDC90 for motor FIM was 17.84, with 21.2% of patients ex- ceeding this value; standardized response mean and effect size were large (1.03 and 1.39, respectively). Conclusion: This study suggests that the presence of comorbidities in a population of dysvascular am- putees participating in inpatient rehabilitation did not increase the risk of unplanned transfers or affect FIM gains. Key words: amputation; inpatient rehabilitation; comorbidity, interrupted stay, healthcare quality; lower extremity ampu- tee. Accepted Mar 25, 2019: Epub ahead of print Apr 9, 2019 J Rehabil Med 2019; 51: 369–375 Correspondence address: Raymond Cheng, 3301 Matlock Road, Inpa- tient Rehabilitation Unit, 4th Floor, Arlington, TX 76015, USA. E-mail: [email protected] I n the USA, patients are currently being admitted to inpatient rehabilitation more quickly following ma- jor surgery, and lengths of stay in acute care are decrea- sing. This is due to many factors, including increased scrutiny of inpatient rehabilitation facilities by payers LAY ABSTRACT Patients who undergo a lower extremity amputation due to poor blood flow often have multiple, long-term med- ical conditions that increase the risk of complications after surgery. They also tend to be in worse physical condition than the average person, even prior to am- putation. After an amputation, people often participate in physical rehabilitation in a hospital to improve their strength, and to learn how to get around their homes and communities without a limb. We suspected that chronic medical conditions related to poor blood flow and amputation would make it more difficult for patients to participate in rehabilitation. This study of 118 patients who required lower extremity amputation due to poor blood flow found that, despite multiple medical comorbidities, these patients benefited from in-hospital rehabilitation after their surgeries as much as patients who were in rehabilitation for other reasons. and an increase in prospective payment structures for many surgical services that discharge patients to inpa- tient rehabilitation (1–3). As the medical complexity of patients admitted to inpatient rehabilitation increases, the incidence of unplanned transfers from inpatient rehabilitation units to acute medical services due to medical complications has also increased (4). Unplan- ned transfers negatively affect patients’ rehabilitation trajectories and increase healthcare costs, making appropriate selection and medical management of pa- tients admitted to inpatient rehabilitation increasingly important (5). Screening patients to identify those at high risk of medical emergencies is essential to avoid unplanned transfers from inpatient rehabilitation. Among common diagnoses seen in inpatient rehabi- litation patients, dysvascular lower extremity amputee patients represent a population that is particularly vul- nerable to medical complications due to the significant chronic comorbidities that often contributed to the amputation, such as diabetes. As a result, patients with lower extremity amputation are at particularly high risk of unplanned transfers from inpatient rehabilita- tion units compared with other diagnoses commonly admitted to inpatient rehabilitation (4, 6). Patients with dysvascular lower extremity amputation also have a higher rate of re-hospitalization, more so than other common inpatient rehabilitation diagnoses, such as spinal cord injury (SCI) (6), traumatic brain injury (TBI) (7), and stroke (8), which suggests that the co- This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm Journal Compilation © 2019 Foundation of Rehabilitation Information. ISSN 1650-1977 doi: 10.2340/16501977-2554