Cost differences in VHA acute and subacute rehabilitation units: implications for VHA resource planning.

Within the Veterans Health Administration (VHA), the top tier of postacute rehabilitation care is provided in acute rehabilitation bedservice units (ARBUs). The next level of care is provided in subacute rehabilitation bedservice units (SRBUs). We fitted reduced-form and structural models to explain VHA cost differences between ARBUs and SRBUs across time and for the individual cost components. We included sociodemographic variables, time since stroke onset, care facility, and the Functional Independence Measure at admission as explanatory variables. The multivariable results indicate that total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared with SRBUs. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.

Demographic and clinical variation in Veterans Health Administration provision of assistive technology devices to veterans poststroke.

OBJECTIVES: To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region. DESIGN: Retrospective population-based study. SETTING: VHA. PARTICIPANTS: Veterans poststroke in fiscal years 2001 and 2002 (N=12,046). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Provision of 8 categories of AT devices. RESULTS: There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R(2) was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R(2) to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R(2) to 9.8%. CONCLUSIONS: Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.

Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA.

BACKGROUND: The increase in provision of assistive technology devices (ATDs) has spurred controversy over Medicare policy aimed at reducing cost-policy that forces social isolation and conflicts with legislation, facilitating participation for individuals with disabilities. In contrast, Department of Veterans Affairs (VA) policy does not limit provision of AT to "in home" use only but rather, states "all enrolled and some non-enrolled veterans are eligible for all needed prosthetics." OBJECTIVES: Examine ATD provision policy by comparing 2 systems, Medicare and VA. Empirically analyze differences in ATDs provided, cost, and duplication in provision. RESEARCH DESIGN: Retrospective study of VA databases, including VA Medicare data. SUBJECTS: A population based study of 12,0461 veterans post-stroke. MEASURES: Frequency of provision of ATDs by Health Care Common Procedural Code, purchase price, and capped rental payments. RESULTS: Of the poststroke veteran cohort, 39% received no AT, 56% received AT from the VA only, 1% received AT from Medicare only, and 3% received AT from both the VA and Medicare. Most ATDs were for activities of daily living, followed by walkers/canes/crutches. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items and slightly lower than Medicare for capped rental payments. CONCLUSION: VA provides a broader variety of ATDs at a lesser cost than Medicare. Analyses of policy differences between VA and Medicare suggest VA policy is driven by veteran need whereas Medicare policy is driven at least in part, by containing costs that have skyrocketed as a result of fraudulent claims.

Factors influencing decisions to admit patients to veterans affairs specialized rehabilitation units after lower-extremity amputation.

UNLABELLED: Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE: To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN: Database study. SETTING: All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS: Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to an SRU. RESULTS: There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS: The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.

Survival analysis in amputees based on physical independence grade achievement.

BACKGROUND: Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES: To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN: Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING: Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS: Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE: Cumulative 6-month survival after rehabilitation discharge. RESULTS: The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS: Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system.

OBJECTIVE: To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN: An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING: Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS: A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS: After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS: The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Factors associated with VHA costs of care for first 12 months after first stroke.

We examined the use patterns and costs of care for a validated stroke cohort (n = 172) from 13 Department of Veterans Affairs (VA) medical centers 1 year poststroke. Decision Support System (DSS) cost and use data (inpatient and outpatient) are profiled. We provide preliminary information about the costs associated with inpatient and outpatient care and explore the relationship between the cost of stroke care, location of service (inpatient and outpatient), and patient functional outcomes. Data on both clinical and sociodemographic characteristics were abstracted from the medical record and merged with VA DSS cost data from each patient's first year poststroke. Descriptive statistics assessed patterns in treatment costs. We found that DSS costs varied as expected across key indicators, including function, health status, discharge location, and the number of comorbidities. These findings provide broad support for the use of DSS cost data in studies of VA stroke care.

Does the presence of a specialized rehabilitation unit in a Veterans Affairs facility impact referral for rehabilitative care after a lower-extremity amputation?

OBJECTIVE: To determine if the presence of specialized rehabilitation units (SRUs) within Veterans Affairs medical centers (VAMC) influences access to rehabilitation services. DESIGN: Retrospective cohort analysis. SETTING: Two types of VAMCs: those with and without SRUs. PARTICIPANTS: Veterans with lower-extremity amputations discharged from VAMCs between October 1, 2002, and September 30, 2003. There were a total of 2375 veterans with amputations: 99% were men; and 60% had transtibial, 40% had transfemoral, and less than 1% had hip disarticulation amputations. Nine hundred sixty-six patients (41%) were seen at a VAMC with an SRU. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Level of service provided expressed as: no evidence of rehabilitation during the hospitalization, generalized rehabilitation through consultation only, or admission to an SRU. RESULTS: There were no differences between patients treated at facilities with SRUs and those treated in a facility without SRU beds with respect to age, sex, marital status, source of hospital admission, or level of amputation (all P<.05). Patients with lower initial FIM instrument scores were more likely to be treated in facilities with SRUs, and to have longer lengths of acute hospitalization (P<.01). Patients at facilities with an SRU compared with those without an SRU had comparable likelihoods of being seen for an initial rehabilitation consultation (75% vs 74%, P=.56), but were more likely to be admitted for high intensity specialty rehabilitation services (26% vs 11%, P<.01). CONCLUSIONS: Although the majority of patients were seen in consultation, structural differences in service availability among clinically similar populations appear to be causing access disparities to specialized rehabilitation among amputees in the VAMC setting. The implication of these differences with regard to patient outcomes will need to be determined.

Characteristics of community nursing homes serving per diem veterans, 1999 to 2002.

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.

Clinical factors associated with prescription of a prosthetic limb in elderly veterans.

OBJECTIVES: To determine how advanced age influences prosthetic prescription. DESIGN: Retrospective cohort analysis with theory-driven logistic regression models. A Post Amputation Quality-of-Life (PAQ) framework of outcomes was proposed and empirically tested. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Two thousand three hundred seventy-five veterans with lower extremity amputations discharged between October 1, 2002, and September 30, 2003. MEASUREMENTS: Prosthetic prescription within 1 year of amputation. RESULTS: Patients younger than 76 were 4.5 times as likely to receive a prescription compared to those aged 86 and older (odds ratio=4.51, 95% confidence interval=1.36-14.99) after controlling for sex, marital status, living circumstance before hospitalization, anatomical level, etiologies, comorbidities, medical acuity, and initial functional status. Patients admitted from extended care and patients with peripheral vascular disease, systemic sepsis, renal failure, congestive heart failure, psychoses, metastatic cancer, paralysis, or other neurological disorders were less likely to receive a prescription, as were patients who underwent procedures for acute central nervous system disorders, severe renal disease, or serious nutritional compromise. Veterans evaluated initially as more cognitively and physically able had higher likelihood of prosthetic prescription, and those with transtibial amputations had higher likelihood of prosthetic prescription than those with transfemoral amputations. CONCLUSION: Amputees aged 75 and older are less likely to receive a prosthetic limb prescription than younger individuals, even after controlling for comorbidities and functional status. Findings support the PAQ framework, in which contexts, etiologies, anatomic level, comorbidities, medical acuity, and initial function are determinants of outcome. Medical and functional conditions that adversely affect level of energy, ability to move independently, or ability to exercise judgment reduce the likelihood of prosthetic prescription.

Assessing and using comorbidity measures in elderly veterans with lower extremity amputations.

BACKGROUND: Understanding comorbidity prevalence and the effects of comorbidities in older veterans with lower extremity amputations may aid in assessing patient outcomes, resource use, and facility-level quality of care. OBJECTIVES: To determine the degree to which adding outpatient to inpatient administrative data sources yields higher comorbidity prevalence estimates and improved explanatory power of models predicting 1-year mortality and to compare the Charlson/Deyo and Elixhauser comorbidity measures. METHODS: A retrospective cohort study applying frequencies, cross-tabulations, and logistic regression models was conducted, including data from 2,375 veterans with lower extremity amputations. Comorbidity prevalence according to the Charlson/Deyo and Elixhauser measures, 1-year mortality rates, and standardized mortality ratios (SMRs) were analyzed. RESULTS: Comorbidity prevalence estimates increased sharply for both the Charlson/Deyo and Elixhauser measures with the addition of data from multiple settings. The Elixhauser compared to the Charlson/Deyo generally yielded higher estimates but did not improve explanatory power for mortality. Modeling expected versus actual deaths produced varying SMRs across geographic regions but was not dependent on which measure or data sources were used. CONCLUSIONS: Merging outpatient with inpatient data may reduce the under coding of comorbidities but does not enhance mortality prediction. Compared to the Charlson/Deyo, the Elixhauser has a more complete coding scheme for comorbid conditions, such as diabetes mellitus and peripheral vascular disease, important to addressing lower extremity amputation etiology.

Multiple system utilization and mortality for veterans with stroke.

BACKGROUND AND PURPOSE: Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. METHODS: Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. RESULTS: The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). CONCLUSIONS: Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Distribution and cost of wheelchairs and scooters provided by Veterans Health Administration.

During fiscal years 2000 and 2001, the Veterans Health Administration provided veterans with more than 131,000 wheelchairs and scooters at a cost of $109 million. This national study is the first to investigate Veterans Health Administration costs in providing wheelchairs and scooters and to compare regional prescription patterns. With a retrospective design, we used descriptive methods to analyze fiscal years 2000 and 2001 National Prosthetics Patient Database data (cleaned data set of 113,724 records). Wheelchairs were categorized by function, weight, and adjustability options for meeting individual needs (e.g., axle position, camber, position of wheels, tilt, and recline options). Results displayed a cost distribution that was negatively skewed by low-cost accessories coded as wheelchairs. Of the standard manual wheelchairs, 3.5% could be considered beyond the customary cost. Regionally, 71% to 86% of all wheelchairs provided were manual wheelchairs, 5% to 11% were power wheelchairs, and 5% to 20% were scooters. The considerable variation found in the types of wheelchairs and scooters provided across Veterans Integrated Service Networks may indicate a need for evidence-based prescription guidelines and clinician training in wheeled-mobility technologies.

Race/ethnicity: who is counting what?

Misclassification of race and ethnicity in administrative data may produce misleading results if it is overlooked or ignored. In this study, we examined the racial/ethnic classifications of 1,084 veterans with stroke in Florida who received inpatient and outpatient services within the Department of Veterans Affairs (VA) healthcare system and who were also eligible for Medicare between 2000 and 2001. We compared the reliability of racial/ethnic classifications between VA inpatient data, VA outpatient data, and Medicare data. Our results showed that (1) the rate of unknown racial/ethnic classification in VA outpatient and inpatient data was high, (2) minimizing the unknowns by substituting known values from other data when available would greatly enhance the overall and individual classification reliability, (3) black and white classifications in the VA data had stronger agreement with Medicare data, and (4) Medicare data may under-represent Hispanic patients.

Dysplasia and cancer in a large multicenter cohort of patients with Barrett's esophagus.

BACKGROUND & AIMS: The exact incidence of adenocarcinoma in patients with Barrett's esophagus (BE) is not known and is reported to vary from 0.2%-2% per year. Published series of patients with BE have included relatively small numbers of patients with limited duration of follow-up. The goal of this study was to define the prevalence and incidence of dysplasia and cancer and evaluate the paths of progression in a large multicenter cohort of BE patients. METHODS: The BE study is a multicenter clinical and endoscopic outcomes project involving a single large database of patients with BE. Data from each of the participating centers were merged into the main study database. Cancers and HGD occurring within 12 months of the index endoscopy were regarded as prevalent cases. RESULTS: One thousand three hundred seventy-six patients met the study criteria (95% white, 14% women); 91 patients had cancer at the initial endoscopy (prevalent cases, 6.7%; 95% confidence interval [CI], 4.8%-8.7%). Six hundred eighteen patients were followed for a total of 2546 patient-years; mean follow-up was 4.12 years. Twelve patients developed cancer during follow-up, a cancer incidence of 1 in 212 patient-years of follow-up (0.5% per year; 95% CI, 0%-1.1%). The combined incidence of HGD and/or cancer was 1 in 75 patient-years of follow-up or 1.3% per year (95% CI, 0%-2.2%). Of the 34 patients developing HGD and/or cancer, 18 patients (53%) had at least 2 initial consecutive endoscopies with biopsies revealing nondysplastic mucosa. The incidence of LGD was 4.3% per year (95% CI, 2.8%-6.0%). In the 156 patients with LGD, regression to no dysplasia occurred in 66%, persistent LGD in 21%, and progression to HGD/cancer in 13%. The incidence of cancer in patients with LGD was 1 in 156 patient-years of follow-up or 0.6% per year (95% CI, 0%-1.3%). CONCLUSIONS: Preliminary results from this trial define the prevalence and incidence of dysplasia and cancer in a multicenter cohort of patients with BE. At least half the patients who developed HGD and/or cancer had 2 consecutive initial endoscopies with biopsies revealing nondysplastic mucosa. The majority of patients with LGD regressed and had a cancer incidence similar to all BE patients.

Measuring stroke impact with SIS: construct validity of SIS telephone administration.

OBJECTIVES: The purpose of this study was to examine the construct validity of the Stroke Impact Scale (SIS) using telephone mode of administration. METHODS: Stroke patients were identified using national VA administrative data and ICD-9 codes in 13 participating VA hospitals. Stroke was confirmed by reviewing electronic medical records. Patients were administered SIS by telephone at 12-weeks post-stroke, and administered the Functional Independence Measure (FIM) and SF-36V at 16 weeks post-stroke. The instrument's convergent validity and its ability to differentiate between groups of stroke patients with different disability levels were examined using Pearson's correlations and Kruskal-Wallis one way ANOVA tests. RESULTS: All the relevant relationships yielded high correlation coefficients with statistical significance: 0.86 for FIM-motor vs. SIS-ADL, and 0.77 for PF in SF-36V vs. SIS-PHYSICAL. The SIS presented better score discrimination and distribution for different severity of stroke than FIM and SF-36V without severe ceiling and floor effects. Kruskal-Wallis tests showed the Physical Component Score of SF-36V did not discriminate any disability levels. Physical functioning (PF) in SF-36V, FIM-motor, SIS-PHYSICAL, SIS-16, and SIS-ADL showed better discrimination in person's functioning. The pairwise comparisons showed that SIS-PHYSICAL, SIS-16, and SIS-ADL discriminated more Rankin levels than FIM-motor and PF in SF-36V. CONCLUSIONS: SIS telephone survey had superior convergent validity and was better at differentiating between groups of stroke patients with different disability levels than the FIM and SF-36V with no evidence of ceiling and floor effects. Telephone administration of SIS would be a useful and cost-effective method to follow-up community dwelling veterans with stroke.

Therapeutic exercise and depressive symptoms after stroke.

OBJECTIVES: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation. DESIGN: Planned secondary analysis of the data from a 9-month randomized, controlled trial. SETTING: Participant homes. PARTICIPANTS: One hundred stroke survivors who had completed acute rehabilitation. INTERVENTION: A progressive, structured, 3-month physical exercise program. MEASUREMENTS: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form. RESULTS: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months (P = .03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care (P = .07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life. CONCLUSION: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms.

Demographic characteristics of veterans who received wheelchairs and scooters from Veterans Health Administration.

Little is known about the reasoning process clinicians use when prescribing wheeled mobility equipment (WME) or about the outcomes of this process, i.e., how many devices are prescribed, to whom, how often, and at what cost. This study characterized veterans who received WME from the Veterans Health Administration. We analyzed variance in wheelchair provision based on sex, race/ethnicity, diagnosis, and age. Three years of data from the National Prosthetics Patient Database and the National Patient Care Database were merged, yielding more than 77,000 observations per fiscal year. Logistic regression analysis revealed associations between WME provision and age, sex, and race/ethnicity, when analysis was controlled for diagnosis and number of comorbidities. Hispanics (odds ratio [OR] = 1.864), African Americans (OR = 1.360), and American Indians/Asians (OR = 1.585) were more likely than Caucasians to receive standard wheelchairs. Hispanics (OR = 0.4), African Americans (OR = 0.7), and American Indians/Asians (OR = 0.4) were less likely than Caucasians to receive scooters.

Risk factors associated with mortality in veteran population following transtibial or transfemoral amputation.

This study explored medical conditions associated with mortality among veterans following transfemoral amputation, transtibial amputation, or hip disarticulation. We applied logistic regression models to identify clinical factors associated with mortality postoperatively. The participants included patients with lower-limb amputations (n = 2,375) who were discharged from Veterans Health Administration hospitals between October 1, 2002, and September 30, 2003. Most (98.9%) were male. We measured cumulative in-hospital, 3-month, and 1-year mortality. The results were 180 in-hospital deaths, 368 by 3 months, and 634 by the 1-year postsurgical amputation date. Those who had perioperative systemic sepsis (odds ratio = 4.28, 95% confidence interval = 2.87-6.39) had more than a fourfold increased likelihood of in-hospital mortality. Congestive heart failure, renal failure, and liver disease were significantly associated with mortality at all time periods. Metastatic cancer was associated only at 3 months and 1 year. We concluded that high medical complexity and mortality rates attest to the need for careful medical oversight during the postacute rehabilitation period.