Health Care Utilization After Major Limb Loss in Adults (18-64) Receiving Care in the Military Health System From 2001 to 2017.

OBJECTIVE: To characterize and quantify health care utilization of Military Health System beneficiaries with major limb loss. DESIGN: Retrospective cohort study. SETTING: Military treatment facilities and civilian health care facilities that accept TRICARE insurance across the United States. PARTICIPANTS: A total 5950 adult Military Health System beneficiaries with major limb amputation(s) acquired between January 1st, 2001, and September 30th, 2017 (N=5950). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: This study was an exploratory analysis designed to identify common care specialties, services, and devices utilized by Military Health System beneficiaries with major limb loss. RESULTS: Most beneficiaries were retirees/dependents (63.3%), men (73.1%), and had a single amputation (88.7%), with a mean age of 42 years. Differences between beneficiary categories were found. Active-duty service members used a larger proportion of inpatient, emergency, primary care, physical and occupational therapy, prosthetics and orthotics, physical medicine and rehabilitation, and psychiatry services than retirees/dependents. Most common procedures included "revision of amputation stump" (57.2%) for the active-duty population and "other amputation below knee" (24.3%) for the retirees/dependents. CONCLUSIONS: These findings highlight the rehabilitation trajectories of beneficiaries receiving treatment for major limb loss in military and civilian care settings. The results could inform staffing decisions and training programs for military treatment facilities, American trauma centers, rehabilitation hospitals, and outpatient health care providers treating individuals with amputation.

Patient definitions of transplant success in upper extremity vascularized composite allotransplantation: A mixed-methods study.

Objective: Upper extremity vascularized composite allotransplantation is an innovative treatment option for people with upper extremity amputations. Limited patient-relevant long-term outcomes data about transplant success may impede patients' informed treatment decision-making. We assessed perceptions of what constitutes upper extremity vascularized composite allotransplantation success among individuals with upper extremity amputations. Methods: This multisite study entailed interviews and focus groups with individuals with upper extremity amputations and upper extremity vascularized composite allotransplantation candidates, participants, and recipients. We examined perceptions of transplant success and preferences for five upper extremity vascularized composite allotransplantation outcomes. Qualitative data were analyzed using thematic analysis; and quantitative data were analyzed using descriptive statistics. Results: In all, 50 individuals participated in interviews (61.7% participation rate), and 37 participated in nine focus groups (75.5% participation rate). Most were White (72%, 73%), had a mean age of 45 and 48 years, and had a unilateral amputation (84%, 59%), respectively. Participants conceptualized upper extremity vascularized composite allotransplantation success as transplant outcomes: (1) restoring function and sensation to enable new activities; (2) accepting the transplanted limb into one's identity and appearance; (3) not having transplant rejection; (4) attaining greater quality of life compared to prosthetics; and (5) ensuring benefits outweigh risks. Participants rated their most important upper extremity vascularized composite allotransplantation outcomes as follows: not having transplant rejection, not developing health complications, grasping objects, feeling touch and temperature, and accepting the upper extremity vascularized composite allotransplantation into your identity. Conclusion: Individuals with upper extremity amputations maintain several conceptions of vascularized composite allotransplantation success, spanning functional, psychosocial, clinical, and quality of life outcomes. Providers should address patients' conceptions of success to improve informed consent discussions and outcomes reporting for upper extremity vascularized composite allotransplantation.

Patient preferences of patient selection criteria for upper extremity vascularized composite allotransplantation: A qualitative study.

Background: Upper extremity vascularized composite allotransplantation is a life-enhancing reconstructive treatment option that aims to improve recipients' quality of life and maximize function. This study assessed upper extremity vascularized composite allotransplantation patient selection criteria perceptions among individuals with upper extremity limb loss. The perceptions of individuals with upper extremity limb loss on patient selection criteria may enable vascularized composite allotransplantation centers to improve criteria to avoid mismatched expectations about the posttransplant vascularized composite allotransplantation experience and outcomes. Realistic patient expectations may increase patient adherence, improve outcomes, and reduce vascularized composite allotransplantation graft loss. Methods: We conducted in-depth interviews with civilian and military service members with upper extremity limb loss and upper extremity vascularized composite allotransplantation candidates, participants, and recipients from three US institutions. Interviews assessed perceptions of patient selection criteria for suitability as a candidate for upper extremity vascularized composite allotransplantation. Thematic analysis was used to analyze qualitative data. Results: A total of 50 individuals participated (66% participation rate). Most participants were male (78%), White (72%), with a unilateral limb loss (84%), and a mean age of 45 years. Six themes emerged regarding upper extremity vascularized composite allotransplantation patient selection criteria, including support for candidates who: (1) are of younger age, (2) are in good physical health, (3) have mental stability, (4) are willing to "put in the work," (5) have specific amputation characteristics, and (6) have sufficient social support. Patients had preferences about selecting candidates with unilateral versus bilateral limb loss. Conclusions: Our findings suggest that numerous factors, including medical, social, and psychological characteristics, inform patients' perceptions of patient selection criteria for upper extremity vascularized composite allotransplantation. Patient perceptions of patient selection criteria should inform the development of validated screening measures that optimize patient outcomes.

A Patient-Centered Website (Within Reach) to Foster Informed Decision-making About Upper Extremity Vascularized Composite Allotransplantation: Development and Usability Study.

BACKGROUND: Upper extremity (UE) vascularized composite allotransplantation (VCA; hand transplantation) is a reconstructive treatment option for patients with UE loss. Approximately 37 UE VCAs have been performed in the United States to date; thus, little is known about long-term psychosocial outcomes and whether the benefits outweigh the risks. To make an informed treatment decision, patients must understand the procedure, risks, and potential benefits of UE VCA. However, few educational resources are publicly available providing unbiased, comprehensive information about UE VCA. OBJECTIVE: This paper described the development of a neutral, and accessible, educational website supporting informed decision-making about UE VCA as a treatment option for individuals with UE amputations. METHODS: Website content development was informed by 9 focus groups conducted with individuals with UE amputations at 3 study sites. After initial website development, we conducted usability testing to identify ways to improve navigability, design, content, comprehension, and cultural sensitivity. Participants were administered the After-Scenario Questionnaire to assess user performance after completing navigational tasks, System Usability Scale to measure the perceived usability of the website, and Net Promoter Score to measure user satisfaction. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using rapid thematic analysis. RESULTS: A total of 44 individuals with UE amputations participated in focus groups (n=37, 84%) and usability testing (n=14, 32%). Most participants in the focus groups and usability testing were male (24/37, 65% and 11/14, 79%, respectively) and White (27/37, 73% and 9/14, 64%, respectively), had unilateral limb loss (22/37, 59% and 12/14, 86%, respectively), and had mean ages of 48 (SD 9.2) and 50 (SD 12.0) years, respectively. Focus group results are organized into accessibility, website design, website development, website tone and values, sitemap, terminology, images and videos, and tables and graphics. Usability testing revealed that participants had a positive impression of the website. The mean After-Scenario Questionnaire score of 1.3 to 2.3 across task scenarios indicated high satisfaction with website usability, the mean System Usability Scale score of 88.9 indicated user satisfaction with website usability, and the mean Net Promoter Score of 9.6 indicated that users were enthusiastic and would likely refer individuals to the website. CONCLUSIONS: The findings suggest that our educational website, Within Reach, provides neutral, patient-centered information and may be a useful resource about UE VCA for individuals with UE amputations, their families, and health care professionals. Health care professionals may inform UE VCA candidates about Within Reach to supplement current VCA education processes. Within Reach serves as a resource about treatment options for patients preparing for scheduled or recovering from traumatic UE amputations. Future research should assess whether Within Reach improves knowledge about UE VCA and enhances informed decision-making about UE VCA as a treatment option.

Information needs and development of a question prompt sheet for upper extremity vascularized composite allotransplantation: A mixed methods study.

Background: People with upper extremity (UE) amputations report receiving insufficient information about treatment options. Furthermore, patients commonly report not knowing what questions to ask providers. A question prompt sheet (QPS), or list of questions, can support patient-centered care by empowering patients to ask questions important to them, promoting patient-provider communication, and increasing patient knowledge. This study assessed information needs among people with UE amputations about UE vascularized composite allotransplantation (VCA) and developed a UE VCA-QPS. Methods: This multi-site, cross-sectional, mixed-methods study involved in-depth and semi-structured interviews with people with UE amputations to assess information needs and develop a UE VCA-QPS. Qualitative data were analyzed by thematic analysis; quantitative data were analyzed by descriptive statistics. The initial UE VCA-QPS included 130 items across 18 topics. Results: Eighty-nine people with UE amputations participated. Most were male (73%), had a mean age of 46 years, and had a unilateral (84%) and below-elbow amputation (56%). Participants desired information about UE VCA eligibility, evaluation process, surgery, risks, rehabilitation, and functional outcomes. After refinement, the final UE VCA-QPS included 35 items, across 9 topics. All items were written at a ≤ 6th grade reading level. Most semi-structured interview participants (86%) reported being 'completely' or 'very' likely to use a UE VCA-QPS. Conclusion: People with UE amputations have extensive information needs about UE VCA. The UE VCA-QPS aims to address patients' information needs and foster patient-centered care. Future research should assess whether the UE VCA-QPS facilitates patient-provider discussion and informed decision-making for UE VCA.

Rehabilitation Response to COVID-19: Optimizing Recovery and Social Reintegration for Military Beneficiaries.

COVID-19 is a novel disease with complex primary and secondary health effects that may significantly impact the functional independence and quality of life of patients and their families. While the term "rehabilitation" is often associated with exercise, the interventions employed by rehabilitation professionals in both the inpatient and outpatient setting are much more complex and very relevant in caring for individuals hospitalized with respiratory infections. Since the start of the pandemic, the Department of Rehabilitation at Walter Reed National Military Medical Center has cared for over 85% of the military beneficiaries admitted to the hospital for COVID-19. In addition to providing acute inpatient occupational, physical, and recreational therapy to help maximize each patient's functional independence, the rehabilitation team has also developed a novel program to help facilitate the safe discharge and successful recovery and social reintegration for all patients with COVID-19. Using a holistic approach, a team led by Occupational Therapy has applied a needs-based assessment of each patient and developed an individualized treatment plan, which employs home monitoring, virtual health interventions, peer support, and augmentation to case management and behavioral health care. The overall acceptance and satisfaction of this program by the patients and staff has been excellent, with early evidence to suggest improved quality of life and possible mitigation of long-term complications. This article describes the development and essential elements of this unique rehabilitation program so that other military treatment facilities may consider implementing.

Effects of an Occupational Therapy Hand Dominance Transfer Intervention for Soldiers With Crossed Hand-Eye Dominance.

Crossed dominance (CD) is defined as an individual's dominant hand and dominant eye being on opposite sides of the body. CD negatively impacts an individual's ability to accurately aim and fire long-barreled guns. The authors developed and evaluated a hand dominance transfer (HDT) intervention to improve the M16 rifle shooting accuracy, efficiency, and skill transfer. Twenty-four U.S. Army soldiers with CD were taught how to handle and fire an M16 rifle using the nondominant hand. Training was conducted at a military, indoor laser-equipped weapons simulator. Accuracy for shooting 40 rounds at baseline with the nondominant eye and dominant hand (NDE/DH) was 22.12 compared to shooting 30.46 with the dominant eye and nondominant hand (DE/NDH). This difference was statistically significant with p = .000. The transfer of shooting accuracy skill (retention) following the HDT intervention was 33.42 with a comparative p value of .100. Efficiency of shooting 10 rounds at baseline with the NDE/DH was 6.3 compared to shooting 7.3 with the DE/NDH. This difference was not statistically significant (p = .107). The transfer of shooting efficiency skill (retention) was 7.96 with a comparative p value of .349. This study supports shooting with the DE/NDH. HDT could be further developed to address the soldiering skill of shooting an M16.

Systematic Review of Mindfulness Practice for Reducing Job Burnout.

OBJECTIVE: A systematic search and critical appraisal of interdisciplinary literature was conducted to evaluate the evidence for practicing mindfulness to treat job burnout and to explore implications for occupational therapy practitioners. METHOD: Eight articles met inclusion criteria. Each study was assessed for quality using the Physiotherapy Evidence Database scale. We used the U.S. Agency for Health Care Policy and Research guidelines to determine strength of evidence. RESULTS: Of the studies reviewed, participants included health care professionals and teachers; no studies included occupational therapy practitioners. Six of the 8 studies demonstrated statistically significant decreases in job burnout after mindfulness training. Seven of the studies were of fair to good quality. CONCLUSION: There is strong evidence for the use of mindfulness practice to reduce job burnout among health care professionals and teachers. Research is needed to fill the gap on whether mindfulness is effective for treating burnout in occupational therapy practitioners.