Determinants of postacute care discharge destination after dysvascular lower limb amputation.

OBJECTIVE: To examine the factors affecting postacute care discharge decisions among persons undergoing major lower limb amputations as a result of dysvascular causes. DESIGN: A population-based, multicenter prospective study. SETTING: Eighteen participating hospitals in Baltimore, Maryland, and Milwaukee, Wisconsin, served as the referral base for this study. PATIENTS: The study population consisted of patients aged 21 years or older who underwent a major (foot or higher level) lower limb amputation as a result of dysvascular causes. METHODS: Patients were identified and recruited during their acute hospital admission at one of the participating hospitals. Data were drawn from (1) acute care medical chart reviews; (2) surveys administered shortly after patients underwent amputation, while they were receiving acute care, that assessed their function the month before amputation and other demographic and social information; and (3) a 6-month follow-up telephone interview. MAIN OUTCOME MEASURES: The outcome of interest was the postacute discharge setting in which the initial rehabilitation services, if any, were delivered to the patient during the reference period of 6 months after index amputation surgery. Discharge to alternative postacute settings--inpatient rehabilitation facility (IRF), skilled nursing facility (SNF, reference category), and home--were contrasted with use of t- and χ(2) test statistics. A 3-category, multinominal logit model was used to examine the independent effects of sociodemographic, geographic, health, and amputation-related characteristics on the likelihood of discharge to alternative settings. RESULTS: A total of 348 patients consented to participate in the study, with an overall participation rate of 87.1%. One hundred ninety-two patients (55.2%) were discharged to an IRF, 73 (21%) were discharged to an SNF, and 83 (23.8%) were discharged directly home. The mean age of the sample was 63.7 years; the majority (59.2%) were men, and more than one quarter African Americans. More than half of those reporting were poor (income <$15,000/year). On average, patients had 5 co-morbidities, and nearly half had an amputation at the below-knee level. Discharge to an IRF (versus an SNF) was more likely in patients who were married, had greater cognitive functioning, had unilateral below-knee amputations, had Medicaid coverage, and were living in Milwaukee, Wisconsin. Patients were less likely to be discharged home (versus to an SNF) if they were older, unmarried, had a previous history of nursing home residence, and had more perioperative complications. Discharge destination was not affected by gender or race. CONCLUSION: Postacute care decisions largely appear to be made on the basis of medical and family support factors. The findings of this research provide a necessary first step in the challenging task of assessing and quantitatively modeling the long-term functional outcomes of persons who receive postacute care in alternative settings by allowing more optimal case mix adjustment for factors that simultaneously influence rehabilitation setting and outcomes.

Nerve injury in patients after hip and knee arthroplasties and knee arthroscopy.

OBJECTIVE: To examine the reporting of lower limb neuropathy within 90 days of surgery for patients undergoing hip arthroplasty, knee arthroplasty, or knee arthroscopy. DESIGN: This was a retrospective study using data from the 1998 MarketScan Commercial Claims and Encounter Database (The MEDSTAT Group) to identify lower limb neuropathy after these surgeries. The sample was selected within the first 9 months of 1998 using International Classification of Diseases, 9th Revision (ICD-9), and Current Procedural Terminology (CPT) codes for hip and knee surgical procedures. Lower limb nerve injuries as determined by ICD-9 codes within 90 days postsurgery were the main outcome measures. The influence of diabetes on the rates of nerve injuries after surgery was also examined. RESULTS: A total of 14,979 patients underwent these surgical procedures, 10 of whom were reported to have sustained a nerve injury postsurgery (0.07%). The sample comprised mainly men (53.1%), and the largest groups consisted of those aged 45-54 yrs (27.0%) and 55-64 yrs (27.7%). Nerve injury occurred at a rate of 0.03% after hip arthroplasty, 0.01% after knee arthroplasty, and 0.02% within 3 mos of arthroscopic knee surgery. Overall, nerve injuries were two times more prevalent in the diabetic vs. nondiabetic population (0.11% vs. 0.06%); however, this difference did not meet conventional levels of statistical significance. Specific to knee arthroplasty, there were 10-fold differences in nerve injury rates between diabetic and nondiabetic patients, 0.11% vs. 0.01%, respectively (P