Article

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 chi(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.
CI - Copyright (c) 2011 American Academy of Physical Medicine and Rehabilitation.
Published by Elsevier Inc. All rights reserved.

Langue : ANGLAIS