Amputation Care Quality and Satisfaction With Prosthetic Limb Services: A Longitudinal Study of Veterans With Upper Limb Amputation

We used baseline data to identify factors independently associated with prosthetic limb care satisfaction as measured by a previously validated measure, the OPUS CSS. The CSS addresses satisfaction with prosthetic limb services and does not reflect satisfaction with other amputation care services. We found that persons who received amputation care in the prior year had CSS scores that were a mean 5.1 points better than those who had not received recent care. Although causality cannot be determined with this investigation, this finding highlights an important relationship between frequency of care and satisfaction, which can be leveraged by the VA in future care initiatives. Care satisfaction was also better by 0.7 points for every 1-point decrease (indicating higher satisfaction) in the OPUS CSD prosthetic satisfaction scale. This finding isn’t surprising, given that a major purpose of prosthetic limb care services is to procure and fit a satisfactory device. To determine whether these same relationships were observed in the smaller, longitudinal cohort data at follow-up, we repeated these models and found similar relationships between recent care receipt and prosthesis satisfaction and satisfaction with services. We believe that these findings are meaningful and emphasize the importance of both service and device satisfaction to the veteran with an ULA. Lower service satisfaction scores among those with amputations at the shoulder and those with bilateral limb loss suggest that these individuals may benefit from different service delivery approaches.

We did observe a difference in satisfaction scores by geographic region in the follow-up (but not the baseline) data with satisfaction higher in the Western vs the Southern region (data not shown). This finding suggests a need for continued monitoring of care satisfaction over time to determine whether differences by region persist. We grouped respondents into geographic region based on the location where they had received their most recent VA care of any type. Many veterans receive care at multiple VA locations. Thus, it is possible that some veterans received their amputation care at a non-VA facility or a VA facility in a different region.

Our findings related to prosthetic limb care services satisfaction are generalizable to veteran prosthesis users. Findings may not be generalizable to nonusers, because in our study, the CSS only was administered to prosthesis users. Thus, we were unable to identify factors associated with care satisfaction for persons who were not current users of an upper limb prosthesis.

The study findings confirmed that most veterans with ULA receive amputation-related care in the VA or DoD. We compared CSS and Quality of Care item scores for those who reported receiving care at the VA or DoD vs elsewhere. Amputation care within the VA is complex. Some services are provided at VA facilities and some are ordered by VA clinicians but provided by community-based HCPs. However, we found that better (though not statistically significantly different) CSS scores and several Quality of Care items were endorsed by a significantly more of those reporting care in the VA or DoD as compared to elsewhere. Given the dissemination of a rehabilitation of upper limb amputees CPG, we hypothesized that VA and DoD HCPs would be more aware of care guidelines and would provide better care. Overall, our findings supported this hypothesis while also suggesting that areas such as caregiver involvement and peer visitation may benefit from additional attention and program improvement.

We used longitudinal data to describe and compare CSS and Quality of Care Index scores. Our analyses did not detect any statistically significant differences between baseline and follow-up. This finding may reflect that this was a relatively stable population with regard to amputation experiences given the mean time since amputation was 31.4 years. However, we also recognize that our measures may not have captured all aspects of care satisfaction or quality. It is possible that there were other changes that had occurred over the course of the year that were not captured by the CSS or by the Quality of Care Index. It is also possible that some implementation and adoption of the CPG had happened prior to our baseline survey. Finally, it is possible that some elements of the CPG have not yet been fully integrated into clinical care. We believe that the latter is likely, given that nearly 80% of respondents did not report receiving any amputation care within the past year at follow-up, though the CPGs recommend an annual visit.

Aside from recall bias, 2 explanations must be considered relative to the low rate of adherence to the CPG recommendation for an annual follow-up. The first is that the CPG simply may not be widely adopted. The second is that the majority of patients with ULA who use prostheses use a body-powered system. These tend to be low maintenance, long-lasting systems and may ultimately not need annual maintenance and repair. Further, if the veteran’s body-powered system is functioning properly and health status has not changed, they may simply be opting out of an annual visit despite the CPG recommendation. Nonetheless, this apparent low rate of annual follow-up emphasizes the need for additional process improvement measures for the VA.

Strengths and Limitations

The VA provides a unique setting for a nationally representative study of amputation rehabilitation because it has centralized data sources that can be used to identify veterans with ULA. Our study had a strong response rate, and its prosthetic limb care satisfaction findings are generalizable to all veterans with major ULA who received VA care from 2010 to 2015. However, there are limits to generalizability outside of this population to civilians or to veterans who do not receive VA care. To examine possible nonresponse bias, which could limit generalizability, we compared the baseline characteristics of respondents and nonrespondents to the follow-up study (eAppendix 4 available at doi:10.12788/fp.0096). There were no significant differences in satisfaction, quality of care, or receipt of amputation-related care between those lost to follow-up and those with follow-up data. Although, we did find small differences in gender, race, and service era (defined by amputation date). We do not believe that these differences threaten the interpretation of findings at follow-up, but there may be limits to generalizability of these findings to the full baseline sample. The data were from a telephone survey of veterans. It is possible that some veterans did not recall their care receipt or did not understand some of the questions and thus may not have accurately answered questions related to type of care received or the timing of that care.

Our interpretation of findings comparing care received within the VA and DoD or elsewhere is also limited because we cannot say with certainty whether those who indicated no care in the VA or DoD actually had care that was sponsored by the VA or DoD as contract or fee-basis care. Just 8 respondents indicated that they had received care only outside of the VA or DoD in the prior year. There were also some limitations in the collection of data about care location. We asked about receipt of amputation care in the prior year and about location of any amputation care received between baseline and follow-up, and there were differences in responses. Thus, we used a combination of these items to identify location of care received in the prior year.