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IIR 05-244 – HSR&D Study

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IIR 05-244
Impact of the DoD Paradigm Shift on VA Amputee Prosthetic Care
Gayle E. Reiber MPH PhD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: April 2006 - December 2009

BACKGROUND/RATIONALE:
A recent Department of Defense (DoD) Rehabilitation Directive aims to return amputees from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) to pre-injury function and provide the option of returning to active duty. To meet this goal, Walter Reed and Brooke Army Medical Center Rehabilitation Centers offer state-of-the-art rehabilitation care and prosthetic devices. Current state-of the-art prosthetic technology is approximately six times more expensive than prosthetic technology used in 2000. VA limb distribution practice now allows all veteran amputees to request and receive any prosthetic device.

OBJECTIVE(S):
The primary objective is to provide VA clinicians and policy-makers with information on changes in prosthetic utilization patterns, project costs, amputee satisfaction, prosthetic procurement alternatives and expert recommendations to guide future prosthesis-related personnel, laboratory and economic decisions.

METHODS:
A Survey for Prosthetic Use was developed to address key issues for veterans and service members with major upper and lower limb loss, by a group of rehabilitation and surgery clinicians and researchers using conventional survey methodology. Survey components include demographics and lifestyle variables, combat-associated injuries, health status and comorbidity, prosthetic and assistive devices and services, and satisfaction with prostheses and care. Other sources of data included the Amputee Database, Austin databases, Compensation and Pension databases. We enrolled 298 veterans from the Vietnam conflict, and 283 service members and veterans from the OIF/OEF conflict. Person-level analysis for both conflicts was grouped into the following three categories: unilateral upper limb loss, unilateral lower limb loss, and multiple limb loss. Univariate, bivariate and multivariate analyses were performed.

FINDINGS/RESULTS:
We achieved a 62% response rate in our Survey for Prosthetic Use involving 298 Vietnam veterans and 283 OIF/OEF service members/veterans who sustained major traumatic limb loss. Despite the serious injuries suffered, health status was rated excellent, very good, or good by 71% of Vietnam and 86% of OIF/OEF participants. However, many health issues persist for Vietnam and OIF/OEF participants (respectively): phantom pain (72%, 76%), chronic back pain (36%, 42%), residual limb pain (48%, 63%), prosthesis-related skin problems (51%, 58%), hearing loss (47%, 47%), TBI (3%, 34%), depression (25%, 24%), and PTSD (38%, 59%). Prosthetic devices are currently used by 78% of Vietnam and 90.5% of OIF/OEF participants to improve function and mobility. On average, the annual rate for prosthetic receipt is 10.7-fold higher for OIF/OEF than for Vietnam participants.

IMPACT:
Amputations and subsequent prosthetic use are high priorities for the VA system. Future prosthetic utilization is influenced by the new DoD directive and new technology. The survey developed and used in this project represents the largest across-conflict comparison of prosthetic device use and satisfaction for veterans and service members with major traumatic limb loss. Many advances are evident in restoring function through appropriate rehabilitation care and use of prostheses. Issues still remain in management of phantom, residual limb, and back pain, skin problems, and improvement of satisfaction with prosthetic devices. It is necessary to plan for the future demand on the VA in terms of prostheses utilization, continued rehabilitation, and costs, to guide future prosthesis-related services and economic decisions.

PUBLICATIONS:

Journal Articles

  1. Katon JG, Reiber GE. Major traumatic limb loss among women veterans and servicemembers. Journal of rehabilitation research and development. 2013 Jan 1; 50(2):173-82.
  2. Williams LH, Miller DR, Fincke G, Lafrance JP, Etzioni R, Maynard C, Raugi GJ, Reiber GE. Depression and incident lower limb amputations in veterans with diabetes. Journal of diabetes and its complications. 2011 May 1; 25(3):175-82.
  3. McFarland LV, Hubbard Winkler SL, Heinemann AW, Jones M, Esquenazi A. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. Journal of rehabilitation research and development. 2010 Dec 20; 47(4):299-316.
  4. Reiber GE, McFarland LV, Hubbard S, Maynard C, Hubbard S, Blough DK, Gambel JM, Smith DG, Smith DG. Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. Journal of rehabilitation research and development. 2010 Dec 20; 47(4):275-97.
  5. Maynard CC, Flohr B, Guagliardo TA, Martin CH, McFarland LV, Pruden JD, Reiber GE. Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss. Journal of rehabilitation R&D / Veterans Administration, Department of Medicine and Surgery, Rehabilitation R&D Service. 2010 Jul 1; 47(4):403-408.
  6. Berke GM, Fergason J, Milani JR, Hattingh J, McDowell M, Nguyen V, Reiber GE. Comparison of satisfaction with current prosthetic care in veterans and servicemembers from Vietnam and OIF/OEF conflicts with major traumatic limb loss. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):361-71.
  7. Blough DK, Hubbard S, McFarland LV, Smith DG, Gambel JM, Reiber GE. Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):387-402.
  8. Dougherty PJ, McFarland LV, Smith DG, Esquenazi A, Blake DJ, Reiber GE. Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF servicemembers. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):333-48.
  9. Gailey R, McFarland LV, Cooper RA, Czerniecki J, Gambel JM, Hubbard S, Maynard C, Smith DG, Raya M, Reiber GE. Unilateral lower-limb loss: prosthetic device use and functional outcomes in servicemembers from Vietnam war and OIF/OEF conflicts. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):317-31.
  10. Laferrier JZ, McFarland LV, Boninger ML, Cooper RA, Reiber GE. Wheeled mobility: factors influencing mobility and assistive technology in veterans and servicemembers with major traumatic limb loss from Vietnam war and OIF/OEF conflicts. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):349-60.
  11. Reiber GE, Expert Panel. Expert Panel recommendations--based on research and deliberations from VA HSR&D project "impact of the DOD paradigm shift on VA amputee prosthetic care". Journal of rehabilitation research and development. 2010 Jan 1; 47(4):xxix-xxxii.
  12. Reiber GE, Smith DG. VA paradigm shift in care of veterans with limb loss. Journal of rehabilitation research and development. 2010 Jan 1; 47(4):vii-x.


DRA: Military and Environmental Exposures, Acute and Combat-Related Injury
DRE: none
Keywords: Utilization patterns
MeSH Terms: none

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