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.