Joseph Webster, MD

Veterans with upper limb amputation (ULA) are a small, but important population, who have received more attention in the past decade due to the increased growth of the population of veterans with conflict-related amputation from recent military engagements. Among the 808 veterans with ULA receiving any care in the US Department of Veterans Affairs (VA) from 2010 to 2015 who participated in our national study, an estimated 28 to 35% had a conflict-related amputation.¹ The care of these individuals with ULA is highly specialized, and there is a recognized shortage of experienced professionals in this area.^2,3 The provision of high-quality prosthetic care is increasingly complex with advances in technology, such as externally powered devices with multiple functions.

The VA is a comprehensive, integrated health care system that serves more than 8.9 million veterans each year. Interdisciplinary amputation care is provided within the VA through a traditional clinic setting or by using one of several currently available virtual care modalities.^4,5 In consultation with the veteran, VA health care providers (HCPs) prescribe prostheses and services based on the clinical needs and furnish authorized items and services to eligible veterans. Prescribed items and/or services are furnished either by internal VA resources or through a community-based prosthetist who is an authorized vendor or contractor. Although several studies have reported that the majority of veterans with ULA utilize VA services for at least some aspects of their health care, little is known about: (1) prosthetic limb care satisfaction or the quality of care that veterans receive; or (2) how care within the VA or Department of Defense (DoD) compares with care provided in the civilian sector.^6-8

Earlier studies that examined the amputation rehabilitation services received by veterans with ULA pointed to quality gaps in care and differences in satisfaction in the VA and DoD when compared with the civilian sector but were limited in their scope and methodology.^7,8 A 2008 study of veterans of the Vietnam War, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) compared satisfaction by location of care receipt (DoD only, VA only, private only, and multiple sources). That study dichotomized response categories for items related to satisfaction with care (satisfied/not), but did not estimate degree of satisfaction, calculate summary scores of the items, or utilize validated care satisfaction metrics. That study found that a greater proportion of Vietnam War veterans (compared with OIF/OEF veterans receiving care in the private sector) agreed that they “had a role in choosing prosthesis” and disagreed that they wanted to change their current prosthesis to another type.⁷ The assumption made by the authors is that much of this private sector care was actually VA-sponsored care prescribed and procured by the VA but delivered in the community. However, no data were collected to confirm or refute this assumption, and it is possible that some care was both VA sponsored and delivered, some was VA sponsored but commercially delivered, and in some cases, care was sponsored by other sources and delivered in still other facilities.

A 2012 VA Office of the Inspector General study of OIF, OEF, and Operation New Dawn (OND) veterans reported lower prosthetic satisfaction for veterans with upper limb when compared with lower limb amputation and described respondents concerns about lack of VA prosthetic expertise, difficulty with accessing VA services, and dissatisfaction with the sometimes lengthy approval process for obtaining fee-basis or VA contract care.⁸ Although this report suggested that there were quality gaps and areas for improvement, it did not employ validated metrics of prosthesis or care satisfaction and instead relied on qualitative data collected through telephone interviews.

Given the VA effort to enhance the quality and consistency of its amputation care services through the formal establishment of the Amputation System of Care, which began in 2008, further evaluation of care satisfaction and quality of care is warranted. In 2014 the VA and DoD released the first evidence-based clinical practice guidelines (CPGs) for the rehabilitation of persons with ULA.² The CPG describes care paths to improve outcomes and basic tenets of amputation rehabilitation care and can be used to identify process activities that are essential aspects of quality care. However, the extent to which the CPG has impacted the quality and timeliness of care for veterans with ULA are presently unclear.

Thus, the purposes of this study were to: (1) measure veteran satisfaction with prosthetic limb care and identify factors associated with service satisfaction; (2) assess quality indicators that potentially reflect CPG) adoption; (3) compare care satisfaction and quality for those who received care in or outside of the VA or DoD; and (4) evaluate change in satisfaction over time.

Methods

The study was approved by the VA Central Institutional Review Board (IRB) (Study #16-20) and Human Research Protection Office, U.S. Army Medical Research and Development Command. The sampling frame consisted of veterans with major ULA who received care in the VA between 2010 and 2015 identified in VA Corporate Data Warehouse. We sent recruitment packages to nondeceased veterans who had current addresses and phone numbers. Those who did not opt out or inform us that they did not meet eligibility criteria were contacted by study interviewers. A waiver of documentation of written informed consent was obtained from the VA Central IRB. When reached by the study interviewer, Veterans provided oral informed consent. At baseline, 808 veterans were interviewed for a response rate of 47.7% as calculated by the American Association for Public Opinion Research (AAPOR) methodology.⁹ Follow-up interviews approximately 1 year later (mean [SD] 367 [16.8] days), were conducted with 585 respondents for a 72.4% response rate (Figure).

Survey Content

Development and pilot testing of the survey instrument previously was reported.¹ The content of the survey drew from existing survey items and metrics, and included new items specifically designed to address patterns of amputation care, based on care goals within the CPG. All new and modified items were tested and refined through cognitive interviews with 10 participants, and tested with an additional 13 participants.

The survey collected data on demographics, amputation characteristics (year of amputation, level, laterality, and etiology), current prosthesis use, and type of prosthesis. This article focused on the sections of the survey pertaining to satisfaction with prosthetic care and indicators of quality of care. A description of the content of the full survey and a synopsis of overall findings are reported in a prior publication.¹ The key independent, dependent, and other variables utilized in the analyses reported in this manuscript are described below.

Primary Independent Variables

In the follow-up survey, we asked respondents whether they had any amputation care in the prior 12 months, and if so to indicate where they had gone for care. We categorized respondents as having received VA/DoD care if they reported any care at the VA or DoD, and as having received non-VA/DoD care if they did not report care at the VA or DoD but indicated that they had received amputation care between baseline and follow-up.

Two primary outcomes were utilized; the Orthotics and Prosthetics User’s Survey (OPUS), client satisfaction with services scale (CSS), and a measure of care quality specifically developed for this study. The CSS is a measure developed specifically for orthotic and prosthesis users.¹⁰ This 11-item scale measures satisfaction with prosthetic limb services and contains items evaluating facets of care such as courtesy received from prosthetists and clinical staff, care coordination, appointment wait time, willingness of the prosthetist to listen to participant concerns, and satisfaction with prosthesis training. Items are rated on a 4-point scale (strongly agree [1] to strongly disagree [4]), thus higher CSS scores indicate worse satisfaction with services. The CSS was administered only to prosthesis users.

The Quality of Care assessment developed for this study contained items pertaining to amputation related care receipt and care quality. These items were generated by the study team in consultation with representatives from the VA/DoD Extremity Amputation Center of Excellence after review of the ULA rehabilitation CPG. Survey questions asked respondents about the clinicians visited for amputation related care in the past 12 months, whether they had an annual amputation-related checkup, whether any clinician had assessed their function, worked with them to identify goals, and/or to develop an amputation-related care plan. Respondents were also asked whether there had been family/caregiver involvement in their care and care coordination, whether a peer visitor was involved in their initial care, whether they had received information about amputation management in the prior year, and whether they had amputation-related pain. Those that indicated that they had amputation-related pain were subsequently asked whether their pain was well managed, whether they used medication for pain management, and whether they used any nonpharmaceutical strategies.

Quality of Care Index

We initially developed 15 indicator items of quality of care. We selected 7 of the items to create a summary index. We omitted 3 items about pain management, since these items were completed only by participants who indicated that they had experienced pain; however, we examined the 3 pain items individually given the importance of this topic. We omitted an additional 2 items from the summary index because they would not be sensitive to change because they pertained to the care in the year after initial amputation. One of these items asked whether caregivers were involved in initial amputation management and the other asked whether a peer visit occurred after amputation. Another 3 items were omitted because they only were completed by small subsamples due to intentional skip patterns in the survey. These items addressed whether clinical HCPs discussed amputation care goals in the prior year, worked to develop a care plan in the prior year, or helped to coordinate care after a move. Completion rates for all items considered for the index are shown in eAppendix 1 (Available at doi:10.12788/fp.0096). After item selection, we generated an index score, which was the number of reported “yes” responses to the seven relevant items.

Other Variables

We created a single variable called level/laterality which categorized ULA as unilateral or bilateral. We further categorized respondents with unilateral amputation by their amputation level. We categorized respondents as transradial for wrist joint or below the elbow amputations; transhumeral for at or above the elbow amputations; and shoulder for shoulder joint or forequarter amputations. Participants indicated the amputation etiology using 7 yes/no variables: combat injury, accident, burn, cancer, diabetes mellitus, and infection. Participants could select ≥ 1 etiology.

Primary prosthesis type was categorized as body powered, myoelectric/hybrid, cosmetic, other/unknown, or nonuser. The service era was classified based on amputation date as Before Vietnam, Vietnam War, After Vietnam to Gulf War, After Gulf War to September 10, 2001, and September 11, 2001 to present. For race, individuals with > 1 race were classified as other. We classified participants by region, using the station identification of the most recent VA medical center that they had visited between January 1, 2010 and December 30, 2015.

The survey also employed 2 measures of satisfaction with the prosthesis, the Trinity Amputation and Prosthetic Experience Scale (TAPES) satisfaction scale and the OPUS Client Satisfaction with Devices (CSD). TAPES consists of 10 items addressing color, shape, noise, appearance, weight, usefulness, reliability, fit, comfort and overall satisfaction.¹¹ Items are rated on a 5-point Likert scale from very dissatisfied (1) to very satisfied (5). An 8-item version of the CSD scale was created for this study, after conducting a Rasch analysis (using Winsteps version 4.4.2) of the original 11-item CSD. The 8 items assess satisfaction with prosthesis fit, weight, comfort, donning ease, appearance, durability, skin contact, and pain. Items are rated on a 4-point scale from strongly agree (1) to strongly disagree (4); higher CSD scores indicate less satisfaction with devices. Psychometric analysis of the revised CSD score was reported in a prior publication.¹² We also reported on the CSS using the original 10-item measure.

Data Analyses

We described characteristics of respondents at baseline and follow-up. We used baseline data to calculate CSS scores and described scores for all participants, for subgroups of unilateral and bilateral amputees, and for unilateral amputees stratified by amputation level. Wilcoxon rank sum tests were used to compare the CSS item and total scores of 461 prosthesis users with unilateral amputation and 29 with bilateral amputation. To identify factors that we hypothesized might be associated with CSS scores at baseline, we developed separate bivariate linear regression models. We added those factors that were associated with CSS scores at P ≤ .1 in bivariate analyses to a multivariable linear regression model of factors associated with CSS score. The P ≤ .1 threshold was used to ensure that relevant confounders were controlled for in regression models. We excluded 309 participants with no reported prosthesis use (who were not asked to complete the CSS), 20 participants with other/unknown prosthesis types, and 106 with missing data on amputation care in the prior year or on satisfaction metrics. We used baseline data for this analysis to maximize the sample size.

We compared CSS scores for those who reported receiving care within or outside of the VA or DoD in the prior year, using Wilcoxon Mann-Whitney rank tests. We also compared scores of individual quality of care items for these groups using Fisher exact tests. We chose to examine individual items rather than the full Index because several items specified care receipt within the VA and thus would be inappropriate to utilize in comparisons by site location; however, we described responses to all items. In these analyses, we excluded 2 respondents who had conflicting information regarding location of care. We used follow-up data for this analysis because it allowed us to identify location of care received in the prior year.

We also described the CSS scores, the 7-item Quality of Care Index and responses to other items related to quality of care at baseline and follow-up. To examine whether satisfaction with prosthetic care or aspects of care quality had changed over time, we compared baseline and follow-up CSS and quality of care scores for respondents who had measures at both times using Wilcoxon signed ranks tests. Individual items were compared using McNemar tests.

Results

Respondents were 97.4% male and included 776 unilateral amputees and 32 bilateral amputees with a mean (SD) age of 63.3 (14.1) years (Table 1). Respondents had lost their limbs a mean (SD) 31.4 (14.1) years prior, and half were transradial, 34.2% transhumeral, and 11.6% shoulder amputation. At baseline 185 (22.9%) participants received amputation-related care in the prior year and 118 (20.2%) participants received amputation-related care within 1 year of follow-up. Of respondents, 113 (19.3%) stated that their care was between baseline and follow-up and 89 (78.8%) of these received care at either the VA, the DoD or both; just 16 (14.2%) received care elsewhere.

Mean (SD) CSS scores were highest (lower satisfaction) for those with amputation at the shoulder and lowest for those with transhumeral amputation: 42.2 (20.0) vs 33.4 (20.8). Persons with bilateral amputation were less satisfied in almost every category when compared with those with unilateral amputation, although the total CSS score was not substantially different. Wilcoxon rank sum analyses revealed statistically significant differences in wait time satisfaction: bilateral amputees were less satisfied than unilateral amputees. Factors associated with overall CSS score in bivariate analyses were CSD score, TAPES score, amputation care receipt, prosthesis type, race, and region of care (eAppendix 2, available at doi:10.12788/fp.0096).

Discussion

Our longitudinal study provides insights into the experiences of veterans with major ULA related to satisfaction with prosthetic limb care services and receipt of amputation-related care. We reported on the development and use of a new summary measure of amputation care quality, which we designed to capture some of the key elements of care quality as provided in the VA/DoD CPG.²

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.

Despite these limitations, we believe that our study provides novel, important findings about the satisfaction with prosthetic limb care services and quality of amputation rehabilitation care for veterans. Findings from this study can be used to address amputation and prosthetic limb care satisfaction and quality weaknesses highlighted and to benchmark care satisfaction and CPG compliance. Other studies evaluating care guideline compliance have used indicators obtained from clinical records or data repositories.^13-15 Future work could combine self-reported satisfaction and care quality measures with indicators obtained from clinical or repository sources to provide a more complete snapshot of care delivery.

Conclusions

We reported on a national survey of veterans with major upper limb loss that assessed satisfaction with prosthetic limb care services and quality of amputation care. Satisfaction with prosthetic limb care was independently associated with satisfaction with the prosthesis, and receipt of care within the prior year. Most of the veterans surveyed received care within the VA or DoD and reported receiving higher quality of care, when compared with those who received care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the year of this study. Data presented in this study can serve to direct VA amputation care process improvement initiatives as benchmarks for future work. Future studies are needed to track satisfaction with and quality of care for veterans with ULA.

Veterans with upper limb amputation (ULA) are a small, but important population, who have received more attention in the past decade due to the increased growth of the population of veterans with conflict-related amputation from recent military engagements. Among the 808 veterans with ULA receiving any care in the US Department of Veterans Affairs (VA) from 2010 to 2015 who participated in our national study, an estimated 28 to 35% had a conflict-related amputation.¹ The care of these individuals with ULA is highly specialized, and there is a recognized shortage of experienced professionals in this area.^2,3 The provision of high-quality prosthetic care is increasingly complex with advances in technology, such as externally powered devices with multiple functions.

The VA is a comprehensive, integrated health care system that serves more than 8.9 million veterans each year. Interdisciplinary amputation care is provided within the VA through a traditional clinic setting or by using one of several currently available virtual care modalities.^4,5 In consultation with the veteran, VA health care providers (HCPs) prescribe prostheses and services based on the clinical needs and furnish authorized items and services to eligible veterans. Prescribed items and/or services are furnished either by internal VA resources or through a community-based prosthetist who is an authorized vendor or contractor. Although several studies have reported that the majority of veterans with ULA utilize VA services for at least some aspects of their health care, little is known about: (1) prosthetic limb care satisfaction or the quality of care that veterans receive; or (2) how care within the VA or Department of Defense (DoD) compares with care provided in the civilian sector.^6-8

Earlier studies that examined the amputation rehabilitation services received by veterans with ULA pointed to quality gaps in care and differences in satisfaction in the VA and DoD when compared with the civilian sector but were limited in their scope and methodology.^7,8 A 2008 study of veterans of the Vietnam War, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) compared satisfaction by location of care receipt (DoD only, VA only, private only, and multiple sources). That study dichotomized response categories for items related to satisfaction with care (satisfied/not), but did not estimate degree of satisfaction, calculate summary scores of the items, or utilize validated care satisfaction metrics. That study found that a greater proportion of Vietnam War veterans (compared with OIF/OEF veterans receiving care in the private sector) agreed that they “had a role in choosing prosthesis” and disagreed that they wanted to change their current prosthesis to another type.⁷ The assumption made by the authors is that much of this private sector care was actually VA-sponsored care prescribed and procured by the VA but delivered in the community. However, no data were collected to confirm or refute this assumption, and it is possible that some care was both VA sponsored and delivered, some was VA sponsored but commercially delivered, and in some cases, care was sponsored by other sources and delivered in still other facilities.

A 2012 VA Office of the Inspector General study of OIF, OEF, and Operation New Dawn (OND) veterans reported lower prosthetic satisfaction for veterans with upper limb when compared with lower limb amputation and described respondents concerns about lack of VA prosthetic expertise, difficulty with accessing VA services, and dissatisfaction with the sometimes lengthy approval process for obtaining fee-basis or VA contract care.⁸ Although this report suggested that there were quality gaps and areas for improvement, it did not employ validated metrics of prosthesis or care satisfaction and instead relied on qualitative data collected through telephone interviews.

Given the VA effort to enhance the quality and consistency of its amputation care services through the formal establishment of the Amputation System of Care, which began in 2008, further evaluation of care satisfaction and quality of care is warranted. In 2014 the VA and DoD released the first evidence-based clinical practice guidelines (CPGs) for the rehabilitation of persons with ULA.² The CPG describes care paths to improve outcomes and basic tenets of amputation rehabilitation care and can be used to identify process activities that are essential aspects of quality care. However, the extent to which the CPG has impacted the quality and timeliness of care for veterans with ULA are presently unclear.

Thus, the purposes of this study were to: (1) measure veteran satisfaction with prosthetic limb care and identify factors associated with service satisfaction; (2) assess quality indicators that potentially reflect CPG) adoption; (3) compare care satisfaction and quality for those who received care in or outside of the VA or DoD; and (4) evaluate change in satisfaction over time.

Methods

The study was approved by the VA Central Institutional Review Board (IRB) (Study #16-20) and Human Research Protection Office, U.S. Army Medical Research and Development Command. The sampling frame consisted of veterans with major ULA who received care in the VA between 2010 and 2015 identified in VA Corporate Data Warehouse. We sent recruitment packages to nondeceased veterans who had current addresses and phone numbers. Those who did not opt out or inform us that they did not meet eligibility criteria were contacted by study interviewers. A waiver of documentation of written informed consent was obtained from the VA Central IRB. When reached by the study interviewer, Veterans provided oral informed consent. At baseline, 808 veterans were interviewed for a response rate of 47.7% as calculated by the American Association for Public Opinion Research (AAPOR) methodology.⁹ Follow-up interviews approximately 1 year later (mean [SD] 367 [16.8] days), were conducted with 585 respondents for a 72.4% response rate (Figure).

Survey Content

Development and pilot testing of the survey instrument previously was reported.¹ The content of the survey drew from existing survey items and metrics, and included new items specifically designed to address patterns of amputation care, based on care goals within the CPG. All new and modified items were tested and refined through cognitive interviews with 10 participants, and tested with an additional 13 participants.

The survey collected data on demographics, amputation characteristics (year of amputation, level, laterality, and etiology), current prosthesis use, and type of prosthesis. This article focused on the sections of the survey pertaining to satisfaction with prosthetic care and indicators of quality of care. A description of the content of the full survey and a synopsis of overall findings are reported in a prior publication.¹ The key independent, dependent, and other variables utilized in the analyses reported in this manuscript are described below.

Primary Independent Variables

In the follow-up survey, we asked respondents whether they had any amputation care in the prior 12 months, and if so to indicate where they had gone for care. We categorized respondents as having received VA/DoD care if they reported any care at the VA or DoD, and as having received non-VA/DoD care if they did not report care at the VA or DoD but indicated that they had received amputation care between baseline and follow-up.

Two primary outcomes were utilized; the Orthotics and Prosthetics User’s Survey (OPUS), client satisfaction with services scale (CSS), and a measure of care quality specifically developed for this study. The CSS is a measure developed specifically for orthotic and prosthesis users.¹⁰ This 11-item scale measures satisfaction with prosthetic limb services and contains items evaluating facets of care such as courtesy received from prosthetists and clinical staff, care coordination, appointment wait time, willingness of the prosthetist to listen to participant concerns, and satisfaction with prosthesis training. Items are rated on a 4-point scale (strongly agree [1] to strongly disagree [4]), thus higher CSS scores indicate worse satisfaction with services. The CSS was administered only to prosthesis users.

The Quality of Care assessment developed for this study contained items pertaining to amputation related care receipt and care quality. These items were generated by the study team in consultation with representatives from the VA/DoD Extremity Amputation Center of Excellence after review of the ULA rehabilitation CPG. Survey questions asked respondents about the clinicians visited for amputation related care in the past 12 months, whether they had an annual amputation-related checkup, whether any clinician had assessed their function, worked with them to identify goals, and/or to develop an amputation-related care plan. Respondents were also asked whether there had been family/caregiver involvement in their care and care coordination, whether a peer visitor was involved in their initial care, whether they had received information about amputation management in the prior year, and whether they had amputation-related pain. Those that indicated that they had amputation-related pain were subsequently asked whether their pain was well managed, whether they used medication for pain management, and whether they used any nonpharmaceutical strategies.

Quality of Care Index

We initially developed 15 indicator items of quality of care. We selected 7 of the items to create a summary index. We omitted 3 items about pain management, since these items were completed only by participants who indicated that they had experienced pain; however, we examined the 3 pain items individually given the importance of this topic. We omitted an additional 2 items from the summary index because they would not be sensitive to change because they pertained to the care in the year after initial amputation. One of these items asked whether caregivers were involved in initial amputation management and the other asked whether a peer visit occurred after amputation. Another 3 items were omitted because they only were completed by small subsamples due to intentional skip patterns in the survey. These items addressed whether clinical HCPs discussed amputation care goals in the prior year, worked to develop a care plan in the prior year, or helped to coordinate care after a move. Completion rates for all items considered for the index are shown in eAppendix 1 (Available at doi:10.12788/fp.0096). After item selection, we generated an index score, which was the number of reported “yes” responses to the seven relevant items.

Other Variables

We created a single variable called level/laterality which categorized ULA as unilateral or bilateral. We further categorized respondents with unilateral amputation by their amputation level. We categorized respondents as transradial for wrist joint or below the elbow amputations; transhumeral for at or above the elbow amputations; and shoulder for shoulder joint or forequarter amputations. Participants indicated the amputation etiology using 7 yes/no variables: combat injury, accident, burn, cancer, diabetes mellitus, and infection. Participants could select ≥ 1 etiology.

Primary prosthesis type was categorized as body powered, myoelectric/hybrid, cosmetic, other/unknown, or nonuser. The service era was classified based on amputation date as Before Vietnam, Vietnam War, After Vietnam to Gulf War, After Gulf War to September 10, 2001, and September 11, 2001 to present. For race, individuals with > 1 race were classified as other. We classified participants by region, using the station identification of the most recent VA medical center that they had visited between January 1, 2010 and December 30, 2015.

The survey also employed 2 measures of satisfaction with the prosthesis, the Trinity Amputation and Prosthetic Experience Scale (TAPES) satisfaction scale and the OPUS Client Satisfaction with Devices (CSD). TAPES consists of 10 items addressing color, shape, noise, appearance, weight, usefulness, reliability, fit, comfort and overall satisfaction.¹¹ Items are rated on a 5-point Likert scale from very dissatisfied (1) to very satisfied (5). An 8-item version of the CSD scale was created for this study, after conducting a Rasch analysis (using Winsteps version 4.4.2) of the original 11-item CSD. The 8 items assess satisfaction with prosthesis fit, weight, comfort, donning ease, appearance, durability, skin contact, and pain. Items are rated on a 4-point scale from strongly agree (1) to strongly disagree (4); higher CSD scores indicate less satisfaction with devices. Psychometric analysis of the revised CSD score was reported in a prior publication.¹² We also reported on the CSS using the original 10-item measure.

Data Analyses

We described characteristics of respondents at baseline and follow-up. We used baseline data to calculate CSS scores and described scores for all participants, for subgroups of unilateral and bilateral amputees, and for unilateral amputees stratified by amputation level. Wilcoxon rank sum tests were used to compare the CSS item and total scores of 461 prosthesis users with unilateral amputation and 29 with bilateral amputation. To identify factors that we hypothesized might be associated with CSS scores at baseline, we developed separate bivariate linear regression models. We added those factors that were associated with CSS scores at P ≤ .1 in bivariate analyses to a multivariable linear regression model of factors associated with CSS score. The P ≤ .1 threshold was used to ensure that relevant confounders were controlled for in regression models. We excluded 309 participants with no reported prosthesis use (who were not asked to complete the CSS), 20 participants with other/unknown prosthesis types, and 106 with missing data on amputation care in the prior year or on satisfaction metrics. We used baseline data for this analysis to maximize the sample size.

We compared CSS scores for those who reported receiving care within or outside of the VA or DoD in the prior year, using Wilcoxon Mann-Whitney rank tests. We also compared scores of individual quality of care items for these groups using Fisher exact tests. We chose to examine individual items rather than the full Index because several items specified care receipt within the VA and thus would be inappropriate to utilize in comparisons by site location; however, we described responses to all items. In these analyses, we excluded 2 respondents who had conflicting information regarding location of care. We used follow-up data for this analysis because it allowed us to identify location of care received in the prior year.

We also described the CSS scores, the 7-item Quality of Care Index and responses to other items related to quality of care at baseline and follow-up. To examine whether satisfaction with prosthetic care or aspects of care quality had changed over time, we compared baseline and follow-up CSS and quality of care scores for respondents who had measures at both times using Wilcoxon signed ranks tests. Individual items were compared using McNemar tests.

Results

Respondents were 97.4% male and included 776 unilateral amputees and 32 bilateral amputees with a mean (SD) age of 63.3 (14.1) years (Table 1). Respondents had lost their limbs a mean (SD) 31.4 (14.1) years prior, and half were transradial, 34.2% transhumeral, and 11.6% shoulder amputation. At baseline 185 (22.9%) participants received amputation-related care in the prior year and 118 (20.2%) participants received amputation-related care within 1 year of follow-up. Of respondents, 113 (19.3%) stated that their care was between baseline and follow-up and 89 (78.8%) of these received care at either the VA, the DoD or both; just 16 (14.2%) received care elsewhere.

Mean (SD) CSS scores were highest (lower satisfaction) for those with amputation at the shoulder and lowest for those with transhumeral amputation: 42.2 (20.0) vs 33.4 (20.8). Persons with bilateral amputation were less satisfied in almost every category when compared with those with unilateral amputation, although the total CSS score was not substantially different. Wilcoxon rank sum analyses revealed statistically significant differences in wait time satisfaction: bilateral amputees were less satisfied than unilateral amputees. Factors associated with overall CSS score in bivariate analyses were CSD score, TAPES score, amputation care receipt, prosthesis type, race, and region of care (eAppendix 2, available at doi:10.12788/fp.0096).

Discussion

Our longitudinal study provides insights into the experiences of veterans with major ULA related to satisfaction with prosthetic limb care services and receipt of amputation-related care. We reported on the development and use of a new summary measure of amputation care quality, which we designed to capture some of the key elements of care quality as provided in the VA/DoD CPG.²

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.

Despite these limitations, we believe that our study provides novel, important findings about the satisfaction with prosthetic limb care services and quality of amputation rehabilitation care for veterans. Findings from this study can be used to address amputation and prosthetic limb care satisfaction and quality weaknesses highlighted and to benchmark care satisfaction and CPG compliance. Other studies evaluating care guideline compliance have used indicators obtained from clinical records or data repositories.^13-15 Future work could combine self-reported satisfaction and care quality measures with indicators obtained from clinical or repository sources to provide a more complete snapshot of care delivery.

Conclusions

We reported on a national survey of veterans with major upper limb loss that assessed satisfaction with prosthetic limb care services and quality of amputation care. Satisfaction with prosthetic limb care was independently associated with satisfaction with the prosthesis, and receipt of care within the prior year. Most of the veterans surveyed received care within the VA or DoD and reported receiving higher quality of care, when compared with those who received care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the year of this study. Data presented in this study can serve to direct VA amputation care process improvement initiatives as benchmarks for future work. Future studies are needed to track satisfaction with and quality of care for veterans with ULA.

Veterans with upper limb amputation (ULA) are a small, but important population, who have received more attention in the past decade due to the increased growth of the population of veterans with conflict-related amputation from recent military engagements. Among the 808 veterans with ULA receiving any care in the US Department of Veterans Affairs (VA) from 2010 to 2015 who participated in our national study, an estimated 28 to 35% had a conflict-related amputation.¹ The care of these individuals with ULA is highly specialized, and there is a recognized shortage of experienced professionals in this area.^2,3 The provision of high-quality prosthetic care is increasingly complex with advances in technology, such as externally powered devices with multiple functions.

The VA is a comprehensive, integrated health care system that serves more than 8.9 million veterans each year. Interdisciplinary amputation care is provided within the VA through a traditional clinic setting or by using one of several currently available virtual care modalities.^4,5 In consultation with the veteran, VA health care providers (HCPs) prescribe prostheses and services based on the clinical needs and furnish authorized items and services to eligible veterans. Prescribed items and/or services are furnished either by internal VA resources or through a community-based prosthetist who is an authorized vendor or contractor. Although several studies have reported that the majority of veterans with ULA utilize VA services for at least some aspects of their health care, little is known about: (1) prosthetic limb care satisfaction or the quality of care that veterans receive; or (2) how care within the VA or Department of Defense (DoD) compares with care provided in the civilian sector.^6-8

Earlier studies that examined the amputation rehabilitation services received by veterans with ULA pointed to quality gaps in care and differences in satisfaction in the VA and DoD when compared with the civilian sector but were limited in their scope and methodology.^7,8 A 2008 study of veterans of the Vietnam War, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) compared satisfaction by location of care receipt (DoD only, VA only, private only, and multiple sources). That study dichotomized response categories for items related to satisfaction with care (satisfied/not), but did not estimate degree of satisfaction, calculate summary scores of the items, or utilize validated care satisfaction metrics. That study found that a greater proportion of Vietnam War veterans (compared with OIF/OEF veterans receiving care in the private sector) agreed that they “had a role in choosing prosthesis” and disagreed that they wanted to change their current prosthesis to another type.⁷ The assumption made by the authors is that much of this private sector care was actually VA-sponsored care prescribed and procured by the VA but delivered in the community. However, no data were collected to confirm or refute this assumption, and it is possible that some care was both VA sponsored and delivered, some was VA sponsored but commercially delivered, and in some cases, care was sponsored by other sources and delivered in still other facilities.

A 2012 VA Office of the Inspector General study of OIF, OEF, and Operation New Dawn (OND) veterans reported lower prosthetic satisfaction for veterans with upper limb when compared with lower limb amputation and described respondents concerns about lack of VA prosthetic expertise, difficulty with accessing VA services, and dissatisfaction with the sometimes lengthy approval process for obtaining fee-basis or VA contract care.⁸ Although this report suggested that there were quality gaps and areas for improvement, it did not employ validated metrics of prosthesis or care satisfaction and instead relied on qualitative data collected through telephone interviews.

Given the VA effort to enhance the quality and consistency of its amputation care services through the formal establishment of the Amputation System of Care, which began in 2008, further evaluation of care satisfaction and quality of care is warranted. In 2014 the VA and DoD released the first evidence-based clinical practice guidelines (CPGs) for the rehabilitation of persons with ULA.² The CPG describes care paths to improve outcomes and basic tenets of amputation rehabilitation care and can be used to identify process activities that are essential aspects of quality care. However, the extent to which the CPG has impacted the quality and timeliness of care for veterans with ULA are presently unclear.

Thus, the purposes of this study were to: (1) measure veteran satisfaction with prosthetic limb care and identify factors associated with service satisfaction; (2) assess quality indicators that potentially reflect CPG) adoption; (3) compare care satisfaction and quality for those who received care in or outside of the VA or DoD; and (4) evaluate change in satisfaction over time.

Methods

The study was approved by the VA Central Institutional Review Board (IRB) (Study #16-20) and Human Research Protection Office, U.S. Army Medical Research and Development Command. The sampling frame consisted of veterans with major ULA who received care in the VA between 2010 and 2015 identified in VA Corporate Data Warehouse. We sent recruitment packages to nondeceased veterans who had current addresses and phone numbers. Those who did not opt out or inform us that they did not meet eligibility criteria were contacted by study interviewers. A waiver of documentation of written informed consent was obtained from the VA Central IRB. When reached by the study interviewer, Veterans provided oral informed consent. At baseline, 808 veterans were interviewed for a response rate of 47.7% as calculated by the American Association for Public Opinion Research (AAPOR) methodology.⁹ Follow-up interviews approximately 1 year later (mean [SD] 367 [16.8] days), were conducted with 585 respondents for a 72.4% response rate (Figure).

Survey Content

Development and pilot testing of the survey instrument previously was reported.¹ The content of the survey drew from existing survey items and metrics, and included new items specifically designed to address patterns of amputation care, based on care goals within the CPG. All new and modified items were tested and refined through cognitive interviews with 10 participants, and tested with an additional 13 participants.

The survey collected data on demographics, amputation characteristics (year of amputation, level, laterality, and etiology), current prosthesis use, and type of prosthesis. This article focused on the sections of the survey pertaining to satisfaction with prosthetic care and indicators of quality of care. A description of the content of the full survey and a synopsis of overall findings are reported in a prior publication.¹ The key independent, dependent, and other variables utilized in the analyses reported in this manuscript are described below.

Primary Independent Variables

In the follow-up survey, we asked respondents whether they had any amputation care in the prior 12 months, and if so to indicate where they had gone for care. We categorized respondents as having received VA/DoD care if they reported any care at the VA or DoD, and as having received non-VA/DoD care if they did not report care at the VA or DoD but indicated that they had received amputation care between baseline and follow-up.

Two primary outcomes were utilized; the Orthotics and Prosthetics User’s Survey (OPUS), client satisfaction with services scale (CSS), and a measure of care quality specifically developed for this study. The CSS is a measure developed specifically for orthotic and prosthesis users.¹⁰ This 11-item scale measures satisfaction with prosthetic limb services and contains items evaluating facets of care such as courtesy received from prosthetists and clinical staff, care coordination, appointment wait time, willingness of the prosthetist to listen to participant concerns, and satisfaction with prosthesis training. Items are rated on a 4-point scale (strongly agree [1] to strongly disagree [4]), thus higher CSS scores indicate worse satisfaction with services. The CSS was administered only to prosthesis users.

The Quality of Care assessment developed for this study contained items pertaining to amputation related care receipt and care quality. These items were generated by the study team in consultation with representatives from the VA/DoD Extremity Amputation Center of Excellence after review of the ULA rehabilitation CPG. Survey questions asked respondents about the clinicians visited for amputation related care in the past 12 months, whether they had an annual amputation-related checkup, whether any clinician had assessed their function, worked with them to identify goals, and/or to develop an amputation-related care plan. Respondents were also asked whether there had been family/caregiver involvement in their care and care coordination, whether a peer visitor was involved in their initial care, whether they had received information about amputation management in the prior year, and whether they had amputation-related pain. Those that indicated that they had amputation-related pain were subsequently asked whether their pain was well managed, whether they used medication for pain management, and whether they used any nonpharmaceutical strategies.

Quality of Care Index

We initially developed 15 indicator items of quality of care. We selected 7 of the items to create a summary index. We omitted 3 items about pain management, since these items were completed only by participants who indicated that they had experienced pain; however, we examined the 3 pain items individually given the importance of this topic. We omitted an additional 2 items from the summary index because they would not be sensitive to change because they pertained to the care in the year after initial amputation. One of these items asked whether caregivers were involved in initial amputation management and the other asked whether a peer visit occurred after amputation. Another 3 items were omitted because they only were completed by small subsamples due to intentional skip patterns in the survey. These items addressed whether clinical HCPs discussed amputation care goals in the prior year, worked to develop a care plan in the prior year, or helped to coordinate care after a move. Completion rates for all items considered for the index are shown in eAppendix 1 (Available at doi:10.12788/fp.0096). After item selection, we generated an index score, which was the number of reported “yes” responses to the seven relevant items.

Other Variables

We created a single variable called level/laterality which categorized ULA as unilateral or bilateral. We further categorized respondents with unilateral amputation by their amputation level. We categorized respondents as transradial for wrist joint or below the elbow amputations; transhumeral for at or above the elbow amputations; and shoulder for shoulder joint or forequarter amputations. Participants indicated the amputation etiology using 7 yes/no variables: combat injury, accident, burn, cancer, diabetes mellitus, and infection. Participants could select ≥ 1 etiology.

Primary prosthesis type was categorized as body powered, myoelectric/hybrid, cosmetic, other/unknown, or nonuser. The service era was classified based on amputation date as Before Vietnam, Vietnam War, After Vietnam to Gulf War, After Gulf War to September 10, 2001, and September 11, 2001 to present. For race, individuals with > 1 race were classified as other. We classified participants by region, using the station identification of the most recent VA medical center that they had visited between January 1, 2010 and December 30, 2015.

The survey also employed 2 measures of satisfaction with the prosthesis, the Trinity Amputation and Prosthetic Experience Scale (TAPES) satisfaction scale and the OPUS Client Satisfaction with Devices (CSD). TAPES consists of 10 items addressing color, shape, noise, appearance, weight, usefulness, reliability, fit, comfort and overall satisfaction.¹¹ Items are rated on a 5-point Likert scale from very dissatisfied (1) to very satisfied (5). An 8-item version of the CSD scale was created for this study, after conducting a Rasch analysis (using Winsteps version 4.4.2) of the original 11-item CSD. The 8 items assess satisfaction with prosthesis fit, weight, comfort, donning ease, appearance, durability, skin contact, and pain. Items are rated on a 4-point scale from strongly agree (1) to strongly disagree (4); higher CSD scores indicate less satisfaction with devices. Psychometric analysis of the revised CSD score was reported in a prior publication.¹² We also reported on the CSS using the original 10-item measure.

Data Analyses

We described characteristics of respondents at baseline and follow-up. We used baseline data to calculate CSS scores and described scores for all participants, for subgroups of unilateral and bilateral amputees, and for unilateral amputees stratified by amputation level. Wilcoxon rank sum tests were used to compare the CSS item and total scores of 461 prosthesis users with unilateral amputation and 29 with bilateral amputation. To identify factors that we hypothesized might be associated with CSS scores at baseline, we developed separate bivariate linear regression models. We added those factors that were associated with CSS scores at P ≤ .1 in bivariate analyses to a multivariable linear regression model of factors associated with CSS score. The P ≤ .1 threshold was used to ensure that relevant confounders were controlled for in regression models. We excluded 309 participants with no reported prosthesis use (who were not asked to complete the CSS), 20 participants with other/unknown prosthesis types, and 106 with missing data on amputation care in the prior year or on satisfaction metrics. We used baseline data for this analysis to maximize the sample size.

We compared CSS scores for those who reported receiving care within or outside of the VA or DoD in the prior year, using Wilcoxon Mann-Whitney rank tests. We also compared scores of individual quality of care items for these groups using Fisher exact tests. We chose to examine individual items rather than the full Index because several items specified care receipt within the VA and thus would be inappropriate to utilize in comparisons by site location; however, we described responses to all items. In these analyses, we excluded 2 respondents who had conflicting information regarding location of care. We used follow-up data for this analysis because it allowed us to identify location of care received in the prior year.

We also described the CSS scores, the 7-item Quality of Care Index and responses to other items related to quality of care at baseline and follow-up. To examine whether satisfaction with prosthetic care or aspects of care quality had changed over time, we compared baseline and follow-up CSS and quality of care scores for respondents who had measures at both times using Wilcoxon signed ranks tests. Individual items were compared using McNemar tests.

Results

Respondents were 97.4% male and included 776 unilateral amputees and 32 bilateral amputees with a mean (SD) age of 63.3 (14.1) years (Table 1). Respondents had lost their limbs a mean (SD) 31.4 (14.1) years prior, and half were transradial, 34.2% transhumeral, and 11.6% shoulder amputation. At baseline 185 (22.9%) participants received amputation-related care in the prior year and 118 (20.2%) participants received amputation-related care within 1 year of follow-up. Of respondents, 113 (19.3%) stated that their care was between baseline and follow-up and 89 (78.8%) of these received care at either the VA, the DoD or both; just 16 (14.2%) received care elsewhere.

Mean (SD) CSS scores were highest (lower satisfaction) for those with amputation at the shoulder and lowest for those with transhumeral amputation: 42.2 (20.0) vs 33.4 (20.8). Persons with bilateral amputation were less satisfied in almost every category when compared with those with unilateral amputation, although the total CSS score was not substantially different. Wilcoxon rank sum analyses revealed statistically significant differences in wait time satisfaction: bilateral amputees were less satisfied than unilateral amputees. Factors associated with overall CSS score in bivariate analyses were CSD score, TAPES score, amputation care receipt, prosthesis type, race, and region of care (eAppendix 2, available at doi:10.12788/fp.0096).

Discussion

Our longitudinal study provides insights into the experiences of veterans with major ULA related to satisfaction with prosthetic limb care services and receipt of amputation-related care. We reported on the development and use of a new summary measure of amputation care quality, which we designed to capture some of the key elements of care quality as provided in the VA/DoD CPG.²

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.

Despite these limitations, we believe that our study provides novel, important findings about the satisfaction with prosthetic limb care services and quality of amputation rehabilitation care for veterans. Findings from this study can be used to address amputation and prosthetic limb care satisfaction and quality weaknesses highlighted and to benchmark care satisfaction and CPG compliance. Other studies evaluating care guideline compliance have used indicators obtained from clinical records or data repositories.^13-15 Future work could combine self-reported satisfaction and care quality measures with indicators obtained from clinical or repository sources to provide a more complete snapshot of care delivery.

Conclusions

We reported on a national survey of veterans with major upper limb loss that assessed satisfaction with prosthetic limb care services and quality of amputation care. Satisfaction with prosthetic limb care was independently associated with satisfaction with the prosthesis, and receipt of care within the prior year. Most of the veterans surveyed received care within the VA or DoD and reported receiving higher quality of care, when compared with those who received care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the year of this study. Data presented in this study can serve to direct VA amputation care process improvement initiatives as benchmarks for future work. Future studies are needed to track satisfaction with and quality of care for veterans with ULA.

The US Department of Veterans Affairs (VA) established a formal Amputation System of Care (ASoC) in 2008 with the goal of enhancing the quality and consistency of amputation rehabilitation care for veterans with limb loss.^1,2 Throughout its history, the VA has placed a high priority on the care that is provided to veterans with limb amputation.^1,3 Amputations have medical, physical, social, and psychological ramifications for the veteran and his or her family. Therefore, management of veterans with limb loss requires a comprehensive, coordinated, transdisciplinary program of services throughout the continuum of care. This includes offering the latest practices in medical interventions, artificial limbs, assistive technologies, and rehabilitation strategies to restore function and thereby optimize quality of life.

Amputation System of Care

The ASoC is an integrated system within the Veterans Health Administration (VHA) that provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation therapies, artificial limbs, and assistive technologies. The system facilitates patient-centered, gender-sensitive, lifelong care and care coordination across the entire health continuum from acute inpatient hospitalization through a spectrum of inpatient, residential, and outpatient rehabilitation care settings. Through the provision of quality rehabilitation and prosthetic limb care, the ASoC strives to minimize disability and enable the highest level of social, vocational, and recreational success for veterans with an amputation.^1-3

The policy and procedures for the ASoC have been detailed in prior VA Handbooks and in the ASoC Directive.¹ This article highlights the background, population served, and organizational structure of the ASoC by detailing the outcomes and accomplishments of this systems-based approach to longitudinal amputation care between 2009 and 2019. Four core areas of activities and accomplishments are highlighted: (1) learning organization creation; (2) trust in VA care; (3) system modernization; and (4) customer service. This analysis and description of the VA amputation care program serves as a model of amputation care that can be used in the civilian sector. There also is potential for the ASoC to serve as a care model example for other populations within the VA.

Organizational Structure

The ASoC is an integrated, national health care delivery system in which each VA medical center (VAMC) has a specific designation that reflects the level of expertise and accessibility across the system based on an individual veteran’s needs and the specific capabilities of each VAMC.^1-3 The organizational structure for the ASoC is similar to the Polytrauma System of Care in that facilities are divided into 4 tiers.^1,4

For the ASoC, the 4 tiers are Regional Amputation Centers (RAC) at 7 VAMCs, Polytrauma Amputation Network Sites (PANS) at 18 VAMCs, Amputation Clinic Teams (ACT) at 106 VAMCs, and Amputation Points of Contact (APoC) at 22 VAMCs. The RAC locations provide the highest level of specialized expertise in clinical care and prosthetic limb technology and have rehabilitation capabilities to manage the most complicated cases. Like the RAC facilities, PANS provide a full range of clinical and ancillary services to veterans within their catchment area and serve as referral locations for veterans with needs that are more complex. ACT sites have a core amputation specialty team that provides regular follow-up and address ongoing care needs. ACT sites may or may not have full ancillary services, such as surgical subspecialties or an in-house prosthetics laboratory. APoC facilities have at least 1 person on staff who serves as the point of contact for consultation, assessment, and referral of a veteran with an amputation to a facility capable of providing the level of services required.¹

The VA also places a high priority on both primary and secondary amputation prevention. The Preventing Amputations in Veterans Everywhere (PAVE) program and the ASoC coordinate efforts in order to address the prevention of an initial amputation, the rehabilitation of veterans who have had an amputation, and the prevention of a second amputation in those with an amputation.^1,5

Population Served

The ASoC serves veterans with limb loss regardless of the etiology. This includes care of individuals with complex limb trauma and those with other injuries or disease processes resulting in a high likelihood of requiring a limb amputation. In 2019, the VA provided care to 96,519 veterans with amputation, and about half (46,214) had at least 1 major limb amputation, which is defined as an amputation at or proximal to the wrist or ankle.⁶ The majority of veterans with amputation treated within the VA have limb loss resulting from disease processes, such as diabetes mellitus (DM) and peripheral vascular disease (PVD). Amputations caused by these diseases generally occur in the older veteran population and are associated with comorbidities, such as cardiovascular disease, hypertension, and end-stage renal disease. Veterans with amputation due to trauma, including conflict-related injuries, are commonly younger at the time of their amputation. Although the number of conflict-related amputations is small compared with the number of amputations associated with disease processes, both groups require high-quality, comprehensive, lifelong care.

Between 2009 and 2019, the number of veterans with limb loss receiving care in the VA increased 34%.⁶ With advances in vascular surgery and limb-sparing procedures, minor amputations are more common than major limb amputations and more below-knee rather than above-knee amputations have been noted over the same time. However, the high prevalence of DM in the overall veteran population places about 1.8 million veterans at risk for amputation, and it is anticipated that the volume of limb loss in the veteran population will continue to grow and possibly accelerate.⁵

Performance Metrics

Over the past 10 years, the ASoC has focused on ensuring that an amputation specialty care team addresses the needs of veterans with amputation. Between 2009 and 2019, the VA amputation specialty clinics saw a 49% annual increase in the number of unique veterans treated and a 64% annual increase in the number of total clinic encounters (Figure 1).⁶ This growth is attributed to the larger amputation population receiving enhanced access to the specialty team providing consistent, comprehensive, lifelong care.

During this same period, the amputation specialty clinic encounter to unique ratio (a measure of how frequently patients return to the clinic each year) rose from 1.8 in 2009 to 2.3 in 2019 for both the total amputation population and for those with major limb amputation. When looking more specifically at the RAC facilities, the encounter to unique ratio increased from 1.5 to 3.0 over the same time, reflecting the added benefit of having dedicated resources for the amputation specialty program.⁶

Comparing the percentage of veterans with amputation who are seen in the VA for any service with those who also are seen in the amputation specialty clinic in the same year is a performance metric that reflects the penetration of amputation specialty services across the system. Between 2009 and 2019, this increased from 2.9 to 12.7% for the overall amputation population and from 4.8 to 26% for those with major limb amputation (Figure 2). This metric improved to a greater extent in RAC facilities; 44% of veterans with major limb amputation seen at a RAC were also seen in the amputation specialty clinic in 2019.⁶

System Hallmarks

One of the primary hallmarks of the ASoC is the interdisciplinary team approach addressing all aspects of management across the continuum of care (Table). The core team consists of a physician, therapist, and prosthetist, and may include a variety of other disciplines based on a veteran’s individual needs. This model promotes veteran-centric care. Comprehensive management of veterans with limb loss includes addressing medical considerations such as residual limb skin health to the prescription of artificial limbs and the provision of therapy services for prosthetic limb gait training.^1,2

Lifelong care for veterans living with limb loss is another hallmark of the ASoC. The provision of care coordination across the continuum of care from acute hospitalization following an amputation to long-term follow-up in the outpatient setting for veteran’s lifespan is essential. Care coordination is provided across the system of care, which assures that a veteran with limb loss can obtain the required services through consultation or referral to a RAC or PANS as needed. Care coordination for the ASoC is facilitated by amputation rehabilitation coordinators at each of the RAC and PANS designated VAMCs.

Integration of services and resource collaboration are additional key aspects of the ASoC (Figure 3). In order to be successful, care of the veteran facing potential amputation or living with the challenges postamputation must be well-integrated into the broader care of the individual. Many veterans who undergo amputation have significant medical comorbidities, including a high prevalence of DM and peripheral vascular disease. Management of these conditions in collaboration with primary care and other medical specialties promotes the achievement of rehabilitation goals. Integration of surgical services and amputation prevention strategies is critical. Another essential element of the system is maintaining amputation specialty care team contact with all veterans with limb loss on at least an annual basis. A clinical practice guideline published in 2017 on lower Limb amputation rehabilitation emphasizes this need for an annual contact and includes a management and referral algorithm to assist primary care providers in the management of veterans with amputation (Figure 4).⁷

Collaboration with external partners has been an important element in the system of care development. The VA has partnered extensively with the US Department of Defense (DoD) to transition service members with amputation from the military health care system to the VA. The VA and DoD also have collaborated through the development and provision of joint provider trainings, clinical practice guidelines, incentive funding programs, and patient education materials. Congress authorized the Extremity Trauma and Amputation Center of Excellence (EACE) in 2009 with the mission to serve as the joint DoD and VA lead element focused on the mitigation, treatment, and rehabilitation of traumatic extremity injuries and amputations. The EACE has several lines of effort, including clinical affairs, research, and global outreach focused on building partnerships and fostering collaboration to optimize quality of life for those with extremity trauma and amputation. The Amputee Coalition, the largest nonprofit consumer-based amputee advocacy organization in the US, has been an important strategic partner for the dissemination of guideline recommendations and patient education as well as the development and provision of peer support services.

Methods

The ASoC created a learning organization to develop and maintain a knowledgeable and highly skilled clinical workforce through the identification of best practices related to amputation rehabilitation and the use of innovative education delivery models. During the past 10 years, the ASoC conducted 9 national, live health care provider training events in conjunction with the DoD. In conjunction with the EACE, the ASoC holds 6 national Grand Rounds sessions each year. Dissemination of information and trainings across both the VA and DoD has been facilitated through a national listserv referred to as the Federal Amputation Interest Group (FAIG), which has > 800 members. Since 2009, the VA, in collaboration with the DoD, has produced 3 clinical practice guidelines (CPGs) related to amputation care. The Lower Limb Amputation CPG was published in 2007 and updated in 2017, and a CPG and associated clinician resources focused on upper extremity amputation were published in 2014.^7,8 In addition to these formal, comprehensive, and evidence-driven guidelines, the ASoC has developed other clinical support documents covering a range of topics from prosthesis prescription candidacy determination to osseointegration. In conjunction with the EACE, The ASoC also has published guidance for clinical implementation of new technologies such as the Mobius Bionics LUKE arm and Dynamic Response Ankle-Foot Orthoses.

The ASoC strives to improve the psychosocial welfare of veterans with amputation and enhance trust in VA amputation care services through sharing results on the quality and timeliness of care. The Commission on Accreditation for Rehabilitation Facilities (CARF) provides an international, independent, peer-reviewed system of accreditation that is widely recognized by federal agencies, state governments, major insurers, and professional organizations.^1,2 CARF offers amputation specialty accreditation for inpatient and outpatient programs that signifies the attainment of a distinguished level of expertise and the provision of a comprehensive spectrum of services related to amputation care and rehabilitation. During its development, the ASoC established the expectation that each of the RAC and PANS designated VAMCs would attain and maintain CARF amputation specialty accreditation. The ASoC has achieved 100% success on this metric.

In addition, the ASoC has completed many other initiatives focused on enhancing trust in VA amputation care services. These include assuring compliance with implementation of the Mission Act as it relates to the provision of amputation care and prosthetic limb delivery so that any services provided in the community are well integrated and at the direction of the amputation specialty team. The ASoC has maintained a strong relationship with the Amputee Coalition to provide veterans with high-quality patient education materials as well as integrated peer support services.

ASoC virtual and face-to-face training events incorporate suicide prevention training for providers. Special focus has been placed on care provision for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with conflict-related multiple limb amputations. Although relatively small, this cohort is recognized as a unique and important population due to their unique care needs and increased risk for secondary complications. In 2019, 83% of these individuals were contacted to assure their amputation care needs were being adequately addressed.

Discussion

Over the past 10 years, the ASoC has built a modern, high-performance network of care to best serve veterans with amputation. Maturation of the system has included the addition of 3 new PANS locations to improve access to services as well as to better support geographic regions near large DoD military treatment facilities. The number of ACT designated VAMCs also has grown from 101 to 106 locations. The regional organization of sites has been modified to enhance the availability of referral and consultative services across the system. In addition, the ASoC has supported the development of an upper extremity amputation specialty program for consultation or referral to a highly specialized team of providers well versed in the significant technology advances that have taken place with upper extremity prostheses.⁹

One of the key components to high-performance network development is attaining a clear picture of the clinical demands and service delivery needs of the population served. The Amputee Data Repository was developed with the support of the VHA Support Service Center (VSSC) in order to better understand and track the population of veterans with amputation.⁶ The development and implementation of the Amputee Data Repository took place over several years, and the product was officially released into publication in 2015. The overall goals of this resource are to provide a data system for the ASoC to identify clinical care volumes and patterns of treatment; better understand the demographics of the veteran amputee population; assess the effectiveness of new treatment strategies; and utilize data analysis outcomes to influence clinical practice. The acquisition and analysis of this information will provide justification for the modification of clinical practice and will enhance the quality of care for all veterans with amputation.

Although the ASoC focuses primarily on the provision of clinical services, the system has been leveraged to support research activities and the advancement of artificial limb technologies. For example, ASoC providers and investigators supported the clinical research required to test and optimize the development of the DEKA arm. These research efforts resulted in the US Food and Drug Administration approval and commercialization of this device. Once the device became commercially available as the LUKE arm, the ASoC developed a clinical implementation strategy that assured availability and appropriate prescription and training with the new technology. The VA also has supported research and program development in osseointegration with further investigations and clinical implementation being planned.

Telehealth

The goal of the ASoC is to provide timely access and greater choice to specialty amputation rehabilitation services for veterans as determined by their clinical needs. One key strategy used to achieve this goal has been the expansion of virtual communication tools to enhance access to clinical expertise. Telehealth (Virtual Care) amputation services afford the opportunity to provide specialized clinical expertise to veterans who otherwise may not have access to this level of service or consultation.^1,2 For others, virtual care services reduce the need for travel. The ASoC has leveraged these services effectively to enhance specialty amputation care for veterans in rural areas. Over time, the scope of virtual care services has expanded to provide virtual peer support services as well as care in the veteran’s home.

Another unique example is the use of virtual care to see veterans when they are being provided services by a community prosthetist. This service improves the timeliness of care and reduces the travel burden for the veteran. Between 2009 and 2019, total virtual care encounters to provide amputation-related services grew from 44 encounters to 3,905 encounters (Figure 5). In 2019, 13.8% of veterans seen in a VA outpatient amputation specialty clinic had at least 1 virtual encounter in the same year.⁶

In addition to the expansion of virtual care and building capacity through increasing the number of amputation specialty clinics and providers, the ASoC has used a host of other strategies to improve care access. The development of provider expertise in amputation care has been achieved through the methods of extensive provider training. Implementation of Patient Self-Referral Direct Scheduling allows veterans to access the outpatient amputation specialty clinic without a referral and without having to be seen by their primary care provider. This initiative provides easier and more timely access to amputation specialty services while reducing burden on primary care services. The amputation outpatient specialty clinic was one of a few specialty programs to be an early adopter of national online scheduling. The implementation of this service is still ongoing, but this program gives veterans greater control over scheduling, canceling, and rescheduling appointments.

Conclusions

During the 10 years following its implementation, the VA ASoC has successfully enhanced the quality and consistency of care and rehabilitation services provided to veterans with limb loss through the provision of highly specialized services in the areas of medical care, rehabilitation services, and prosthetic technology. This mission has been accomplished through prioritization and implementation of key strategic initiatives in learning organization creation, trust in VA care, development of a modern, high-performance network, and customer service. Collaborative partnerships both internally within the VA and externally with key stakeholders has facilitated this development, and these will need to be enhanced for future success. Evolving trends in amputation surgery, limb transplantation, artificial limb control and suspension strategies as well as advances in assistive technology also will need to be integrated into best practices and program development.

The US Department of Veterans Affairs (VA) established a formal Amputation System of Care (ASoC) in 2008 with the goal of enhancing the quality and consistency of amputation rehabilitation care for veterans with limb loss.^1,2 Throughout its history, the VA has placed a high priority on the care that is provided to veterans with limb amputation.^1,3 Amputations have medical, physical, social, and psychological ramifications for the veteran and his or her family. Therefore, management of veterans with limb loss requires a comprehensive, coordinated, transdisciplinary program of services throughout the continuum of care. This includes offering the latest practices in medical interventions, artificial limbs, assistive technologies, and rehabilitation strategies to restore function and thereby optimize quality of life.

Amputation System of Care

The ASoC is an integrated system within the Veterans Health Administration (VHA) that provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation therapies, artificial limbs, and assistive technologies. The system facilitates patient-centered, gender-sensitive, lifelong care and care coordination across the entire health continuum from acute inpatient hospitalization through a spectrum of inpatient, residential, and outpatient rehabilitation care settings. Through the provision of quality rehabilitation and prosthetic limb care, the ASoC strives to minimize disability and enable the highest level of social, vocational, and recreational success for veterans with an amputation.^1-3

The policy and procedures for the ASoC have been detailed in prior VA Handbooks and in the ASoC Directive.¹ This article highlights the background, population served, and organizational structure of the ASoC by detailing the outcomes and accomplishments of this systems-based approach to longitudinal amputation care between 2009 and 2019. Four core areas of activities and accomplishments are highlighted: (1) learning organization creation; (2) trust in VA care; (3) system modernization; and (4) customer service. This analysis and description of the VA amputation care program serves as a model of amputation care that can be used in the civilian sector. There also is potential for the ASoC to serve as a care model example for other populations within the VA.

Organizational Structure

The ASoC is an integrated, national health care delivery system in which each VA medical center (VAMC) has a specific designation that reflects the level of expertise and accessibility across the system based on an individual veteran’s needs and the specific capabilities of each VAMC.^1-3 The organizational structure for the ASoC is similar to the Polytrauma System of Care in that facilities are divided into 4 tiers.^1,4

For the ASoC, the 4 tiers are Regional Amputation Centers (RAC) at 7 VAMCs, Polytrauma Amputation Network Sites (PANS) at 18 VAMCs, Amputation Clinic Teams (ACT) at 106 VAMCs, and Amputation Points of Contact (APoC) at 22 VAMCs. The RAC locations provide the highest level of specialized expertise in clinical care and prosthetic limb technology and have rehabilitation capabilities to manage the most complicated cases. Like the RAC facilities, PANS provide a full range of clinical and ancillary services to veterans within their catchment area and serve as referral locations for veterans with needs that are more complex. ACT sites have a core amputation specialty team that provides regular follow-up and address ongoing care needs. ACT sites may or may not have full ancillary services, such as surgical subspecialties or an in-house prosthetics laboratory. APoC facilities have at least 1 person on staff who serves as the point of contact for consultation, assessment, and referral of a veteran with an amputation to a facility capable of providing the level of services required.¹

The VA also places a high priority on both primary and secondary amputation prevention. The Preventing Amputations in Veterans Everywhere (PAVE) program and the ASoC coordinate efforts in order to address the prevention of an initial amputation, the rehabilitation of veterans who have had an amputation, and the prevention of a second amputation in those with an amputation.^1,5

Population Served

The ASoC serves veterans with limb loss regardless of the etiology. This includes care of individuals with complex limb trauma and those with other injuries or disease processes resulting in a high likelihood of requiring a limb amputation. In 2019, the VA provided care to 96,519 veterans with amputation, and about half (46,214) had at least 1 major limb amputation, which is defined as an amputation at or proximal to the wrist or ankle.⁶ The majority of veterans with amputation treated within the VA have limb loss resulting from disease processes, such as diabetes mellitus (DM) and peripheral vascular disease (PVD). Amputations caused by these diseases generally occur in the older veteran population and are associated with comorbidities, such as cardiovascular disease, hypertension, and end-stage renal disease. Veterans with amputation due to trauma, including conflict-related injuries, are commonly younger at the time of their amputation. Although the number of conflict-related amputations is small compared with the number of amputations associated with disease processes, both groups require high-quality, comprehensive, lifelong care.

Between 2009 and 2019, the number of veterans with limb loss receiving care in the VA increased 34%.⁶ With advances in vascular surgery and limb-sparing procedures, minor amputations are more common than major limb amputations and more below-knee rather than above-knee amputations have been noted over the same time. However, the high prevalence of DM in the overall veteran population places about 1.8 million veterans at risk for amputation, and it is anticipated that the volume of limb loss in the veteran population will continue to grow and possibly accelerate.⁵

Performance Metrics

Over the past 10 years, the ASoC has focused on ensuring that an amputation specialty care team addresses the needs of veterans with amputation. Between 2009 and 2019, the VA amputation specialty clinics saw a 49% annual increase in the number of unique veterans treated and a 64% annual increase in the number of total clinic encounters (Figure 1).⁶ This growth is attributed to the larger amputation population receiving enhanced access to the specialty team providing consistent, comprehensive, lifelong care.

During this same period, the amputation specialty clinic encounter to unique ratio (a measure of how frequently patients return to the clinic each year) rose from 1.8 in 2009 to 2.3 in 2019 for both the total amputation population and for those with major limb amputation. When looking more specifically at the RAC facilities, the encounter to unique ratio increased from 1.5 to 3.0 over the same time, reflecting the added benefit of having dedicated resources for the amputation specialty program.⁶

Comparing the percentage of veterans with amputation who are seen in the VA for any service with those who also are seen in the amputation specialty clinic in the same year is a performance metric that reflects the penetration of amputation specialty services across the system. Between 2009 and 2019, this increased from 2.9 to 12.7% for the overall amputation population and from 4.8 to 26% for those with major limb amputation (Figure 2). This metric improved to a greater extent in RAC facilities; 44% of veterans with major limb amputation seen at a RAC were also seen in the amputation specialty clinic in 2019.⁶

System Hallmarks

One of the primary hallmarks of the ASoC is the interdisciplinary team approach addressing all aspects of management across the continuum of care (Table). The core team consists of a physician, therapist, and prosthetist, and may include a variety of other disciplines based on a veteran’s individual needs. This model promotes veteran-centric care. Comprehensive management of veterans with limb loss includes addressing medical considerations such as residual limb skin health to the prescription of artificial limbs and the provision of therapy services for prosthetic limb gait training.^1,2

Lifelong care for veterans living with limb loss is another hallmark of the ASoC. The provision of care coordination across the continuum of care from acute hospitalization following an amputation to long-term follow-up in the outpatient setting for veteran’s lifespan is essential. Care coordination is provided across the system of care, which assures that a veteran with limb loss can obtain the required services through consultation or referral to a RAC or PANS as needed. Care coordination for the ASoC is facilitated by amputation rehabilitation coordinators at each of the RAC and PANS designated VAMCs.

Integration of services and resource collaboration are additional key aspects of the ASoC (Figure 3). In order to be successful, care of the veteran facing potential amputation or living with the challenges postamputation must be well-integrated into the broader care of the individual. Many veterans who undergo amputation have significant medical comorbidities, including a high prevalence of DM and peripheral vascular disease. Management of these conditions in collaboration with primary care and other medical specialties promotes the achievement of rehabilitation goals. Integration of surgical services and amputation prevention strategies is critical. Another essential element of the system is maintaining amputation specialty care team contact with all veterans with limb loss on at least an annual basis. A clinical practice guideline published in 2017 on lower Limb amputation rehabilitation emphasizes this need for an annual contact and includes a management and referral algorithm to assist primary care providers in the management of veterans with amputation (Figure 4).⁷

Collaboration with external partners has been an important element in the system of care development. The VA has partnered extensively with the US Department of Defense (DoD) to transition service members with amputation from the military health care system to the VA. The VA and DoD also have collaborated through the development and provision of joint provider trainings, clinical practice guidelines, incentive funding programs, and patient education materials. Congress authorized the Extremity Trauma and Amputation Center of Excellence (EACE) in 2009 with the mission to serve as the joint DoD and VA lead element focused on the mitigation, treatment, and rehabilitation of traumatic extremity injuries and amputations. The EACE has several lines of effort, including clinical affairs, research, and global outreach focused on building partnerships and fostering collaboration to optimize quality of life for those with extremity trauma and amputation. The Amputee Coalition, the largest nonprofit consumer-based amputee advocacy organization in the US, has been an important strategic partner for the dissemination of guideline recommendations and patient education as well as the development and provision of peer support services.

Methods

The ASoC created a learning organization to develop and maintain a knowledgeable and highly skilled clinical workforce through the identification of best practices related to amputation rehabilitation and the use of innovative education delivery models. During the past 10 years, the ASoC conducted 9 national, live health care provider training events in conjunction with the DoD. In conjunction with the EACE, the ASoC holds 6 national Grand Rounds sessions each year. Dissemination of information and trainings across both the VA and DoD has been facilitated through a national listserv referred to as the Federal Amputation Interest Group (FAIG), which has > 800 members. Since 2009, the VA, in collaboration with the DoD, has produced 3 clinical practice guidelines (CPGs) related to amputation care. The Lower Limb Amputation CPG was published in 2007 and updated in 2017, and a CPG and associated clinician resources focused on upper extremity amputation were published in 2014.^7,8 In addition to these formal, comprehensive, and evidence-driven guidelines, the ASoC has developed other clinical support documents covering a range of topics from prosthesis prescription candidacy determination to osseointegration. In conjunction with the EACE, The ASoC also has published guidance for clinical implementation of new technologies such as the Mobius Bionics LUKE arm and Dynamic Response Ankle-Foot Orthoses.

The ASoC strives to improve the psychosocial welfare of veterans with amputation and enhance trust in VA amputation care services through sharing results on the quality and timeliness of care. The Commission on Accreditation for Rehabilitation Facilities (CARF) provides an international, independent, peer-reviewed system of accreditation that is widely recognized by federal agencies, state governments, major insurers, and professional organizations.^1,2 CARF offers amputation specialty accreditation for inpatient and outpatient programs that signifies the attainment of a distinguished level of expertise and the provision of a comprehensive spectrum of services related to amputation care and rehabilitation. During its development, the ASoC established the expectation that each of the RAC and PANS designated VAMCs would attain and maintain CARF amputation specialty accreditation. The ASoC has achieved 100% success on this metric.

In addition, the ASoC has completed many other initiatives focused on enhancing trust in VA amputation care services. These include assuring compliance with implementation of the Mission Act as it relates to the provision of amputation care and prosthetic limb delivery so that any services provided in the community are well integrated and at the direction of the amputation specialty team. The ASoC has maintained a strong relationship with the Amputee Coalition to provide veterans with high-quality patient education materials as well as integrated peer support services.

ASoC virtual and face-to-face training events incorporate suicide prevention training for providers. Special focus has been placed on care provision for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with conflict-related multiple limb amputations. Although relatively small, this cohort is recognized as a unique and important population due to their unique care needs and increased risk for secondary complications. In 2019, 83% of these individuals were contacted to assure their amputation care needs were being adequately addressed.

Discussion

Over the past 10 years, the ASoC has built a modern, high-performance network of care to best serve veterans with amputation. Maturation of the system has included the addition of 3 new PANS locations to improve access to services as well as to better support geographic regions near large DoD military treatment facilities. The number of ACT designated VAMCs also has grown from 101 to 106 locations. The regional organization of sites has been modified to enhance the availability of referral and consultative services across the system. In addition, the ASoC has supported the development of an upper extremity amputation specialty program for consultation or referral to a highly specialized team of providers well versed in the significant technology advances that have taken place with upper extremity prostheses.⁹

One of the key components to high-performance network development is attaining a clear picture of the clinical demands and service delivery needs of the population served. The Amputee Data Repository was developed with the support of the VHA Support Service Center (VSSC) in order to better understand and track the population of veterans with amputation.⁶ The development and implementation of the Amputee Data Repository took place over several years, and the product was officially released into publication in 2015. The overall goals of this resource are to provide a data system for the ASoC to identify clinical care volumes and patterns of treatment; better understand the demographics of the veteran amputee population; assess the effectiveness of new treatment strategies; and utilize data analysis outcomes to influence clinical practice. The acquisition and analysis of this information will provide justification for the modification of clinical practice and will enhance the quality of care for all veterans with amputation.

Although the ASoC focuses primarily on the provision of clinical services, the system has been leveraged to support research activities and the advancement of artificial limb technologies. For example, ASoC providers and investigators supported the clinical research required to test and optimize the development of the DEKA arm. These research efforts resulted in the US Food and Drug Administration approval and commercialization of this device. Once the device became commercially available as the LUKE arm, the ASoC developed a clinical implementation strategy that assured availability and appropriate prescription and training with the new technology. The VA also has supported research and program development in osseointegration with further investigations and clinical implementation being planned.

Telehealth

The goal of the ASoC is to provide timely access and greater choice to specialty amputation rehabilitation services for veterans as determined by their clinical needs. One key strategy used to achieve this goal has been the expansion of virtual communication tools to enhance access to clinical expertise. Telehealth (Virtual Care) amputation services afford the opportunity to provide specialized clinical expertise to veterans who otherwise may not have access to this level of service or consultation.^1,2 For others, virtual care services reduce the need for travel. The ASoC has leveraged these services effectively to enhance specialty amputation care for veterans in rural areas. Over time, the scope of virtual care services has expanded to provide virtual peer support services as well as care in the veteran’s home.

Another unique example is the use of virtual care to see veterans when they are being provided services by a community prosthetist. This service improves the timeliness of care and reduces the travel burden for the veteran. Between 2009 and 2019, total virtual care encounters to provide amputation-related services grew from 44 encounters to 3,905 encounters (Figure 5). In 2019, 13.8% of veterans seen in a VA outpatient amputation specialty clinic had at least 1 virtual encounter in the same year.⁶

In addition to the expansion of virtual care and building capacity through increasing the number of amputation specialty clinics and providers, the ASoC has used a host of other strategies to improve care access. The development of provider expertise in amputation care has been achieved through the methods of extensive provider training. Implementation of Patient Self-Referral Direct Scheduling allows veterans to access the outpatient amputation specialty clinic without a referral and without having to be seen by their primary care provider. This initiative provides easier and more timely access to amputation specialty services while reducing burden on primary care services. The amputation outpatient specialty clinic was one of a few specialty programs to be an early adopter of national online scheduling. The implementation of this service is still ongoing, but this program gives veterans greater control over scheduling, canceling, and rescheduling appointments.

Conclusions

During the 10 years following its implementation, the VA ASoC has successfully enhanced the quality and consistency of care and rehabilitation services provided to veterans with limb loss through the provision of highly specialized services in the areas of medical care, rehabilitation services, and prosthetic technology. This mission has been accomplished through prioritization and implementation of key strategic initiatives in learning organization creation, trust in VA care, development of a modern, high-performance network, and customer service. Collaborative partnerships both internally within the VA and externally with key stakeholders has facilitated this development, and these will need to be enhanced for future success. Evolving trends in amputation surgery, limb transplantation, artificial limb control and suspension strategies as well as advances in assistive technology also will need to be integrated into best practices and program development.

The US Department of Veterans Affairs (VA) established a formal Amputation System of Care (ASoC) in 2008 with the goal of enhancing the quality and consistency of amputation rehabilitation care for veterans with limb loss.^1,2 Throughout its history, the VA has placed a high priority on the care that is provided to veterans with limb amputation.^1,3 Amputations have medical, physical, social, and psychological ramifications for the veteran and his or her family. Therefore, management of veterans with limb loss requires a comprehensive, coordinated, transdisciplinary program of services throughout the continuum of care. This includes offering the latest practices in medical interventions, artificial limbs, assistive technologies, and rehabilitation strategies to restore function and thereby optimize quality of life.

Amputation System of Care

The ASoC is an integrated system within the Veterans Health Administration (VHA) that provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation therapies, artificial limbs, and assistive technologies. The system facilitates patient-centered, gender-sensitive, lifelong care and care coordination across the entire health continuum from acute inpatient hospitalization through a spectrum of inpatient, residential, and outpatient rehabilitation care settings. Through the provision of quality rehabilitation and prosthetic limb care, the ASoC strives to minimize disability and enable the highest level of social, vocational, and recreational success for veterans with an amputation.^1-3

The policy and procedures for the ASoC have been detailed in prior VA Handbooks and in the ASoC Directive.¹ This article highlights the background, population served, and organizational structure of the ASoC by detailing the outcomes and accomplishments of this systems-based approach to longitudinal amputation care between 2009 and 2019. Four core areas of activities and accomplishments are highlighted: (1) learning organization creation; (2) trust in VA care; (3) system modernization; and (4) customer service. This analysis and description of the VA amputation care program serves as a model of amputation care that can be used in the civilian sector. There also is potential for the ASoC to serve as a care model example for other populations within the VA.

Organizational Structure

The ASoC is an integrated, national health care delivery system in which each VA medical center (VAMC) has a specific designation that reflects the level of expertise and accessibility across the system based on an individual veteran’s needs and the specific capabilities of each VAMC.^1-3 The organizational structure for the ASoC is similar to the Polytrauma System of Care in that facilities are divided into 4 tiers.^1,4

For the ASoC, the 4 tiers are Regional Amputation Centers (RAC) at 7 VAMCs, Polytrauma Amputation Network Sites (PANS) at 18 VAMCs, Amputation Clinic Teams (ACT) at 106 VAMCs, and Amputation Points of Contact (APoC) at 22 VAMCs. The RAC locations provide the highest level of specialized expertise in clinical care and prosthetic limb technology and have rehabilitation capabilities to manage the most complicated cases. Like the RAC facilities, PANS provide a full range of clinical and ancillary services to veterans within their catchment area and serve as referral locations for veterans with needs that are more complex. ACT sites have a core amputation specialty team that provides regular follow-up and address ongoing care needs. ACT sites may or may not have full ancillary services, such as surgical subspecialties or an in-house prosthetics laboratory. APoC facilities have at least 1 person on staff who serves as the point of contact for consultation, assessment, and referral of a veteran with an amputation to a facility capable of providing the level of services required.¹

The VA also places a high priority on both primary and secondary amputation prevention. The Preventing Amputations in Veterans Everywhere (PAVE) program and the ASoC coordinate efforts in order to address the prevention of an initial amputation, the rehabilitation of veterans who have had an amputation, and the prevention of a second amputation in those with an amputation.^1,5

Population Served

The ASoC serves veterans with limb loss regardless of the etiology. This includes care of individuals with complex limb trauma and those with other injuries or disease processes resulting in a high likelihood of requiring a limb amputation. In 2019, the VA provided care to 96,519 veterans with amputation, and about half (46,214) had at least 1 major limb amputation, which is defined as an amputation at or proximal to the wrist or ankle.⁶ The majority of veterans with amputation treated within the VA have limb loss resulting from disease processes, such as diabetes mellitus (DM) and peripheral vascular disease (PVD). Amputations caused by these diseases generally occur in the older veteran population and are associated with comorbidities, such as cardiovascular disease, hypertension, and end-stage renal disease. Veterans with amputation due to trauma, including conflict-related injuries, are commonly younger at the time of their amputation. Although the number of conflict-related amputations is small compared with the number of amputations associated with disease processes, both groups require high-quality, comprehensive, lifelong care.

Between 2009 and 2019, the number of veterans with limb loss receiving care in the VA increased 34%.⁶ With advances in vascular surgery and limb-sparing procedures, minor amputations are more common than major limb amputations and more below-knee rather than above-knee amputations have been noted over the same time. However, the high prevalence of DM in the overall veteran population places about 1.8 million veterans at risk for amputation, and it is anticipated that the volume of limb loss in the veteran population will continue to grow and possibly accelerate.⁵

Performance Metrics

Over the past 10 years, the ASoC has focused on ensuring that an amputation specialty care team addresses the needs of veterans with amputation. Between 2009 and 2019, the VA amputation specialty clinics saw a 49% annual increase in the number of unique veterans treated and a 64% annual increase in the number of total clinic encounters (Figure 1).⁶ This growth is attributed to the larger amputation population receiving enhanced access to the specialty team providing consistent, comprehensive, lifelong care.

During this same period, the amputation specialty clinic encounter to unique ratio (a measure of how frequently patients return to the clinic each year) rose from 1.8 in 2009 to 2.3 in 2019 for both the total amputation population and for those with major limb amputation. When looking more specifically at the RAC facilities, the encounter to unique ratio increased from 1.5 to 3.0 over the same time, reflecting the added benefit of having dedicated resources for the amputation specialty program.⁶

Comparing the percentage of veterans with amputation who are seen in the VA for any service with those who also are seen in the amputation specialty clinic in the same year is a performance metric that reflects the penetration of amputation specialty services across the system. Between 2009 and 2019, this increased from 2.9 to 12.7% for the overall amputation population and from 4.8 to 26% for those with major limb amputation (Figure 2). This metric improved to a greater extent in RAC facilities; 44% of veterans with major limb amputation seen at a RAC were also seen in the amputation specialty clinic in 2019.⁶

System Hallmarks

One of the primary hallmarks of the ASoC is the interdisciplinary team approach addressing all aspects of management across the continuum of care (Table). The core team consists of a physician, therapist, and prosthetist, and may include a variety of other disciplines based on a veteran’s individual needs. This model promotes veteran-centric care. Comprehensive management of veterans with limb loss includes addressing medical considerations such as residual limb skin health to the prescription of artificial limbs and the provision of therapy services for prosthetic limb gait training.^1,2

Lifelong care for veterans living with limb loss is another hallmark of the ASoC. The provision of care coordination across the continuum of care from acute hospitalization following an amputation to long-term follow-up in the outpatient setting for veteran’s lifespan is essential. Care coordination is provided across the system of care, which assures that a veteran with limb loss can obtain the required services through consultation or referral to a RAC or PANS as needed. Care coordination for the ASoC is facilitated by amputation rehabilitation coordinators at each of the RAC and PANS designated VAMCs.

Integration of services and resource collaboration are additional key aspects of the ASoC (Figure 3). In order to be successful, care of the veteran facing potential amputation or living with the challenges postamputation must be well-integrated into the broader care of the individual. Many veterans who undergo amputation have significant medical comorbidities, including a high prevalence of DM and peripheral vascular disease. Management of these conditions in collaboration with primary care and other medical specialties promotes the achievement of rehabilitation goals. Integration of surgical services and amputation prevention strategies is critical. Another essential element of the system is maintaining amputation specialty care team contact with all veterans with limb loss on at least an annual basis. A clinical practice guideline published in 2017 on lower Limb amputation rehabilitation emphasizes this need for an annual contact and includes a management and referral algorithm to assist primary care providers in the management of veterans with amputation (Figure 4).⁷

Collaboration with external partners has been an important element in the system of care development. The VA has partnered extensively with the US Department of Defense (DoD) to transition service members with amputation from the military health care system to the VA. The VA and DoD also have collaborated through the development and provision of joint provider trainings, clinical practice guidelines, incentive funding programs, and patient education materials. Congress authorized the Extremity Trauma and Amputation Center of Excellence (EACE) in 2009 with the mission to serve as the joint DoD and VA lead element focused on the mitigation, treatment, and rehabilitation of traumatic extremity injuries and amputations. The EACE has several lines of effort, including clinical affairs, research, and global outreach focused on building partnerships and fostering collaboration to optimize quality of life for those with extremity trauma and amputation. The Amputee Coalition, the largest nonprofit consumer-based amputee advocacy organization in the US, has been an important strategic partner for the dissemination of guideline recommendations and patient education as well as the development and provision of peer support services.

Methods

The ASoC created a learning organization to develop and maintain a knowledgeable and highly skilled clinical workforce through the identification of best practices related to amputation rehabilitation and the use of innovative education delivery models. During the past 10 years, the ASoC conducted 9 national, live health care provider training events in conjunction with the DoD. In conjunction with the EACE, the ASoC holds 6 national Grand Rounds sessions each year. Dissemination of information and trainings across both the VA and DoD has been facilitated through a national listserv referred to as the Federal Amputation Interest Group (FAIG), which has > 800 members. Since 2009, the VA, in collaboration with the DoD, has produced 3 clinical practice guidelines (CPGs) related to amputation care. The Lower Limb Amputation CPG was published in 2007 and updated in 2017, and a CPG and associated clinician resources focused on upper extremity amputation were published in 2014.^7,8 In addition to these formal, comprehensive, and evidence-driven guidelines, the ASoC has developed other clinical support documents covering a range of topics from prosthesis prescription candidacy determination to osseointegration. In conjunction with the EACE, The ASoC also has published guidance for clinical implementation of new technologies such as the Mobius Bionics LUKE arm and Dynamic Response Ankle-Foot Orthoses.

The ASoC strives to improve the psychosocial welfare of veterans with amputation and enhance trust in VA amputation care services through sharing results on the quality and timeliness of care. The Commission on Accreditation for Rehabilitation Facilities (CARF) provides an international, independent, peer-reviewed system of accreditation that is widely recognized by federal agencies, state governments, major insurers, and professional organizations.^1,2 CARF offers amputation specialty accreditation for inpatient and outpatient programs that signifies the attainment of a distinguished level of expertise and the provision of a comprehensive spectrum of services related to amputation care and rehabilitation. During its development, the ASoC established the expectation that each of the RAC and PANS designated VAMCs would attain and maintain CARF amputation specialty accreditation. The ASoC has achieved 100% success on this metric.

In addition, the ASoC has completed many other initiatives focused on enhancing trust in VA amputation care services. These include assuring compliance with implementation of the Mission Act as it relates to the provision of amputation care and prosthetic limb delivery so that any services provided in the community are well integrated and at the direction of the amputation specialty team. The ASoC has maintained a strong relationship with the Amputee Coalition to provide veterans with high-quality patient education materials as well as integrated peer support services.

ASoC virtual and face-to-face training events incorporate suicide prevention training for providers. Special focus has been placed on care provision for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with conflict-related multiple limb amputations. Although relatively small, this cohort is recognized as a unique and important population due to their unique care needs and increased risk for secondary complications. In 2019, 83% of these individuals were contacted to assure their amputation care needs were being adequately addressed.

Discussion

Over the past 10 years, the ASoC has built a modern, high-performance network of care to best serve veterans with amputation. Maturation of the system has included the addition of 3 new PANS locations to improve access to services as well as to better support geographic regions near large DoD military treatment facilities. The number of ACT designated VAMCs also has grown from 101 to 106 locations. The regional organization of sites has been modified to enhance the availability of referral and consultative services across the system. In addition, the ASoC has supported the development of an upper extremity amputation specialty program for consultation or referral to a highly specialized team of providers well versed in the significant technology advances that have taken place with upper extremity prostheses.⁹

One of the key components to high-performance network development is attaining a clear picture of the clinical demands and service delivery needs of the population served. The Amputee Data Repository was developed with the support of the VHA Support Service Center (VSSC) in order to better understand and track the population of veterans with amputation.⁶ The development and implementation of the Amputee Data Repository took place over several years, and the product was officially released into publication in 2015. The overall goals of this resource are to provide a data system for the ASoC to identify clinical care volumes and patterns of treatment; better understand the demographics of the veteran amputee population; assess the effectiveness of new treatment strategies; and utilize data analysis outcomes to influence clinical practice. The acquisition and analysis of this information will provide justification for the modification of clinical practice and will enhance the quality of care for all veterans with amputation.

Although the ASoC focuses primarily on the provision of clinical services, the system has been leveraged to support research activities and the advancement of artificial limb technologies. For example, ASoC providers and investigators supported the clinical research required to test and optimize the development of the DEKA arm. These research efforts resulted in the US Food and Drug Administration approval and commercialization of this device. Once the device became commercially available as the LUKE arm, the ASoC developed a clinical implementation strategy that assured availability and appropriate prescription and training with the new technology. The VA also has supported research and program development in osseointegration with further investigations and clinical implementation being planned.

Telehealth

The goal of the ASoC is to provide timely access and greater choice to specialty amputation rehabilitation services for veterans as determined by their clinical needs. One key strategy used to achieve this goal has been the expansion of virtual communication tools to enhance access to clinical expertise. Telehealth (Virtual Care) amputation services afford the opportunity to provide specialized clinical expertise to veterans who otherwise may not have access to this level of service or consultation.^1,2 For others, virtual care services reduce the need for travel. The ASoC has leveraged these services effectively to enhance specialty amputation care for veterans in rural areas. Over time, the scope of virtual care services has expanded to provide virtual peer support services as well as care in the veteran’s home.

Another unique example is the use of virtual care to see veterans when they are being provided services by a community prosthetist. This service improves the timeliness of care and reduces the travel burden for the veteran. Between 2009 and 2019, total virtual care encounters to provide amputation-related services grew from 44 encounters to 3,905 encounters (Figure 5). In 2019, 13.8% of veterans seen in a VA outpatient amputation specialty clinic had at least 1 virtual encounter in the same year.⁶

In addition to the expansion of virtual care and building capacity through increasing the number of amputation specialty clinics and providers, the ASoC has used a host of other strategies to improve care access. The development of provider expertise in amputation care has been achieved through the methods of extensive provider training. Implementation of Patient Self-Referral Direct Scheduling allows veterans to access the outpatient amputation specialty clinic without a referral and without having to be seen by their primary care provider. This initiative provides easier and more timely access to amputation specialty services while reducing burden on primary care services. The amputation outpatient specialty clinic was one of a few specialty programs to be an early adopter of national online scheduling. The implementation of this service is still ongoing, but this program gives veterans greater control over scheduling, canceling, and rescheduling appointments.

Conclusions

During the 10 years following its implementation, the VA ASoC has successfully enhanced the quality and consistency of care and rehabilitation services provided to veterans with limb loss through the provision of highly specialized services in the areas of medical care, rehabilitation services, and prosthetic technology. This mission has been accomplished through prioritization and implementation of key strategic initiatives in learning organization creation, trust in VA care, development of a modern, high-performance network, and customer service. Collaborative partnerships both internally within the VA and externally with key stakeholders has facilitated this development, and these will need to be enhanced for future success. Evolving trends in amputation surgery, limb transplantation, artificial limb control and suspension strategies as well as advances in assistive technology also will need to be integrated into best practices and program development.