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Factors Affecting the Use of Prosthetic Services

Caroline C. Nielsen, Ph.D.
Richard A. Psonak, C.P.
Terry L. Kalter, C.P.

The objective of this exploratory research was to identify and analyze factors which have a significant effect on patient use of prosthetic services, satisfaction with these services, and on the quality of life of the amputee. Twenty-one amputees were interviewed to obtain personal views of their concerns and experiences. We were interested in looking at the contemporary role of the prosthetist in meeting the needs of the amputee during a period of rapid technological change and advancement. Our goal was to obtain data on amputee concerns to assist the prosthetist in providing the most effective patient care possible.

Background

Advances in medical technology have permitted an increasing number of persons with limb amputations to survive and to live longer, potentially fulfilling lives. Innovations in materials and applications have dramatically increased the range of prosthetic options potentially available to the amputee. However, the quality of life an amputee is able to maintain is in part related to the proper fitting and regular adjustment of a prosthesis, and the opportunity to utilize new technologies as they become available.

The role of the consumer in healthcare has increased dramatically in the past 10 years. Efforts in health promotion place an emphasis on self-responsibility. Such efforts reflect the trend toward educating the individuals and groups in health promoting behaviors. Increasingly, the consumer is expected to be informed and to act as a partner with the health professional in obtaining necessary healthcare. Healthcare personnel and policies are compelled to respond to consumer interests and demands.^1,11 The rapid growth in the number of amputee consumer support groups reflect this trend. Presently, over 50 groups in the United States are active in supporting new amputees, sharing experiences, and importantly, expressing united concerns and interest in prosthetic services.

In light of these changes in the overall healthcare system, and prosthetics in particular, it is increasingly important for the prosthetist to be aware of the concerns of the amputee and the ways in which prosthetic services can address these concerns most effectively.

Methods

A review of previous research was conducted to suggest areas of demonstrated concern to amputees. Although studies were sparse, two areas seemed to suggest a need for further investigation: (1) availability of information, and (2) issues related to communication. A survey of 2,176 amputees in Canada documented amputees' concern with the availability of information about prosthetic options. These amputees expressed the need for information about new prostheses, modifications, and fitting techniques. The literature related to patient/physician interaction suggests the importance of the role of communication. Studies demonstrated that effective communication is associated with increased patient satisfaction, treatment compliance, and improved health outcome.^2,21 The roles of information and communication are addressed in this research, as well as those factors which may be unique to the provision of prosthetic services.

Data Acquisition

An interview schedule for adults with a prosthesis was designed to obtain information on the following issues.

1. Demographic variables including age, education, occupation, and amputation site.
2. Function of prosthesis including work and leisure activities, life satisfaction, level of pain, and aesthetics.
3. Treatment setting including number of annual appointments, compliance with treatment schedule, accessibility, continuity of service.
4. Communication with prosthetist including provision of information about prosthesis, role in decision-making, interaction in treatment setting.
5. Role of cost/reimbursement policies.

The interview schedule combined both structured and open-ended questions to maximize rapport and to increase the opportunity to raise new issues which may not have been considered. Responses to open-ended questions are shaped by what the informant considers to be important rather than confined to pre-set categories. These personal and intensive interviews clarified factors generally related to patient satisfaction and identified factors unique to the provision of prosthetic services.

Sample

Twenty-one adult amputees residing in Connecticut and Massachusetts were interviewed. Participants included 16 amputees who were attending a newly formed support group in Massachusetts and five amputees who were obtaining services at an urban clinic. This sample was not considered representative of all amputees, but was used for the purpose of this exploratory study to raise concerns which may be relevant in other situations. It is possible, perhaps even likely, that amputees who attend support group meetings have special concerns and are more outspoken.

The participants were 14 males and seven females with ages ranging from 23 to 74, with a mean age of 50 (Table 1) . Years of education ranged from eighth grade through college, with 11 high school graduates. Most participants were recent amputees, which may account for their interest in a support group. Eight were employed part or fulltime. Below-knee was the predominant site of amputation in the sample (Table 2) .

Discussion

After an amputation, the amputee patient "travels through" the medical system in a particular way. The characteristics of the amputee, the prosthetist, and the health care system affect this experience. When asked about their experiences amputees frequently alluded to (1) level of function; (2) quality of life; (3) interaction with the prosthetist; (4) preparation and information; and (5) cost/ reimbursement policies.

Level of Function

First, it is significant that 15 (71.4%) of the amputees interviewed reported that they were moderately to very satisfied with their present prosthesis (Table 3) . All but two participants reported that they wore their prostheses most of the day, yet 11 reported they had moderate to severe pain most of the day (Table 4) . In spite of reported pain, the amputees continued to wear their prostheses 12 or more hours each day. There also appeared to be some discrepancies in reporting of pain. Interviewers reported seeing the expressions of pain on the faces of two participants while they reported never feeling residual limb pain. Upon further questioning, the two participants reported some degree of pain all the time. This high incidence of residual pain is similar to that reported in a 1983 study of 179 amputees in the San Francisco Bay area. ¹³ These results suggest that amputees may expect some level of pain, and not fully report these concerns.

The ability to participate in work and leisure activities was an important concern of all. Thirteen of the amputees reported that they were not working. This is in part a reflection of the advanced age of the group. Most of the amputees participated in some kind of leisure activity. The limitations reported were very similar to those described in the Canadian study of 2,176 amputees.⁵ Running, dancing, skiing, hunting and stream fishing were activities described as difficult or impossible for the amputee. Not surprisingly, younger amputees were considerably more vocal about their dissatisfaction with ability to participate in leisure activities, while older participants were more likely to passively accept limitations.

When asked what is their primary concern with their prosthesis (Table 5) , 10 cited comfort. Other frequently cited concerns were inability to achieve desired activity level, problems with fit, and cosmesis. For the seven females in the study, appearance was their second most important concern after comfort. A frequently mentioned concern, usually related to activity level, was the weight of the prosthesis.

Quality of Life

Results relating to the quality of life of the amputee appeared to be contradictory. When asked about life satisfaction, 18 reported that they were "highly satisfied" (Table 6) . Some amputees reported high levels of life satisfaction while also reporting constant pain, inability to work or to participate in desired leisure activities. Older respondents frequently commented that they were "fortunate to be alive" and were content to passively accept their limitations.

Although amputees are increasingly active in consumer/support groups, traditionally they have not taken the initiative to obtain prosthetic services which meet their individual needs. Similar studies have found low expectations, particularly among older amputees, while young adults have become more assertive in obtaining desired prosthetic services. 16

Interaction with the Prosthetist

This section of the study investigates amputees' perception of time the prosthetist spends with them, communication of information, and problem resolution.

The ultimate goal of the prosthetist is to provide the best possible prosthetic services to the amputee. This goal may be achieved by determining which factors of the patientprosthetist relationship are important to the amputee. According to recent literature on the subject, the duration of the visit and the prosthetist's ability to communicate effectively with the patient are two very important factors leading to patient satisfaction. Surveys suggest that patients complain little about the technical competence of the prosthetist, but tend to be dissatisfied with the quality of prosthetist-patient interaction. If the healthcare provider expresses interest in the whole person the quality of interaction tends to improve.

In this investigation 19 amputees reported on the duration and quality of their visits. Ten amputees' visits to their prosthetists lasted 15-30 minutes, while nine reported visits of 31-60 minutes. Most participants felt that their prosthetist spent an adequate amount of time with them. Thirteen (61.9%) of the respondents reported that their prosthetist adequately explained and prepared them in the use of their prosthesis and virtually all of the participants indicated that they were given an opportunity to ask questions (Table 7) . Nine of the respondents had seen two or more prosthetists during the period of time that they had been amputees. Considering that most had been amputees less than five years these figures suggest a fairly high turnover rate. Indicative of the importance of communication, two respondents changed prosthetists after perceiving that patient initiated suggestions about their prostheses were largely ignored.

The identification and resolution of a problem is frequently the goal of a prosthetist during a patient visit. The patient's perception of problem resolution appears to be related to communication. Although not statistically significant, it does appear that patients are more likely to perceive their problem resolved when their visit to the prosthetist is for a longer period of time (r =.39, P<=.08), when they feel adequately prepared (r =38, P<=.09), and when they have the opportunity to ask questions (r =.40, P<=.07). These results concur with those studies on patient/physician communication which indicate a higher rate of compliance and satisfaction when the patient feels actively involved in his healthcare. Problems were also more likely to be resolved if the patient had medical insurance (r =.51, P<=.02), suggesting that the availability of insurance may be related to the length and/ or number of visits to the prosthetist.

Patient/physician communication studies note that level of patient education has an important effect on communications.^2,4,18 Studies have demonstrated that working class patients tend to be diffident in questioning the healthcare professional about their illness or treatment. The reasons for such hesitance have been attributed to: (1) the belief among working class patients that healthcare providers do not expect them to ask questions, and that in fact, asking questions may imply that the patient lacks confidence in the provider's judgement; (2) the reverence some patients hold for healthcare professionals; and (3) the patients' unfamiliarity with technical terminology.^4,10,25

Data obtained in this study suggests that amputees with higher levels of education may be better able to negotiate their own interests (Table 8) . Participants with more years of education were likely to have seen more prosthetists, to have longer appointments with the prosthetist, and to have had a greater number of prostheses. Further research is necessary to determine the effects of patient education on obtaining prosthetic services.

When interviewees were asked what they liked about visits with the prosthetist, their responses suggested the importance of communication in this relationship: "My prosthetist listens to me;" "I feel that I have input; He feels like a friend and treats me gently."

When inteviewees were asked what they disliked about visits, comments suggested a breakdown in communication: "I changed prosthetists when my prosthetist kept putting the problem on me;" "There was no time for questions and no follow-up;" "Another prosthetist came into the room to discuss another patient for half an hour during my appointment." These kinds of comments indicate patient concern not only with technology, but with the interaction which took place during an appointment.

Preparation and Information

Feeling prepared and having information available were important concerns of virtually all of the participants. Several interviewees expressed a desire for information prior to and immediately following their amputation. One person expressed intense fears prior to amputation which might have been alleviated with more information. This amputee was surprised to find that the attending physician knew little about prosthetics. It appears that the new amputee may sometimes be caught in an information gap between surgery and the initial process of fitting a prosthesis. These sentiments were echoed by others who would like to have been visited in the hospital by other amputees as well as the prosthetist. Interestingly, this seems to be a role that support groups are rapidly filling.

As amputees "traveled through" the prosthetic care system, they felt they needed several kinds of information which were unavailable to them. They wanted to work in partnership with their prosthetist, but felt unable to do so because of lack of information. One respondent commented that he felt "kept in the dark," while another felt that he was in the position of "blindly trusting the prosthetist" because the information necessary for decision-making was unavailable to him. These comments are similar to those of the Canadian study in which amputees expressed needs for information about new technologies and prosthetics.⁵ Respondents also seemed unsure of the prosthetist's role and what they could reasonably expect. Addressing these concerns will become increasingly important with the growth of consumer groups and the shift in healthcare toward consumer responsibility.

Cost/Reimbursement Policies

Chadderton's Canadian study in 1983 suggests that reimbursement policies may play an important role in the availability of advanced prostheses.⁵. the relationship of cost/ reimbursement policies to services needs further clarification. in this limited sample, seven amputees had no medical insurance coverage for prosthetic expenses, and three commented that the cost was a prohibitive factor in obtaining the most effective prostheses. one respondent said, "The insurance company had too much control over where you go and what you get," and two respondents indicated that insurance would cover only a basic prosthesis "a wooden leg" as she put it. The role of these policies in restricting the use of innovative prostheses requires further investigation with a larger sample.

Future Research

These preliminary data from this exploratory study based on a very small sample of amputees indicate that interaction among amputee characteristics, the prosthetist, and the healthcare system may account for the varied experiences of amputees with prosthetic services. The amputee response to this research suggests a need for further study.

Interviews with prosthetists and amputees, data from this pilot study, and a review of published research in prosthetics, orthopedics, psychology and rehabilitation suggest three comprehensive areas which require further research with a large national sample: (1) implementation of biomedical technologies; (2) patient/prosthetist interaction; and (3) attitudes and expectations of the amputee.

Implementation of Biomedical Technologies

The rapid increase in medical technological advancements in the past 30 years has created a greater segmentation within the healthcare profession. The growing distance between segments increases problems of communication and comprehension.⁶ Thirty years ago less differentiation was found between research and practice, and between the producers of innovative medical technologies and the practitioners using the technology. The prosthetist was the craftsman, the creator of the artificial limb, and the practitioner applying the limb.

The explosion of medical technology in many areas, but particularly in prosthetics, has had profound affects on the acceptance and incorporation of biomedical innovations into healthcare practice. The time lag between the discovery of new techniques by the research scientist, and their availability to the consumer is frequently long and the rate at which new results are adopted in practice is often slow. ¹⁹ Considered a rough measure of a health professional's competence is knowledge of recent research findings and the willingness to adopt those which may be applicable to his own practice. The failure to utilize new technological means to their fullest capacity is a matter of great concern, which requires constant acquisition and evaluation of new knowledge by both the health professional and the consumer.

Although this lag period between the development of new technologies and their implementation by practitioners has been demonstrated in several areas of medicine, the issue has not been researched in prosthetics. The recent explosion of new technologies in prosthetics, including new roles for the computer and the development of new materials such as graphite, titanium and copolymers, has the potential to dramatically improve the quality of life of many amputees. However, the fulfillment of this potential requires both consumer and practitioner knowledge of their availability and uses. Factors which affect this process have not yet been documented.

Amputee concern with the availability of innovative prostheses and information about prosthetic options has been documented.⁵ Similar concerns were expressed by amputees interviewed in this study in Connecticut and Massachusetts. These amputees expressed the need for information about new prostheses, modifications, and fitting techniques. Although access to new technology is an area of concern, further research is needed to identify the extent of the problem and the most effective ways to address these concerns.

It also appears that present reimbursement policies may affect the ability of some amputees to obtain the lighter, more effective prostheses. In both the Canadian study and the pilot study, some subjects indicated that their present reimbursement plans prohibited access to innovative, more costly prostheses which would have greatly improved their quality of life. The role of reimbursement policies in controlling the availability of new technology requires further investigation.

An investigation of those factors which affect the implementation of new technological advancements in prosthetics will provide ways to increase the flow of information and provide the results of recent technology to those amputees who may benefit from these developments.

Patient/Prosthetist Interaction

As the practice and process of prosthetics becomes increasingly dependent on technology, the human role in the process becomes less clear. The gains provided by the use of advanced technologies tend to separate the prosthetist's role into two diverging directions: the role of master technician (which now assumes increasing significance) and the more diffuse role of healthcare professionals. Effective communication can provide an important bridge between the use of technology and the art of healing.²⁰

Research on patient-physician interaction demonstrates that such communication is associated with increased patient satisfaction, treatment compliance, and improved health outcome.^3,7,23 Factors affecting communication in the healthcare setting include the patient's socio-economic status, ability to ask questions and negotiate his own interests, the patient's perception of a partnership with the physician and their involvement in the decision-making process regarding treatment.^5,9,17 Allowing the patient to release tension and to offer suggestions about his treatment is consistently associated with increased compliance. ^12,23

The significance of some elements in the amputee/prosthetist interaction has been identified in previous studies. Amputees have indicated a desire to plan treatment in "partnership" with their prosthetist and a desire for more information. Amputees interviewed in this exploratory study reported a range of variations in interaction. Further study is needed with a large sample of amputees to illuminate those factors which significantly influence patient/prosthetist interaction.

Amputee Attitudes and Expectations

The effect of attitudes and expectations on prosthetic services may be subtle and more difficult to document. However, research results and interviews with prosthetists and amputees suggest that amputees' expectations of attainable levels of activity may influence their ability to obtain technologically advanced prostheses, which for some could potentially improve their level of activity.

Although amputees are increasingly mobilizing in consumer/support groups, traditionally they have not been active in obtaining innovative services. Low expectations have been found, particularly among older amputees, while young adults have become more assertive in obtaining desired prosthetic services.

The population of adults over 65 years of age has nearly doubled in the past 25 years. ¹⁵ As life expectancy increases the norm or level of activity expected of the older population also increases. Approximately 80% of amputees are in this category. With the present level of prosthetics technology, the older amputee can attain a higher level of activity. However, these preliminary data suggest that there may be a relationship between the amputee's passive acceptance of his ability to function, society's view of the level of services it can afford, and the level of services provided.

A comprehensive national survey of adult amputees would provide timely and useful data on the role of these factors in providing prosthetic services. The strength of these relationships and effective ways to address amputee needs can only be demonstrated by obtaining objective data from a widely based sample of amputees. Data obtained with further research will contribute to the goals of the prosthetics profession: to provide the most effective care to the amputee population during a period of rapid technological development.

Caroline C. Nielsen, Ph.D., is a faculty member of the School of Allied Health Professions at the University of Connecticut, School of Allied Health Professions, Box U-IOI, 358 Mansfield Road, Storrs, Connecticut 06268; (203) 486-4839.

Richard A. Psonak, C.P., and Terry L. Kalter, are with Newington Orthotic and Prosthetic Systems, 580 Farmington Avenue, Hartford, Connecticut 06105; (203) 236-1221.

References:

1. Bloch, P.H., "The Wellness Movement: Imperatives for Health Care Marketers." Journal of Health Care Marketing, 4(1), 1984, pp.9-16.
2. Boreham, P. and D. Gibson, "The Informative Process in Private Medical Consultations: A Preliminary Investigation." Soc Sci Med., 12, 1978, pp.409-416.
3. Carter, W.B. and T.S. Inui, "OutcomeBased-Doctor-Patient Interaction Analysis II: Identifying Effective Provider and Patient Behavior," Medical Care, 20, 1982, pp.520-535.
4. Cartwright, A., Human Relations and Hospital Care, Rutledge and Keegan, London, 1964.
5. Chadderton, H.C., "Consumer Concerns in Prosthetics," Prosthetics and Orthotics International, 7, 1983, pp.15-16.
6. Coleman,J.S., E. KatzandH. Menzel, Medical Innovation: A Diffusion Study, Bobbs-Merrill Co., Inc., 1966.
7. DiMatteo, M.R., "A Social Psychological Analysis of Physician Patient Rapport: Toward a Science of the Art of Medicine," Journal ofSocial Lssues, 35, 1979, pp.12-29.
8. DiMatteo, M.R. and R. Hays, "The Significance of Patients' Perceptions of Physician Conduct: A Study of Patient Satisfaction in a Family Practice Center," Journal of Community Health, 6, 1980, pp.18-34.
9. DiMatteo, M.R., I.M. Prince and A. Taranta, "Patients' Perceptions of Physicians' Behavior: Determinants of Patient Commitment to the Therapeutic Relationship." Jounial of Community Health, 4, 1979, pp. 280-290.
10. Frankel, R.M., "Talking In Interviews: A Dispreference for Patient Initiated Questions in Physician-Patient Encounters." Interaction Competence, Irvington, New York, 1985.
11. Green, K., "Health Promotion: Its Terminology, Concepts, and Modes of Practice," Health Promotion, 9(3), 1985, pp.8-14.
12. Heszen-Klemens, I. and E. Lapinska, "Doetor-Patient Interaction, Patients' Health Behavior and Effects of Treatment," Soc Sci Med, 14A, 1980, pp.669-673.
13. Hoaglund, F.T. and H.E. Jergesen, et al., "Evaluation of Problems and Needs of Veteran Lower-Limb Amputees in the San Francisco Bay Area During the Period 1977-1980," Journal of Rehabilitation R. and D., 20(1), 1983, pp.57-71.
14. Holka, B.S., I.L. Kupper, M.B. Daly, et al., "Correlates of Satisfaction and Dissatisfaction with Medical Care: A Community Perspective. Med Care, 13, 1975, pp.648-658.
15. Kart, C.S., E.K. Metress and S.P. Metress, Aging, Health and Society, 2nd Ed., Jones and Gartlett, Pub., Boston, Massachusetts, 1988.
16. Kegel, B., J.C. Webster and E.M. Burgess. "Recreational Activities of Lower Extremity Amputees: A Survey," Arch. Phys. Med. Rehabil., 61, 1980, pp.258-264.
17. Malchow, D. and J.D. Clark, "Interviewing the Amputee A Step Toward Rehabilitation." Orthopaedic Review, 13(11), 1984, pp.47-56.
18. Matthews, J.J., "The Communication Process in Clinical Settings," Soc Sci Med., 17, 1983, pp. 1371-1378.
19. Nielsen, C.C., Medical Innovation and Decision-Making: Factors Affecting the Use of Midtrimester Amniocentesis. Unpublished Ph.D. Dissertation. University of Connecticut, Storrs, Connecticut, 1980.
20. Nielsen, C.C., "The Physician's Dilemma," Connecticut Medicine, 51(2), 1987, pp. 113-115.
21. Ross, C.E. and R.S. Duff, "Returning to the Doctor: The Effect of Client Characteristics, Type of Practice, and Experiences with Care," J. Health and Soc. Beh., 23,1982, pp.119-131.
22. Speedling, E.J. and D.N. Rose, "Building an Effective Doctor-Patient Relationship: From Patient Satisfaction to Patient Participation." Soc. Sci. Med., 21, 1985, pp. 115-120.
23. Stewart, M.A., "What Is a Successful Doetor-Patient Interview? A Study of Interactions and Outcomes," Soc. Sci. Med., 19, 1984. pp. 167-175.
24. Ware, J.E., A. Davies-Avery and A.L. Steward, "The Measurement and Meaning of Patient Satisfaction," HIth. Med. Care Seri'. Rev., 1978, pp.5-IS.
25. West, C., "Ask Me No Questions ... An Analysis of Queries and Replies in Physician-Patient Dialogues," Eds. S. Fisher and A. Todd. The Social Organization of Doctor-Patient Communication, Center for Applied Linguistics, Washington, D.C., 1984, pp.75-106.