Outcomes - 10 Year Analysis of a National Amputee Rehabilitation Database

Elizabeth Condie FCSP
National Centre for Training and Education in Prosthetics and Orthotics
Glasgow, Scotland, U.K.

Introduction: The Scottish Physiotherapy Amputee Research Group (SPARG) has developed and implemented a unique national, standardised system of information collection and analysis for lower limb amputees in Scotland1.

The importance of evidence-based practice, clinical audit and benchmarking is now clearly recognised and demands accurate data(2). Data collection began in 1992 and the first of ten annual reports produced in 1993. It is now possible to examine trends in demographic data, the rehabilitation process and in 'outcome' measures. The recording of 'rehabilitation milestones' has been invaluable in measuring the rehab process.

Method: A "hub and spoke" network collection ensures that virtually all amputees in Scotland are included. Data is entered onto computer either at a local level or at the University of Strathclyde. Analysis and reporting of data is conducted at the University.

Results: Demographic data: There are between 750 and 850 primary amputations of the lower limb each year. For the first five years surveyed, 60% of amputations were transtibial (TT), 35% transfemoral (TF) and less than 3% at 'other' levels. The TT:TF ratio varies considerably when individual hospital data are examined. Around 18% are bilateral. P.A.D., with or without diabetes, remains the cause of almost 90% of amputations. Mean age (69 years) and male: female ratio (63%:37%) are unchanged. Inpatient mortality has risen from 14-18%.

Rehabilitation Process Data: 'Days' to Casting' has been fairly constant with the National median from 35-41 days for TT and 35-42 for TF. 'Days to discharge' shows a downward trend for amputees fitted with a prosthesis (TT 72 → 57.5 TF 74 → 67), and a short term rise for nonfitted TT amputees between 1995 and 1999 which has now reduced (38 → 61 → 43). There is a rising trend in length of stay for non-fitted, TF amputees (35 → 42.5, p = 0.007).

Outcome Data: From 1993-96, around 70% of TT and 40% of TF amputees did receive a prosthesis. From 1998-2002, the percentage dropped to 65% for T.T and to 25% for T.F. Wound infection rates for all levels ranged from 18.77%-26.42%. The place of final discharge shows a reduction in amputees going home to live alone (40.10 → 9.64%), an increase in those going home with live-in help (6.60 → 46.70%) and an increase in number discharged to residential or nursing home, 1993 = 1.02%, 2001 = 19.79%. Function with a prosthesis is measured using the Locomotor Capabilities Index(3,4). In 2002, TT amputees scored a mean of 50 on admission and 48 at discharge,. For TF amputees, the figures are 51 and 42.

Discussion: Demographic data is remarkably constant. The increase in the number of TF is worrying given the importance of retaining the knee joint.

The non-fitted, TF group of patients are remaining in hospital longer; this may be due to a lack of residential or nursing home places. The recent decrease in the percentage of TF patients receiving a prosthesis is of concern.

Conclusion and uses of data: The implementation of a national amputee database for 10 years has been achieved. These data can be used:

  • to examine trends

  • as a basis for benchmarking and audit

  • to develop research

  • to inform clinician, managers and planners

References:

  1. Condie ME, Jones D, Scott H, Treweek (1996). A one year national survey of patients having lower limb amputations in Scotland. Physiotherapy, 82, 14-20.

  2. Department of Health (1996). First statement of research capacity strategy for the Department of Health and the NHS ¨C London : DoH.

  3. Treweek S, Condie M.E. (1998). Three measures of functional outcome for lower limb amputees : a retrospective view. Prosthet Orthot Int 22, 178-185.

  4. Gauthier-Gagnon C, Grise MC, Lepage Y (1998). The Locomotor Capabilities Index : content validity. J. Rehabil Outcomes Meas. 1998. 2(4), 40-46, Aspen Publishers Inc.