Discordant recommended postoperative discharge rehabilitation among patients who undergo a major lower extremity amputation.

Abstract

Postoperative physical therapy (PT) and rehabilitation are critical for meaningful recovery after a major lower extremity amputation. Our goal was to assess for discordance (lower than recommended level of care) between discharge disposition and final inpatient PT recommendations, to identify barriers to appropriate rehabilitation. All major amputations at a single academic medical center (2014-2024) were retrospectively analyzed. Discharge concordance was assessed by comparing a patient's last PT recommended disposition with their final discharge disposition. Patients with concordant and discordant discharge disposition were compared and barriers to appropriate rehabilitation analyzed. A multivariable analysis was performed to determine variables associated with discharge to a lower level of care. The 90-day readmission rate between patients with concordant and discordant discharges was compared. There were 348 patients who underwent a major amputation: 69.5% and 30.2% were below-knee and above-knee amputations, respectively. Of these, 18.4% were two-stage amputations. Indications for amputation included primary infection (73.6%), chronic ischemia (14.9%), traumatic injuries (4.6%), acute limb ischemia (2.3%), postoperative complications (2.3%), malignancy (1.2%), and other causes (1.2%). Postoperatively, 94.2% of patients were evaluated by PT. Of these, 32.1% had a final discordant/lower-level discharge with 67.7% discharged to a subacute rehabilitation center/skilled nursing facility, 20.2% to home with services, and 12.1% home without services. This distribution significantly differed from the concordant group, which had 58.4% of patients discharged to an acute rehabilitation center, 33% to a subacute rehabilitation center/skilled nursing facility, 8.1% to home with services, and only 0.5% to home without services (P < .001). Discordant discharge was associated with Medicaid insurance (odds ratio [OR], 2.17; 95% confidence interval, 1.04-4.53; P = .04). There was no difference in 90-day readmissions between the two groups. Among patients who undergo a major lower extremity amputation, one-third were discharged to a lower-level rehabilitation than their final PT recommendation. Being underinsured was significantly associated with a discordant/lower-level discharge plan. Addressing socioeconomic barriers and insurance guidelines for rehabilitation coverage may help to ensure appropriate postoperative rehabilitation after a major amputation, providing the best chance for functional recovery.