Background: According to the Extremity Trauma Center of Excellence-Registry (EACE-R), 1,718 U.S. military service members have experienced major combat-related amputations affecting one or multiple limbs during the Global War on Terrorism (GWOT) between 2001 and 2017. For wounded warriors, the complex nature of combat injuries often leads to multiple co-existing health conditions beyond limb loss, including traumatic brain injury, chronic or phantom limb pain, burn injuries, sensory impairments, and psychological health disturbances such as post-traumatic stress disorder, anxiety, and depression. Prior research studies have shown that individuals treated with an interdisciplinary model system of care self-reported higher scores for quality of life and health status, higher rates of prosthetic usage, and higher rates of satisfaction with care received. A multifaceted, unified team of providers, often including surgeons, prosthetists, physical and occupational therapists, behavioral and mental health experts, physiatrists, and educators and social workers, is essential to effectively rehabilitate patients with amputation injuries. This level of comprehensive healthcare necessitates substantial labor commitments and cost. Furthermore, differences may exist between post-amputation rehabilitation care for civilians and military healthcare beneficiaries that have not yet been illuminated. Literature suggests that civilian patients seeking physical therapy under Medicare are generally insured for up to 12 encounters per episode of care. One study reported mean and median expenditures per civilian appointment for ambulatory physical therapy to be $188 and $112, respectively, with a comparable average number of visits for persons with public and private insurance, as well as for persons with Medicare. In contrast, healthcare utilization within the military, specifically related to the rehabilitation needs of wounded warriors with amputations experienced as a result of injuries obtained during GWOT, has not been studied before. The present investigation aims to analyze and quantify the utilization of healthcare throughout the entire continuum of care for service members recovering from polytrauma at military treatment facilities (MTFs). In doing so, the study intends to facilitate a better understanding and potential for optimization of U.S. government resources to better support wounded warrior rehabilitation.
Methods: Quantifying the interdisciplinary approach to the rehabilitation of patients with major combat-related amputation(s) requires leveraging longitudinal data extracts from the U.S. Military Health System (MHS). Patients were identified using the EACE-R and identified in the MHS Data Repository (MDR). The MDR was used to query appointment-level details of patient’s engagement with clinics across Military Treatment Facilities. Data collected includes demographic information, clinic designation, diagnoses, procedures performed, and number and type of rehabilitation-related medical/therapy appointments. For the analysis presented, we determined the mean number of physical therapy (PT) visits for combat-wounded individuals with lower limb amputation between 2005 and 2017. PT appointments were defined as any appointment in a MTF clinic designated as an outpatient PT clinic. The data were filtered such that all subjects had to have 1) unilateral amputation, 2) either transfemoral or transtibial injury location, 3) no injury detail that would indicate a delayed or elective amputation, and 4) a PT appointment within 100 days of injury. The mean number of appointments were calculated for patients who continued care within the MHS through six months after injury and through 12 months after injury.
Results: Data extracts provided descriptive statistics regarding usage of PT clinics for individuals with transtibial and transfemoral amputation. The mean number of encounters were obtained for two time periods, 0-6 months post-injury (period 0-6) and 0-12 months post-injury (period 0-12). For N=278 transtibial males the mean number of PT visits was 37.3 (+/- 12.1) during period 0-6. N=150 transtibial males had a mean of 67.6 (+/-22.3) visits during period 0-12. N=5 transtibial females had a mean of 40.6 (+/- 3.4) visits during period 0-6, and N=2 transtibial females had a mean of 84.5 (+/- 26.2) visits. Male transfemoral patients in period 0-6 (N=132) had a mean of 39.3 (+/-10.4) visits; in period 0-12, N=83 transfemoral males had a mean of 72.7 (+/-18.7) visits. N=1 transfemoral female had 42 PT visits during period 0-6, and N=2 transfemoral females had a mean of 72 (+/- 5.7) PT visits during period 0-12.
Conclusions: The data highlights the complexity of long-term treatment of individuals with traumatic limb loss. Within the MHS, presenting injuries are diverse and care received is variable, as well as highly intensive. Patients treated in the MHS attend a far higher number of appointments than the literature suggests is common among civilian counterparts. In one cohort, the number of PT encounters was more than 5 times the number of civilian counterparts. This may be a result of complex injuries that require a longer rehabilitation period, and thus, more therapy appointments. Further analyses of detailed longitudinal person-level healthcare data from other rehabilitation clinics are needed to comprehensively describe healthcare utilization for this population. Additionally, it is important to consider that it has historically been difficult to quantify the intensity or “dosage” of encounters for therapy interventions. No research investigation to date has collated this magnitude of information to understand the overall utilization and cost of healthcare accessed by service members after sustaining combat-related polytrauma. The results of this research may have a far reaching impact in directing future planning for staffing needs within the MHS. Quantifying the number of therapy encounters is just the first step in understanding healthcare utilization and comprehensive rehabilitation care for this population.