Coordinated care - a critique of amputee management in mixed health & rehabilitation systems

Poorly coordinated care – unnecessary delays,

disability and OOP costs in rehabilitation: The case of

amputee management in South

Asia.

Wes Pryor

Orissa Rehab Leadership 1 training, 20125

Direction des Ressources Techniques | Technical Resources Division

Gait training: Some assumptions

Gait training is almost uniformly practiced Reports of usage, but unclear specific

methodology and effectiveness (Baker &

Hewison 1990; Pandian & Kowalske, 1999; Esquenazi & DiGiacomo, 2001

Inconsistent or limited practice Limited current evidence

1 RCT (Yigiter, 2002)


Why is this important?

1 amputation every...

20seconds,

due to diabetes alone

How many are preventable, and how well are we responding?


Gait training in South Asia

High need Global limitations in evidence & standards Particular limitations in South Asia,

potential causes: Emerging ‘professionalism’ in PT, P&O,

Rehab. Medicine w/ interdisciplinary interaction

Limited resources (HR, Infrastructure, $) Low regulation


Research questions

What are the current approaches to Gait Training?

Are there examples of good practice in the region?

What outcome measures are routinely used?

What are some basic outcome measures currently available to establish baseline?


Purpose

To understand limitations in practice and target interventions: Develop synthesised regional picture of

current gait training practices Measure and describe current approaches

Targeted interventions to improve clinical capacity QoL in users


Methods

Cohort, sample of convenience with some snowballing

15 centres in 5 countries approached 8 responses

Nepal, Bangladesh, Sri Lanka


Scope of service

Wide variation in HR approach Approximately 5 P/O, 4PTs per centre Approximate number of devices provided

per P/O per month 15.6(±11.19, range 7-25)


How much gait training?

level Days training SD Range

TT 9.2 6.6 2-20

TF 16.5 11.3 3-35

“Average number of days client spends undergoing gait training after initial fitting”

Number of hours per day highly variable within and between centres.


What kind of gait training?

Range of approaches Most mentioned:

‘client specific’ - weight shifting, balance, parallel bars and complex terrain

None reported the usage of apparatus such as treadmills, weight support or feedback units.

Some suggested that approach was largely ‘what had been taught’ to therapists.


What outcome measures?

Responses included: stump quality Satisfaction instrument after delivery Mobility-related ADLs ‘able to walk independently’, or ‘comfortable

to the client’ capacity to work, suitability of prosthesis for

working environment Unspecified ‘psychological changes’


Simple fitting and discharge indices

Waiting times Efficiencies in HR, procurement,

management Quality of devices, training

chances of return to full participation, disruption to life

1st consultation 1st fitting Delivery



18

+16 = 34

1st c

onsu

lt

1st f

ittin

g

Del

iver

y5-68

7-18


Little systematic collection of key indices

No agreed key indicators for amputee rehabilitation Simple ‘customer experience’ indices Routine demography (for disaggregation) Simple functional indices

Walking velocity, pain scores, standard observational gait analysis, ROM, muscle strength

Participation WHO core set on amputees

No agreed discharge ‘level’


Worst-case scenario = 86 days


18

+16 = 34

1st c

onsu

lt

1st f

ittin

g

Del

iver

y

Rep

air

/ fa

ilure

Best-case scenario = 12 days

Surg – 1st consult: up to 1 year

5-68

7-18


Speculations on delays

Worst-case scenario = 86 days

Complex cases

ProcurementHR limitations Client health, compliance

Geography, accessPoor or absent therapy

Poor or absent therapy

Del

ayed

1st f

ittin

g

Del

ayed

dis

char

ge

1st c

onsu

lt

1st f

ittin

g

Del

iver

y


Other findings

Currently, very limited understanding of the role of P&O in subacute care Post operative care Pre-operative advice RRDs, IPOP etc

Limited interaction between PTs and P/Os not limited to gait training

Complex political HR(H) factors at play


Implications for programs, M&E, Research

retrospective audit Gait training and functional indices

Improving benchmark targets (CPD for rehab professionals)

Pre-amputation situation ‘lived experience’ Faster surgery – rehabilitation transition Building links with PHC/tertiary care


Clinical governance

R&D

Education

Clinical Audit

Clinical Effectiveness

Openness

Risk management

Clinical governance outline

What are simple, practical and useable ‘downstream’ governance measures?

Is it worth it? How do clinical outcomes compare? Which outcomes?

We call rehabilitation a catalyst for other disability (and other) services – is it?


Other findings

Currently, very limited understanding of the role of P&O in subacute care Post operative care Pre-operative advice RRDs, IPOP etc

Limited interaction between PTs and P/Os not limited to gait training

Complex political HR(H) factors at play


Conclusion

Gait training as an example Inconsistent Not standardised Not measured Only one limitation in current situation

We need to Measure a basic set of indices Work to improve those indices

Coordinated care - a critique of amputee management in mixed health & rehabilitation systems

Health & Medicine

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