The AMPREDICT PROsthetics Decision Support Tool: using evidence to guide personalized prosthetic prescription and rehabilitation planning

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Recent research has highlighted the challenges faced by the clinical rehabilitation team in providing a personalized rehabilitation experience for patients undergoing lower extremity amputation due to chronic limb threatening ischemia. These challenges include the prescription of personalized prosthetic componentry, formulating the most appropriate prosthesis rehabilitation plans based upon the patient’s functional goals and potential, and setting appropriate patient expectations by communicating clearly what level of prosthesis mobility they will likely achieve. Though not the primary impetus behind prosthesis prescription justification within the VHA, the traditional paradigm for a lower limb prosthetic prescription is largely driven by the providers best estimation of the patient’s future mobility outcome sometimes using K-levels or other analogous mobility categories. The appropriate prosthetic componentry is then matched to the predicted mobility level. This approach is wrought with challenges and clinicians do not have a lot of confidence in this process. There is no evidence to back the clinician’s ability to predict future mobility. Current clinical practice guidelines also do not offer adequate evidence or guidance to shape these decisions. The time of initial prosthesis evaluation is a key time point in the amputation rehabilitation continuum that can profoundly influence future functional and quality of life outcomes. Lower extremity amputations are a major health care concern within the VA Health Care System. The VA Amputee System of Care (ASoC) is a national clinical program within Rehabilitation and Prosthetic Services with the primary goal of enhancing the care and outcomes of Veterans with limb loss. The ASoC is concerned with the most appropriate management of persons with limb loss to maximize function and quality of life, as well as reducing health care disparities between regions and improving geographical access to health care resources. To improve the rehabilitation clinician’s ability in setting rehabilitation mobility goals, prescribing personalized prosthesis components to meet those goals, helping patients set appropriate expectations, [and reassessing patient progress], we propose to develop the AMPREDICT PROsthetics (aka, AMPREDICT PRO) decision support tool. This tool will use the AMPREDICT PRO prediction model output to develop a calculator that will predict the probability that a patient will achieve each of the following mobility levels 12 months after their prosthesis prescription: (1) wheelchair mobility only, (2) able to walk in the house, (3) able to walk in the community short distances on even surfaces, and (4) ability to walk in the community unlimited distances on several terrains. The tool will be developed and tested by VHA rehabilitation clinicians from all geographic regions to help determine the methods of delivering the tool such as a website, smart phone application, or the electronic health record, and to provide input on ways to ensure the tool will be utilized and successfully implemented throughout the VHA medical system. In addition to assisting in personalized prosthesis prescription and rehabilitation planning [and progress assessment, the tool will generate a patient facing educational handout that will help them understand their predicted mobility level and empower them with strategies to achieve the highest level possible.] The results of this research could be incorporated within the Veterans Affairs and Department of Defense Amputation Clinical Practice Guidelines, ASoC core tools, and accomplish one of the VA Health Information Strategic Recommendations for increased decision support and analytic tools.