Needs, Preferences and Functional Abilities of Veterans and Service Members with Upper Limb Amputation

背景：有报道称，军队和退伍军人上肢截肢患者的护理存在质量差距。 据报道，2008年，在退伍军人事务部接受假肢护理的截肢者的满意度低于同行 在私营部门接受护理。2011年，据报道，退伍军人中普遍存在不满情绪， 上肢丧失导致呼吁努力评估创伤性上肢截肢退伍军人的需求 以提高满意度。自这些研究以来，为提高假肢护理质量做出了重大努力 进行了。2009年，退伍军人管理局重组了截肢护理系统，2014年，退伍军人管理局和国防部 发布了循证临床实践指南（CPG），用于上肢残疾人的康复 截肢现在是进行全面研究以评估质量和结果现状的时候了 为上肢截肢者提供截肢康复服务，并随着时间的推移跟踪质量和结果。 我们的目标是提供全面的横截面和纵向数据的功能， 需要，偏好和满足退伍军人和服务成员与主要上肢截肢。这 项目修改增加了次级目标1a和2a，以提供关于患有老年痴呆症的女退伍军人的全面数据。 截肢 具体目标/假设 1)描述假体使用模式;确定截肢和假体使用对 功能，活动和参与;并确定未满足的假肢需求 假设：1）假体使用率和假体满意度量表评分将高于 与近端截肢的人相比，经桡动脉（TR）截肢者; 2） 过去5年截肢患者的假体使用率和满意度， 那些持续截肢6年或以上; 3）任何假肢使用，肌电使用将 与不使用假体和使用身体动力相比， 4）日常活动功能的感知困难将被评为类似的人与单侧 上肢截肢，无论水平如何，使用者之间没有因假体器械类型而存在差异。 然而，在进行需要双手参与的活动时， 与TR截肢相比，近端截肢的人; 5）将有更大比例的活动 与近端截肢相比，TR截肢患者使用假体进行的手术。 1a.按性别比较调查结果。本子目标将检验以下假设： 按性别进行修改，女性上肢截肢者对其假肢不太满意 无论截肢后的多少年， 2)进行为期一年的纵向跟踪调查，以检查对护理的满意度变化， 假肢服务，身体表现，自我报告的生活质量和身体功能，以评估 实施新的临床实践指南（CPG）。这一目标将测试以下相关的 假设：1）VA对CPG建议的依从性存在地理差异， 与先前研究结果相似的截肢相关服务; 2）随着时间的推移会有所改善 对在退伍军人事务部和国防部接受护理的上肢截肢者的护理满意，但对退伍军人的护理不满意 3）中央政府的各项指标会随时间而改善 合规 2a.按性别比较调查结果。这个子目标将测试假设1）将不会有 男性和女性退伍军人对CPG建议的依从性之间的差异， 上肢截肢，2）女性和男性退伍军人之间没有差异 对护理质量的满意度。 3)使用一系列基于性能的测试来量化身体功能。这一目标是描述性的， 自然，因此没有相关的假设。 研究设计这是一项由3部分组成的研究。第1部分将调查1850人的分层随机样本， 上肢截肢，在VA接受护理和所有上肢截肢的服务人员， 还没有过渡到VA护理。这个N代表人口的约41%，其中97%是男性。我们将分层 根据截断水平，对最小组进行过抽样，并在分析中使用抽样权重。为 为了扩大这个项目，我们建议对所有上肢截肢的女性退伍军人进行抽样， 我们估计，根据2016年VA截肢简报，我们的研究将增加130例受试者。的 调查将包括既往调查的项目、标准化测量（SF-12、QuickDASH、TAPES满意度， 和OPUS护理满意度）和风险-受益评估的新项目以及质量要素。部件2是 对第1部分的667名受访者进行了为期一年的纵向随访调查，估计有80名女性 受访者（考虑到我们预计61%的回复率）。第3部分将涉及5个数据收集站点， 在相隔一年的两个时间点对125人进行灵活性和活动表现的测量。

BACKGROUND Quality gaps in care of military and Veterans with upper limb amputation have been reported. In 2008, amputees receiving prosthetic care in the VA were reported to be less satisfied than counterparts receiving care in the private sector. In 2011, reported widespread dissatisfaction amongst combat Veterans with upper limb loss led to calls for efforts to evaluate needs of Veterans with traumatic upper limb amputations to improve satisfaction. Major efforts to improve quality of prosthetic care have been made since these studies were conducted. In 2009, the VA reorganized its amputation system of care, and in 2014 the VA and DOD released the Evidence-Based Clinical Practice Guidelines (CPGs) for the rehabilitation of persons with upper limb amputation. It is now time for a comprehensive study to assess the current state of quality and outcomes of amputation rehabilitation for upper limb amputees and to track quality and outcomes over time. OBJECTIVES Our objective is to provide comprehensive cross-sectional and longitudinal data on function, needs, preferences, and satisfaction of Veterans and service members with major upper limb amputation. This project modification adds subaims 1a and 2a to provide comprehensive data on women Veterans with upper limb amputation. SPECIFIC AIMS/HYPOTHESES 1) Describe patterns of prosthesis use; identify the impact of amputation and prosthesis use on function, activities and participation; and identify unmet prosthetic needs This aim will test 5 major hypotheses: 1) rates of prosthesis use and scores on prosthesis satisfaction scales will be higher for transradial (TR) amputees as compared to persons with more proximal amputations ; 2) there will be higher rates of prosthesis use and satisfaction amongst those with amputation in the past 5 years as compared to those who sustained amputation 6 or more years ago; 3) any prosthesis use, and myoelectric use will be associated with lower ratings of disability and neck pain compared to no prosthesis use and body-powered use respectively; 4) perceived difficulty of everyday activity function will be rated similarly for persons with unilateral upper limb amputation regardless of level, with no differences between users by type of prosthetic device. However, perceived difficulty in performing activities that require bimanual involvement will be greater for persons with more proximal as compared to TR amputation; 5) a greater proportion of activities will be performed using the prosthesis by persons with TR amputation as compared to more proximal amputation. 1a. Compare findings by gender. This sub aim will test the hypotheses that there will be an effect modification by gender, with female upper limb amputees being less satisfied with their prosthesis regardless years since amputation, 2) Conduct a one year longitudinal follow-up survey to examine changes in satisfaction with care and prosthetic services, physical performance, self-reported quality of life and physical function to assess the implementation of new clinical practice guidelines (CPGs). This aim will test the following associated hypotheses: 1) There will be geographic variation in VA compliance with CPG recommendations with amputation related services that parallels findings from prior research; 2) There will be improvements over time in satisfaction with care for upper limb amputees receiving care at the VA and DoD but not for Veterans receiving care from other sources; and 3) There will be improvements over time in indicators of CPG compliance. 2a. Compare findings by gender. This sub aim would test the hypotheses 1) that there will be no differences between compliance with CPG recommendations between male and female Veterans with upper limb amputation, and 2) there will be no differences between female and male Veterans’ satisfaction with quality of care. 3) Quantify physical function using a battery of performance based tests. This aim is descriptive in nature, and thus there are no associated hypotheses. STUDY DESIGN This is a 3-part study. Part 1 will survey a stratified random sample of 1850 of persons with upper limb amputation that receive care in the VA and all service members with upper limb amputation who have not transitioned to VA care. This N represents ~41% of the population, which is 97% male. We will stratify by level of amputation, oversample the smallest groups, and use sampling weights in analyses. For the expansion of this project, we propose sampling ALL female Veterans with major upper limb amputation, which we estimate, based on 2016 VA amputation briefing book would be 130 additional subjects in our study. The survey will include items from prior surveys, standardized measures (SF-12, QuickDASH, TAPES satisfaction, and OPUS care satisfaction) and new items on risk-benefit assessment, and elements of quality. Part 2 is a one year longitudinal follow-up survey of 667 respondents from Part 1 and an estimated 80 female respondents (given that we anticipate a 61% response rate). Part 3 will involve 5 data collection sites that will administer measures of dexterity and activity performance to 125 persons at two time points one year apart.