Expert Panel recommendations-Based on research and deliberations from VA HSR&D project "Impact of the DOD paradigm shift on VA amputee prosthetic care"

Abstract

[ILLUSTRATION OMITTED] Major limb amputations are part of the sacrifices made by over 2,500 living Vietnam veterans and nearly 1,000 servicemembers to date from the conflicts in Afghanistan and Iraq. The men and women from both conflicts who completed our survey report favorable health and quality of life ratings, tremendous resilience, and hard work to reintegrate into society despite serious injuries and comorbidities. Our 27-member Expert Panel was composed of professionals from academic and clinical settings, clinicians and researchers from the Department of Veterans Affairs (VA) and the Department of Defense (DOD), and three veterans with limb loss from the Vietnam, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) conflicts. They identified issues and unmet needs and provided valuable insight. The Expert Panel communicated by teleconference and met in Seattle in June 2008. During the Expert Panel meeting, the members collaborated on strategies to extend the principles of the DOD paradigm shift to VA care. Expert Panel members share a common rehabilitation goal for servicemembers with limb loss: to restore and maintain function to the fullest extent possible over their lifetimes. Restoration provided by prosthetic limbs (though important) is but one of the contributions of the interdisciplinary rehabilitation team. CLINICAL RECOMMENDATIONS 1. We recommend a VA paradigm shift in limb-loss rehabilitation and prosthetic-device care, as described by Dr. Sigford in her editorial in this issue [1] and approved by VA Patient Care Services. This initiative includes creating VA Regional Limb Loss Centers, Polytrauma Amputation Network sites, Amputation Care Teams, and amputation points-of-contact for veterans with limb loss. We also recommend annual clinical and prosthetic-device reviews. We also recommend opportunities for supervised trials of new prostheses and related education, education on realistic expectations, telehealth options for veterans, and a toll free number for troubleshooting veterans' limb-loss-related issues. 2. We recommend a uniform standard of care based on functional ability, operationalized rehabilitation potential, personal preference, and safety considerations for all veterans with limb loss regarding training and provision of prosthetic devices [1-4]. Survey participants identified differences by military conflict in rehabilitation, training, opportunities for sports and physical activities, and availability of technologically advanced prosthetic devices for those with limb loss. 3. We recognize prostheses are but one component of the rehabilitation process. Therefore, we recommend continuing to allow servicemembers and veterans to select prosthetic-device providers--either in-house fabrication with direct purchase of components and assembly by board-certified VA providers or contracts with prosthetic device providers outside the VA. Veteran satisfaction, access, and proximity to care are enhanced using this approach [4]. 4. We recommend creation of a VA Limb-Loss Registry using the VA Corporate Data Warehouse. The Corporate Data Warehouse currently maintains information on each veteran. A flag can be added to indicate limb-loss level and traumatic etiology for each veteran. This registry can facilitate care coordination, communication, and research by VA and DOD investigators. 5. We recommend a clinical template to document limb-loss-related care, services, and visits be added to the VA electronic medical record (Computerized Patient Record System). 6. We recommend linking to the VA Corporate Data Warehouse a common template for unique servicemembers' detailed prosthetic device data, including dates; number; and type of prostheses provided, repaired, and replaced. This common template would be used by the VA, VA contractors, and the DOD to better understand prosthetic device history and preferences. …