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Estimating Future Costs of Prosthetic Devices

Recently, the Department of Defense (DoD) issued a Rehabilitation Directive, the goal of which is to return service members with limb loss from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/ OIF) to pre-injury function and provide them the option of returning to active duty. To meet this goal, the DoD Amputee Patient Care Programs and VA Medical Centers offer state-of-the-art comprehensive rehabilitation care, including prosthetic care.

VA limb distribution practice allows any Veteran with limb loss to request and/or receive any prosthetic device if deemed medically appropriate, feasible and/or indicated according to their functional level. Prosthetic care is one component of a comprehensive rehabilitation care program for those with major limb loss. As such, it is crucial to estimate future costs of prosthetic devices in order to plan appropriately for effective resource allocation. We conducted a study of prosthetic costs as part of a larger research project involving service members with traumatic limb loss from Vietnam and OEF/OIF.

In step 1 of the study (see figure), researchers conducted a nationwide survey, which identified Vietnam and OEF/OIF service members' prosthetic history since limb loss and current assistive-device use. In step 2, researchers developed a cost matrix for all upper and lower limb prosthetic costs and assistive devices, and then categorized these by level of function using Medicare costs as the common metric.

In step 3, researchers linked each study participant's utilization and function to the cost matrix to compute individual total annual costs. In step 4, the study's expert panel of VA and DoD rehabilitation leadership, rehabilitation and prosthetic specialists, academic and private practice physicians, prosthetists, researchers, and service members with limb loss made recommendations on model parameters in areas where there is no published data. In step 5, researchers projected total cumulative prosthetic costs for 5-year, 10-year, 20-year, and lifetime time horizons. We did this separately for OEF/OIF service members and Vietnam Veterans suffering traumatic limb loss. Type of limb loss was categorized as isolated lower, isolated upper, bilateral upper, and multiple limb loss. For Vietnam and OEF/OIF cohorts, and each category of limb loss, we used separate cost projection models.

The analysis results in cost distributions for projections over all time horizons and types of limb loss. Overall, our model indicates that for OEF/OIF service members with isolated lower limb loss, 5-year, 10-year, 20-year, and lifetime average per-person costs are $229,000, $474,000, $856,000 and $1.5 million, respectively. The corresponding costs for the Vietnam group were estimated to be $82,251, $167,848, $281,234, and $342,716, respectively. The mean costs for the OEF/OIF group are 2.8 fold to 6.2 fold higher than the corresponding costs for the Vietnam group. This reflects higher costs for the more technologically advanced prostheses, use of multiple artificial limbs, and fewer service members abandoning prosthetic devices. The standard deviations of costs steadily increase as the length of the projected time horizon increases for both groups and all types of limb loss, thus estimating costs over longer periods has greater uncertainty.

Based on our findings we recommend a uniform standard of rehabilitation and prosthetic care for service members with limb loss cared for by VA directly or through VA contracts. A uniform standard for coverage of prosthetic and assistive devices as part of their overall rehabilitation care will assist veterans with major traumatic limb loss.

The study provided VA clinicians and policy makers with information on the health, combat injuries, function, quality of life, prosthetic device utilization, replacement, abandonment, and satisfaction of these service members. The results of this study will assist VA clinicians and decision makers in planning for future care of service members with limb loss. Findings from the larger study include four editorials, 10 manuscripts, and the expert panel's clinical and research recommendations for care of service members with limb loss. Complete study findings are slated for a special issue of the Journal of Rehabilitation Research and Development later this year.


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