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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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