(IP109) Discordant Recommended Post-Operative Discharge Rehabilitation among Patients who Undergo an Above Ankle Lower Extremity Amputation

Objectives: Post-operative physical therapy (PT) and rehabilitation is critical towards recovery following a major, above ankle lower extremity amputation. Our goal was to compare a patient’s discharge disposition with their final inpatient physical therapy recommendation and assess barriers to appropriate discharge among those with discordant (discharged to lower level of care) plans.

Methods: All major amputations at a single academic medical center (2014- 2024) were retrospectively analyzed. Patients with concordant and discordant discharge disposition, as compared to their final PT recommendation, were compared and barriers to appropriate rehabilitation analyzed.

Results: There were 348 patients who underwent an above ankle amputation, with 69.5% and 30.2% of patients underwent below-knee (BKA) and above-knee (AKA) amputations, respectively, of which 18.4% were two-stage amputations. Indications included primary infection (73.6%), followed by primary chronic ischemia (14.9%), traumatic injuries (4.6%), acute limb ischemia (2.3%), post-operative complications (2.3%), malignancy (1.2%), and other causes (1.2%). Discharges were to acute rehabilitation centers (33.9%), subacute rehabilitation or skilled nursing facilities (SAR/SNF) (42.5%), home with services (10.3%), and home without services (4%). Following their operation, 94.2% of patients were evaluated by PT. Primary reasons for lack of PT evaluation were pre-existing conditions already necessitating full-time assistance, critical illness, inpatient death, transitions to comfort measures or hospice care, or patient declined. Among patients who received a PT evaluation, 35.1% had a discordant/lower-level discharge. Of these, no patients were discharged to an acute rehabilitation center, 67.7% were discharged to a SAR/SNF, 20.2% to home with services, and 12.1% to home without services (Table). This distribution significantly differed from the concordant group who had 58.4% patients discharged to an acute rehabilitation center, 33% to a SAR/SNF, 8.1% to home with services, and only 0.5% to home without services (P <.001) (Table). Discordant discharge was associated with Medicaid insurance (OR 2.17, 95% CI 1.04-4.53, P =.04). Among patients discharged to home, insurance coverage was the primary reason documented for lower-level discharge.

Conclusions: Among patients who undergo an above ankle lower extremity amputation, one-third were discharged with lower-level physical therapy rehabilitation plans, as compared to their final PT recommendation. Being underinsured was significantly associated with a discordant/lower-level discharge plan. Addressing socioeconomic barriers and insurance guidelines for rehabilitation coverage may help ensure appropriate post-operative rehabilitation among patients who undergo a major amputation, providing the best chance for recovery.