The Facility Case Record Study: A Preliminary Report
Barbara R. Friz, M.S. *
Frank W. Clippinger, Jr., M.D. *
In the spring of 1965 the Conference of Prosthetists of the American Orthotic and Prosthetic Association, in the interest of upgrading professional standards of prosthetics practice, decided to encourage prosthetists to institute a system for keeping complete and accurate records on amputee patients. Subsequently, a standard record form was developed on which pertinent information related to the case history, physical findings and prosthetic prescriptions could be recorded.
Recognizing that information recorded in this manner could yield vast amounts of valuable data, the Conference of Prosthetists further decided to incorporate in their records duplicate tear-off sheets which could be assembled for purposes of collecting such data. The Committee on Prosthetic-Orthotic Education++ (CPOE), National Research Council, furnished the participating facilities with the forms and accepted responsibility for collecting, processing and analyzing the data. Instructions were distributed to guide participants in completion of the forms.
The purpose of this preliminary report is to present data reported by the participating facilities. Discussion of results and conclusions will be included in a final detailed report.
Methods
Forty-four facilities participated in the project and, for over a period of two years, submitted copies of case record forms to the CPOE office. The cut-off date for entering new case records was June 30, 1967.
Each of the facility record forms was edited in the CPOE office. An attempt was made to clarify any questionable entries and obtain complete information on all data by sending follow-up forms to the prosthetics facility owners. Because the data items on the forms were not pre-coded, it was necessary to set up a coding system and to translate and record each item on the form according to this system. The data were then transferred to IBM data processing magnetic tape.
In February 1968 an ad hoc working group met with the CPOE staff and with a consultant for data processing from the National Research Council to formulate pertinent questions which could be answered by the computer technique.
The prosthetists participating in the study represented thirty states, and for purposes of this study, the states are grouped according to geographical areas as shown in Fig. 1. The highest percentage of participation by prosthetists was in the East Central region, and the lowest percentage in the Western region. {Fig. 2 & 3- 2.)
Subjects
Information was collected on a total of 8,323 patients, 7,954 of whom were fitted with one prosthesis; 364 with two; four with three; and one with four. This group presented a total of 8,698 amputations, of which 4,034 were "new" amputations and 4,664 were "old." (link2]- 3.) (The term "new" in this discussion indicates a first fitting and is applied to both the amputee and the amputation. "Old" indicates a replacement prosthesis.)
All statistics reported in this study refer to amputees who were fitted with prostheses. Non-fitted amputees are not included.
Findings
Comparison with Amputee Census
In a study of 12,000 new amputees, commonly known as the "Amputee Census" and reported by Glattly* in 1964, the characteristics of the amputee population, including sex and age of the amputee, and cause, side, and level of the amputation were investigated. A well-defined pattern of these characteristics was established.
In this facility case record study, the pattern approximates that of the former study, thus giving us confidence that our sample includes a typical cross-section of the fitted amputee population.
In comparing statistics of the present study with those of the Amputee Census, we include only the 4,034 "new" patients. Fig. 4, Fig. 5, Fig. 6, Fig. 7 and Fig. 8 show that corresponding tabulations in the two studies approximate each other very closely.
In the present study, distribution by age agains shows the highest incidence of amputations occurring in the seventh decade. (Fig. 4 ) Newly fitted amputees over age 50 account for 61.1 percent of the total. Because many geriatric amputees are not prosthetically fitted, the incidence of amputation in the older age groups would presumably be even higher if statistics on non-fitted amputees were available.
The distribution of right-sided and left-sided amputation is almost equal in both studies, and lower extremity amputations still account for about 85 percent of all fitted amputations. (Fig. 5) The number of male amputees continues to outnumber the number of female amputees by about three to one. (Fig. 6 )
The relative incidence of trauma as a cause of amputation decreased by four percent; the incidence by cause as shown in the other three tabulations increased, but by a relatively small amount. (Fig. 7 ) In Figure 8 a higher incidence of below-knee amputations and a lower incidence of above-knee amputations is reflected in the more recent study. Those sites of amputation not shown in Figure 8 each total less than 2.0 percent of all new amputations. Among new patients there were a total of 3,254 above-knee and below-knee amputations. Of these, 50.9 percent were above-knee.
Replacement Prosthesis
Amputees returned to the facility for a replacement prosthesis for several reasons, but "worn out" is listed in over 60 percent of the cases. "Outgrown" is next in frequency, appearing in approximately 12.5 percent of cases. Whereas 41 percent of new prostheses were above-knee (Fig. 9 ), only 30 percent of replacement prostheses were above-knee. In the below-knee amputee, the situation is reversed, and the percentage of replacement prosthesis is greater (52 percent) than that of the new prostheses (39.6 percent).
The average age of all replaced prostheses was 6.1 years. The above-elbow prostheses averaged 9.2 years; the below-elbow prostheses, 6.5 years; the above-knee prostheses, 6.2 years; and the below-knee prostheses, 5.8 years.
Source of Patient
The tabulation in Fig. 10 reflects the prevalence of amputee clinic referrals. There is still a small group (4.7 percent) of new amputees who are receiving prosthetic fittings without a physician's referral.
Source of Payment
Of the 8,631 prostheses for which source of payment was reported, 25.8 percent were paid for exclusively by the amputee, his family, or both. (Fig. 11 )
Either insurance or compensation alone accounted for payment of 9.9 percent, and essentially all the remaining prostheses were paid for by different governmental agencies. Approximately 400 were paid for from more than one source; the Veterans Administration is the only source of payment not appearing in combination with any other source. The Medicare Act had been in effect during the second year of data collection only.
Components. Lower Extremity.
Prosthetics practice in terms of types of components used by prosthetists varied moderately according to geographical location. The frequency of use of various components is shown in Fig. 12, Fig. 13, Fig. 14, Fig. 15, Fig. 16, Fig. 17, Fig. 18, Fig. 19, Fig. 20, and Fig. 21
In this study the quadrilateral socket is the overwhelming choice of prosthetists in fabrication of above-knee prostheses, although plug sockets are still used in 5.8 percent. (Figure 12.) Wood is used 56.9 percent of the time in fabrication of above-knee sockets; plastic, 38.6 percent; and leather 4.2 percent. Leather is used with greatest frequency in New England (17 percent). Wood is the shank material used in 95.2 percent of above-knee prostheses.
Hydraulic knee components show an 8.4 percent preference (Fig. 13 ), with the Western area showing the highest percentage of usage (17.3 percent) and the Midwest area the lowest (4.6 percent) .
The pelvic belt remains the suspension of choice for above-knee prostheses. Suction socket alone or combined with some other type of suspension is used in 28.6 percent (Fig. 14 ) of the total above-knee prostheses, and 17 percent in above-knee prostheses prescribed for amputees over age 50.
The SACH foot is used with greater frequency than any other foot component, although in the older age groups the frequency of use declines markedly for both above-knee prostheses (Fig. 15 ) and below-knee prostheses (Fig. 16 ). In children the SACH foot is used almost exclusively for those with below-knee prostheses, but slightly less frequently for those wearing above-knee prostheses.
The patellar- tendon-bearing socket in this study out-numbers all other kinds of sockets for below-knee amputees. (Fig. 17 ) Suspension by knee cuff alone is most widely used by teenagers, with a lower frequency of use in young children and in the 65-and-above age groups. (Fig. 18 ) Wood is used in 90 percent of the below-knee shanks.
Components. Upper Extremity.
In this study double wall sockets are used in 89.7 percent of all above-elbow prostheses (Fig. 19 ), and 77.3 percent of below-elbow prostheses (Fig. 20 ). No distinction is made between the Muenster and other types of preflexed sockets in below-elbow prostheses. These numbered 72, or 11.3 percent of the total 635 below-elbow prostheses.
Sixty-nine percent of the elbow units in the above-elbow prostheses are internal locks. In addition, 9 percent have spring flexion assists. In below-elbow, the elbow hinges are flexible in 64.2 percent of prostheses. The triceps pad is the most frequently used type of arm cuff (56 percent), and cuff materials are usually plastic (61.1 percent). The ring figure 8 harness is the most frequently used type of harness, 45.7 percent in the above-elbow prostheses and 53.8 percent in the below-elbow prostheses.
The passive or cosmetic hand was prescribed 113 times (29.5 percent of the total number of hand types) (Fig. 21 ). Of the 268 mechanically controlled hands, the voluntary opening hand was prescribed 7.4 percent more often than the voluntary closing hand. In the hook type terminal device the voluntary opeining hand was used approximately 90 percent of the time. The most frequently used components for four types of prostheses are shown in Fig. 22, Fig. 23, Fig. 24 to Fig. 25.
This paper illustrates the types of tabulations and correlations that can be developed from the facility record data now stored on magnetic tape. Much more information remains to be retrieved. We invite your suggestions and recommendations in selection of those tabulations that you would like to see developed.
++ The Committee on Prosthetic-Orthotic Education is supported by the Social and Rehabilitation Service, Dept. of Health, Education and Welfare, and by the Prosthetic and Sensory Aids Services of the Veterans Administration.
* Glattly, H.W., "A Statistical Study of 12,000 New Amputees," Southern Med. J., 57:1373-1378, November 1964
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