Center for Injury Research and Policy Perceived Need and Unmet Need for Support Services Following Severe Lower Extremity Trauma

Center for Injury Research and Policy Kristin R. Archer, PT, DPT, PhD Ellen J. MacKenzie, PhD Renan C. Castillo, PhD Michael J. Bosse, MD The LEAP Study Group

Center for Injury Research and Policy The LEAP Study Prospectively followed cohort of limb threatening lower extremity trauma patients. Open tibia and foot/ankle fractures as well as severe soft tissue injuries At least at some risk of amputation (~30% were treated with amputation) Average LOS ~ 3 weeks Average time to FWB ~ 6 months.

Center for Injury Research and Policy The LEAP Study (contd.) Recruited during initial admission at one of eight participating Level I Trauma Centers. Followed at 3, 6, 12, 24, and 84 months. N=569 with unilateral injuries. Extensive baseline and follow up data.

Center for Injury Research and Policy The LEAP Study (contd.) Overall, the average LEAP participant had very poor outcomes. Disability as measured by the SIP Return to work Anxiety and depression Chronic pain related disability Consistent with observations from other studies

Center for Injury Research and Policy Motivation Interested in finding “causal” factors for poor outcomes following trauma, ideally ones we could “move”. SES and demographic patient characteristics Intermediates (particularly sub-threshold pain and psychologic distress) Cognitive factors What about access to services?

Center for Injury Research and Policy Services Following Trauma Physical Therapy substantial unmet need factors: financial, pain, convenience, referral patients with unmet need had more impairment Pain management need unknown, but aggressive tx helps Vocational rehabilitation Mental health care Financial assistance Transportation assistance Legal aid Home nursing

Center for Injury Research and Policy Need and Unmet Need Self reported utilization Self reported need: participants who did not report using these services were asked if they would have benefitted from receiving these services since their last interview participants who felt they would have benefitted but did not received services were classified as having unmet need. Participants with unmet need were asked follow up questions about what prevented them from obtaining these services. Separate sets of questions for vocational, mental health and “other” services.

Center for Injury Research and Policy Need and unmet need over first 12 months post trauma Total (N=547) Support Services NeedUnmet Need* Vocational 181 (33%)103 (57%) Mental Health 190 (35%)101 (53%) Financial 226 (41%) 82 (36%) Transportation 207 (38%) 44 (21%) Legal Services 245 (45%) 29 (12%) Home Nursing 262 (48%) 7 (3%) * As a percentage of patients with perceived need.

Center for Injury Research and Policy Vocational Rehabilitation (n=103/181) FactorOR (95% CI) p value Private insurance (vs. public/uninsured)0.58 (0.29, 1.2) 0.12 Non-white (vs. white)2.0 (0.99, 4.2) 0.05 Reconstruction (vs. amputation)5.1 (2.5, 10.1) < < 12 years education (vs. ≥ 12)0.51 (0.24, 1.1) 0.09 Age (years)1.05 (1.01, 1.1) 0.006

Center for Injury Research and Policy Mental Health Services (n=101/181) FactorOR (95% CI) p value Private insurance (vs. public/uninsured)0.56 (0.30, 1.05) 0.07 Non-white (vs. white)2.9 (1.4, 5.9) Reconstruction (vs. amputation)2.4 (1.2, 4.6) < 12 years education (vs. ≥ 12)0.61 (0.30, 1.20) 0.17 Age (years)1.00 (0.98, 1.04) 0.63

Center for Injury Research and Policy Did unmet need make a difference? Unlike physical therapy, unmet need for vocational and mental health services did not appear to predict change in mental health or return to work outcomes It is extremely difficult to overcome indication bias despite accounting for self reported need, patients who receive these services are likely still a lot more severe than patients who did not.

Center for Injury Research and Policy Qualitative data Reasons for not obtaining vocational rehabilitation did not know where to go (28%) unaware services were available (16%) Reasons for not obtaining mental health services thought they would get better on their own (55%) did not know where to go (16%)

Center for Injury Research and Policy Limitations Self reported data (perhaps a strength) Recall of receipt of services Some loss to follow up Indication bias Did participants know what these questions meant?

Center for Injury Research and Policy Conclusions Substantial unmet need for a variety of services following lower extremity trauma Insurance status was a weaker predictor of unmet need than race or age (in the case of vocational services) Reconstruction patients are substantially more likely to have unmet need. Qualitative data suggests patients were not properly informed about these services.