On October 19, the Agency for Healthcare Quality Research (AHRQ) released a draft systematic review of current scientific literature that addressed the use of lower-limb prostheses in the United States. One of the report’s findings was that “there is not evidence to support the selection of specific components for patient subgroups to maximize ambulation, function, and quality of life or to minimize abandonment or limited use.” The American Orthotics & Prosthetics Association (AOPA) released a statement disputing that report’s conclusion, saying, “there is clear evidence, apparently not considered by AHRQ…, to support specific components for patient subgroups for maximizing favorable patient outcomes.”
The Lower Limb Prosthesis Systematic Review (Draft) was conducted to assess the validity of measures used among adults with lower-limb amputation, whether patient characteristics can predict relative effectiveness of various lower-limb prosthetic components, and long-term use of lower-limb prostheses. According to the report, the review found 92 eligible studies that assessed performance characteristics of 61 measures (assessment techniques, prediction tools, and outcome measures). Of these, 29 were validated and found reliable; 19 were generally applicable to the Medicare population, and mostly assessed ambulation and function in lower-limb prostheses users.
Overall, the review determined that the studies did not identify participant’s characteristics that would predict which user would most benefit from a given component (low strength of evidence), whether restricted to validated predictor and outcome measures, assessing all predictors and measures, or based on a multivariable prediction model, according to the review. Two studies provided low-strength evidence that people are satisfied with their encounters with their prosthetists. No eligible study addressed how study participants’ pre-prescription expectations of ambulation align with their functional outcomes. There was moderate strength of evidence that about 11-22 percent of people who receive a lower-limb prosthesis prescription abandon the prosthesis at about one year, and that people with unilateral transfemoral amputations are about twice as likely to abandon their prosthesis than those with unilateral transtibial amputations. There was low strength of evidence that 11-37 percent of recipients use their prostheses only indoors.
AOPA’s response to the draft report focused on omitted research that contradicts AHRQ’s conclusion, including a study by the RAND Corporation, Santa Monica, California, and another by Dobson DaVanzo & Associates, Vienna, Virginia, that specifically studied the clinical and cost effectiveness of the provision of higher technology prosthetic limbs. AOPA noted that it submitted the preliminary findings of those studies before the December 2016 AHRQ deadline for comments, and submitted the final results of both studies seven weeks ago. “It is particularly unfortunate to see a purportedly current literature review be deficient in not reflecting the latest determinative scientific findings,” AOPA said in its announcement.