Outcomes of Lower Extremity Revascularization in Nursing Home Patients Studied

April 6, 2015—A national cohort study that sought to determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents in the United States between 2005 and 2009 found that few of the patients are alive and ambulatory 1 year after treatment, and most of those who were still alive had gained little, if any, function. The study by Lawrence Oresanya, MD, et al is available online in the Journal of the American Medical Association (JAMA): Internal Medicine.

As detailed in JAMA: Internal Medicine, the investigators used full Medicare claims data for 2005 to 2009 from all nursing homes participating in Medicare or Medicaid to identify nursing home residents who underwent lower extremity revascularization. With the Minimum Data Set for Nursing Homes Activities of Daily Living (MDS-ADL) summary score, changes in their ambulatory and functional status after surgery were examined. The investigators identified patient and surgery characteristics associated with a composite measure of clinical and functional failure—death or nonambulatory status 1 year after surgery.

Between 2005 and 2008, 10,784 nursing home residents underwent lower extremity revascularization. Revascularization was performed electively in 67% of cases, and > 50% of all procedures were performed using an endovascular approach. 

The patients’ mean age was 82 years; 37% were men, and 80% were white. Comorbid disease was common: 60% had cognitive impairment, 57% had congestive heart failure, and 29% had renal failure. 

Before treatment, 75% of patients were nonambulatory. The mean baseline MDS-ADL score was 14.5, indicating a high level of preoperative functional dependence. A substantial proportion of residents (40%) had experienced functional decline in the 6 months before treatment.

At 1 year after treatment, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among 1,672 residents who were ambulatory before surgery, 63% had died or were nonambulatory at 1 year. Of the 7,188 who were nonambulatory, 89% had died or were nonambulatory. After multivariate adjustment, factors independently associated with death or nonambulatory status were age ≥ 80 years, cognitive impairment, congestive heart failure, renal failure, emergent surgery, nonambulatory status before surgery, and decline in activities of daily living before surgery, reported the investigators in JAMA: Internal Medicine.

In an accompanying commentary in JAMA: Internal Medicine, William J. Hall, MD, noted that most of the procedures in the study were probably performed for relief of symptoms secondary to ischemic leg pain, nonhealing wounds, or worsening gangrene and that, in this context, lower extremity revascularization should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend life or ambulatory function.

Dr. Hall noted that the study identified a large contemporary cohort of long-stay nursing home residents with low functional status, mostly nonambulatory and with severe dementia. Although the surgical interventions often did not restore function, they may have greatly enhanced the patients’ comfort and reduced their pain.

According to Dr. Hall, this study suggests a more rational clinical approach to the care of frail elders with limited lifespan but with the prospect of constant pain and discomfort. He encouraged continued studies such as this one with large data sets that can allow the delineation of the natural history of disease progression among nursing home residents and facilitate more informed decision about procedures and therapies.

Dr. Hall stated, “The best care will be patient- and family-centered, interdisciplinary, and characterized by communication and determining the goals of care. Attention to pain control and other symptoms can reasonably include selective surgical intervention. Systems of care are being developed primarily at academic medical centers that feature formal comanagement of frail elders on both medical and surgical services.”