Lower extremity revascularization not effective in majority of nursing home residents

Only a few U.S. nursing home residents who undergo lower extremity revascularization procedures are alive and ambulatory a year after surgery, according to UCSF researchers, and most patients still alive gained little, if any, function.

The study appears in the April 6 issue of JAMA Internal Medicine.

"Our findings can inform conversations among physicians, patients and families about the risks and expected outcomes of surgery and whether the surgery is likely to allow patients to achieve their treatment goals," said senior author Emily Finlayson, MD, MS, associate professor of surgery and geriatrics in the Philip R. Lee Institute for Health Policy Studies at UCSF. "Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care."

Lower extremity peripheral arterial disease is common among nursing home residents, a substantial number of whom also are at risk for critical limb ischemia. Lower extremity revascularization through stents and other devices is frequently performed to preserve functional independence through limb preservation. However, these procedures have an operative risk, and their benefit in maintaining walking ability is debatable.

In this study, researchers led by Finlayson analyzed Medicare claims data for 2005-2008 for nursing home residents nationwide who underwent lower extremity revascularization, with follow up through 2009. Changes were examined in the residents' ambulatory and functional status after surgery. Also identified were patient and surgery characteristics associated with a composite measure of clinical and functional failure, defined as death or nonambulatory status a year after surgery.

The key findings are:

• A total of 10,784 long-term nursing home residents received lower extremity revascularization. The average age was 82 years, and 60 percent had cognitive impairment, 57 percent had congestive heart failure, and 29 percent had renal failure.
• Prior to surgery, of the 10,784 residents, 75 percent were not walking, and 40 percent had decline in overall physical functioning.
• A year after surgery, 51 percent of these patients had died, and among survivors, 28 percent were nonambulatory and 32 percent had decline in overall physical functioning.
• Of the 1,672 residents who were ambulatory before surgery, 63 percent died or now were nonambulatory at one year.
• And among 7,188 patients who were nonambulatory prior to surgery, 89 percent died or remained nonambulatory.

As a result, the researchers learned that in patients undergoing lower extremity revascularization, the outcomes in nursing home residents were substantially worse than has been reported in the general population of the same age. These findings are consistent with previous studies that found individuals who are ambulatory prior to this procedure have better outcomes than those who are nonambulatory, and revascularization rarely allows a patient who is nonambulatory to become ambulatory after surgery.

"Among the treatment options, nonoperative symptom management, local wound care, primary amputation and lower extremity revascularization are associated with different risks, benefits and expected outcomes," Finlayson said. "Our findings should be interpreted cautiously; successful relief of pain, healing of wounds and avoidance of major amputation may benefit some of the patients who underwent lower extremity revascularization in the short term."