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Functional Outcomes After Lower Extremity Revascularization in Nursing Home Residents | Journal Scan
Study Questions:
What is the functional status trajectory, changes in ambulatory status, and survival after lower extremity revascularization in nursing home patients with peripheral arterial disease (PAD)?
Methods:
Using the full Medicare claims data set from 2005-2009, nursing home residents with PAD who underwent lower extremity revascularization were analyzed. The authors examined changes in the ambulatory and functional status after surgery using the Minimum Data Set for Nursing Homes activities of daily living summary score. They also identified patient and surgical characteristics associated with a composite measure of clinical and functional failure, including death or nonambulatory status 1 year post-surgery.
Results:
Of the 10,784 long-term nursing home residents with PAD who underwent lower extremity revascularization, 75% were not walking and 40% had experienced functional decline prior to surgery. One-year postoperative, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among the 1,672 preoperative ambulatory patients, 63% had died or were nonambulatory at 1-year postoperative. Among the 7,188 preoperative nonambulatory patients, 89% had died or were nonambulatory 1-year postoperative. After multivariable adjustment, death or nonambulatory status was associated with age 80+ years (adjusted hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.16-1.40), cognitive impairment (adjusted HR, 1.23; 95% CI, 1.18-1.29), congestive heart failure (adjusted HR, 1.16; 95% CI, 1.11-1.22), renal failure (adjusted HR, 1.09; 95% CI, 1.04-1.14), emergent surgery (adjusted HR, 1.29; 95% CI, 1.23-1.35), nonambulatory preoperative status (adjusted HR, 1.88; 95% CI, 1.78-1.99), and a decline in activities of daily living preoperatively (adjusted HR, 1.23; 95% CI, 1.18-1.28).
Conclusions:
The authors concluded that the few nursing home residents who undergo lower extremity revascularization were alive and ambulatory 1 year following surgery. They also concluded that most of the patients alive at 1 year following surgery had gained little to no function.
Perspective:
Advanced PAD and critical limb ischemia are significantly morbid and deadly diseases. While therapeutic options have expanded greatly in the past decade, there is little evidence about the utility of these procedures in patients with limited baseline function. This study highlights the poor outcomes among nursing home residents undergoing lower extremity revascularization. Perhaps most striking is that only 25% of patients undergoing revascularization were ambulatory preoperatively. While the limited functional status may be consistent with the advanced mean age of this population (82 years old), understanding the reasons for pursuing revascularization is challenging. Also notable is that one-third of cases were performed urgently or emergently. These data will be valuable for clinicians to discuss with elderly, nonambulatory patients and their families when assessing appropriate therapies that achieve patients’ quality-of-life goals.
Keywords: Activities of Daily Living, Aged, Cognition, Geriatrics, Heart Failure, Lower Extremity, Medicare, Mobility Limitation, Morbidity, Myocardial Revascularization, Nursing Homes, Peripheral Arterial Disease, Peripheral Vascular Diseases, Renal Insufficiency, Walking
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