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 and director of the UCSF Center for Surgery in Older Adults. “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.”

Other UCSF contributors to the JAMA Internal Medicine study were Michael S. Conte, MD, professor and chief of vascular and endovascular surgery and co-director of the Heart and Vascular Center and Center for Limb Preservation; Kenneth Covinsky, MD, MPH, Edmund G. Brown Distinguished Professorship in Geriatrics at UCSF and San Francisco VA Medical Center geriatrics and palliative medicine service staff physician; Lawrence Oresanya, MD, resident physician of surgery; and Shoujun Zhao, MD, PhD, surgery research specialist. Other contributors were Siqi Gan, MPH, UCLA Fielding School of Public Health; Brant Fries, PhD, Institute of Gerontology and University of Michigan and VA Ann Arbor Healthcare Systems; and Philip Goodney, MD, MS, Dartmouth Geisel School of Medicine, Dartmouth Institute for Health Policy and Clinical Practice, and the VA Outcomes Group.

Funding was provided by the National Institute on Aging/Paul B. Beeson Clinical Scientist Development Award in Aging and the UCSF Claude D. Pepper Older Americans Independence Center.

UCSF is the nation's leading university exclusively focused on health. Now celebrating the 150th anniversary of its founding as a medical college, UCSF is dedicated to transforming health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with world-renowned programs in the biological sciences, a preeminent biomedical research enterprise and top-tier hospitals, UCSF Medical Center and UCSF Benioff Children's Hospitals.