Lower-extremity revascularization appears to yield poor functional outcomes in nursing home residents

Most nursing home residents who undergo lower-extremity revascularization are unlikely to benefit from it, according to a new study.

Researchers used Medicare claims data from 2005 to 2008 with follow-up to 2009 and linked them to the Minimum Data Set for Nursing Homes (MDS) to examine the effect of lower-extremity revascularization in long-term nursing home residents. MDS assessments are mandatory for all U.S. nursing home facilities that participate in Medicare or Medicaid and are done at nursing home admission, readmission, quarterly, and at change in clinical status. Patients who had had a lower-extremity revascularization procedure in the 2 years before the study period were excluded. The MDS for activities of daily living score was used to determine changes in the 3 main outcome measures: functional status, ambulatory status, and death. The study results were published online April 6 by JAMA Internal Medicine.

Data from 10,784 long-term nursing home residents who had lower-extremity revascularization were included in the study. Patients' mean age was 82.1 years. Sixty-three percent were women, and 80% were white. Sixty percent had cognitive impairment. Seventy-five percent of patients were not ambulatory before the revascularization procedure was performed, and 40% had had functional decline in the 6 months before surgery. At 1 year after the surgery, overall mortality rates were 51% among ambulatory residents and 53% among nonambulatory residents, while 82% of patients had died or were nonambulatory.

Of 1,672 patients who were ambulatory before having surgery, 63% had died or were nonambulatory 1 year afterward. Of 7,188 patients who were nonambulatory before surgery, 89% had died or were nonambulatory at 1 year. In the first 3 months after surgery, 40% of the entire cohort and 56% of surviving patients experienced functional decline compared with before surgery. By 1 year after surgery, 36% of surviving patients had improved or maintained their function and in 64% function had declined. The researchers performed multivariate adjustment and found that age 80 years or older, cognitive impairment, congestive heart failure, renal failure, emergent surgery, nonambulatory status before surgery, and decline in activities of daily living before surgery were all factors independently associated with death or with nonambulatory status after surgery.

The authors noted that detailed information about surgery indications was not available and that they did not know which patients with critical limb ischemia did not have revascularization and instead were treated with palliative amputation or pain control and wound care. However, they concluded that although many nursing home residents in the U.S. have lower-extremity revascularization, few appear to gain much benefit from it and the procedure helps a nonambulatory patient to become ambulatory only rarely. They also noted that while ambulatory function may be a goal of care, it might not be attainable in many cases.

“Treatment decisions for elderly, frail patients with critical limb ischemia are complex; shared decision-making is needed,” the authors wrote. “Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile.”

The author of an accompanying invited commentary called the findings “balanced and valuable” and pointed out that since many of the patients in the study were not walking at surgery, the procedures in these cases were probably performed to relieve symptoms of ischemic leg pain, wounds that were not healing, or worsening gangrene. “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,” the commentary author wrote.

The commentary author also noted that this and other studies could help inform a different approach to caring for frail elderly patients who are experiencing chronic pain and discomfort but whose lifespans are limited. “The best care will be patient and family centered, interdisciplinary, and characterized by communication and determining the goals of care,” the commentary author wrote. “Attention to pain control and other symptoms can reasonably include selective surgical intervention.”