Lower-Extremity Revascularization Confers Little Benefit for Nursing Home Patients

The majority of elderly nursing home patients who undergo surgical or endovascular revascularization for lower-extremity PAD are unlikely to have improvements in function, and a high percentage will become nonambulatory, die, or both within a year, according to a study published online April 6, 2015, ahead of print in JAMA Internal Medicine.Lower-Extremity Revascularization Confers Little Benefit for Nursing Home Patients

“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,” write Emily Finlayson, MD, MS, of University of California, San Francisco (San Francisco, CA), and colleagues.

Using Medicare claims data, they identified 10,784 elderly nursing home residents (mean age 82.1 years; 37% male) who underwent lower-extremity revascularization in the United States between 2005 and 2008, with follow-up available through 2009. In all, 67.3% of procedures were elective. Revascularization was open surgery in 44.3% and endovascular therapy in 55.7%.

Three-quarters of patients (75.2%) were nonambulatory (defined as requiring extensive assistance or total dependence to walk or being unable to walk at all), 59.6% had cognitive impairment, and 40% had experienced functional decline in the 6 months prior to revascularization. Additionally, mean baseline Minimum Data Set Activities of Daily Living (MDS-ADL) impairment score was 14.5, indicating a high level of prerevascularization functional dependence.  

High Mortality, Little Functional Gain

At 1 year after treatment, 51% of patients had died and 82% had either died or were nonambulatory. Compared with patients who were ambulatory before revascularization, those who were nonambulatory were more likely to be dead/nonambulatory at 1 year (89% vs 63%). Multivariate analysis identified preoperative ambulatory status as the factor most strongly associated with death or nonambulatory status at 1 year (HR 1.88; 95% CI 1.78-1.99). However, compared with open surgery, patients who underwent endovascular procedures had a lower likelihood of this measure of clinical failure (HR 0.88; 95% CI 0.85-0.92).

Among patients alive at 1 year, 34% who had been ambulatory at baseline were nonambulatory, and 24% who were nonambulatory at baseline were ambulatory.

Revascularization resulted in a mean MDS-ADL score increase of 2.2 points (from 14.5 to 16.7) at 1 year, representing a clinically significant decline in function. The first 3 months after intervention saw the greatest functional decline.

Clarifying the Primary Goal

While other studies have demonstrated improvements in functional status and low mortality rates among older patients with lower-extremity PAD, Dr. Finlayson and colleagues note that many of them “examined outcomes in a group of selected older adults” undergoing treatment at a single institution and employed many exclusion criteria. The current study, on the other hand, involved a population-based cohort of nursing home residents who underwent revascularization across a variety of hospitals.

“Our findings are consistent with those of previous studies that found that individuals who are ambulatory prior to lower-extremity revascularization have better outcomes that those who are nonambulatory and that revascularization only rarely allows a patient who is nonambulatory to become ambulatory postoperatively,” they write. “It is unclear whether the poor outcomes were a result of revascularization per se or the insufficient physiologic reserve of many of the patients who underwent the procedure.”

Dr. Finlayson and colleagues say their findings “highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function, although clearly an important goal, may not be the primary objective of treatment and may be impossible to attain.”

Revascularization as Palliation

In an accompanying editorial, William J. Hall, MD, of the University of Rochester School of Medicine (Rochester, NY), notes that there is little information in national PAD guidelines that specifically addresses the use of lower-extremity revascularization in nursing home residents.

While the authors lacked details on the indications for revascularization, Dr. Hall suggests that most “were probably performed for relief of symptoms secondary to ischemic leg pain, nonhealing wounds, or worsening gangrene.” For these reasons, he says such revascularization “should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend life or ambulatory function.”

According to Dr. Hall, the presence of dementia, symptomatic lower-extremity arterial disease, hip fracture, or other clinical “trigger factors” all signal the need for a palliative approach to care.

“The best care will be patient and family centered, interdisciplinary, and characterized by communication and determining the goals of care,” he says. “Attention to pain control and other symptoms can reasonably include selective surgical intervention.”

 


Sources:

1. Oresanya L, Zhao S, Gan S, et al. Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study. JAMA Intern Med. 2015;Epub ahead of print.

2.Hall WJ. Lower extremity revascularization in nursing home residents: surgery as palliation [editorial]. JAMA Intern Med. 2015;Epub ahead of print.

 

Disclosures:

Dr. Finlayson was supported by a National Institute on Aging/Paul B. Beeson Clinical Scientist Development Award in Aging and the University of California San Francisco Claude D. Pepper Older Americans Independence Center.

Dr. Hall reports no relevant conflicts of interest.

 

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