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Nursing home residents have poor outcomes after lower-extremity revascularization

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This revascularization palliative, not therapeutic

The findings of Oresanya et al. are balanced and valuable, even though the data didn’t give them specific clinical information such as the indications for revascularization and were insensitive to subtle issues such as patient and family wishes for level of care. Such studies point the way to a more rational clinical approach to the care of frail elders with a limited life span but with the prospect of constant pain and discomfort.

But it is important to note that most of the procedures in this study likely were performed to relieve symptoms of ischemic leg pain, nonhealing wounds, or worsening gangrene. In this setting, the surgery should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend ambulatory function.

William J. Hall, M.D., is at the University of Rochester, New York. He reported having no relevant financial disclosures. Dr. Hall made these remarks in an invited commentary accompanying Dr. Oresanya’s report (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.32]).


 

FROM JAMA INTERNAL MEDICINE

References

A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.

In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.

“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. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.

Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.

Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.

The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.

The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.

One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).

The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”

They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.

The authors reported having no relevant financial disclosures.

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