Many nursing home residents who underwent lower extremity revascularization died, did not walk or had functional decline following the procedure, which is commonly used to treat leg pain caused by peripheral arterial disease, wounds that will not heal or worsening gangrene, according to an article published online by JAMA Internal Medicine.
Lower extremity revascularization is often performed so patients with peripheral arterial disease can maintain the ability to walk, which is a key component of functional independence. But outcomes among patients with high levels of functional dependence, such as nursing home residents, are poorly understood, according to background in the study.
Emily Finlayson, M.D., M.S., of the University of California, San Francisco, and coauthors used Medicare claims data for 2005 to 2009 to identify nursing home residents who underwent lower extremity revascularization.
The authors identified 10,784 long-term nursing home residents (37 percent were men, average age 82) who underwent the procedure, which was performed electively in 67 percent of the cases.
Before surgery, 75 percent of the nursing home residents were not walking and 40 percent had experienced functional decline. At one year after surgery, 51 percent of the patients had died, 28 percent were not walking and 32 percent had sustained functional decline, according to the results.
Patients who were walking before surgery did not fare well after the procedure: among 1,672 nursing home residents who were ambulatory before surgery, 63 percent died or were nonambulatory at one year. Among the 7,188 patients who were nonambulatory before surgery, 89 percent had died or were nonambulatory at one year, according to the results.
Among nursing home residents who were alive one year after surgery, 34 percent who were ambulatory before surgery became nonambulatory and 24 percent who were nonambulatory at baseline became ambulatory, results indicate.
Analyses by the authors showed that dying or being nonambulatory was associated with factors such as being 80 years or older, cognitive impairment, congestive heart failure, renal (kidney) failure, emergency surgery, not walking before surgery and a decline in activities of daily living before surgery.
"We found that a substantial number of nursing home residents in the United States undergo lower extremity revascularization, and many gain little, if any, function. The mortality rate, however, is high, with half of residents dying within a year of surgery. .. . Ambulatory function, although clearly an important goal, may not be the primary objective of treatment and may be impossible to attain. Nonambulatory patients with refractory ischemic rest pain, wounds that do not heal despite months of nursing care, or worsening gangrene seek palliation for the relief of symptoms. ... Thus, 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," the study concludes.
Commentary: Surgery as Palliation
In a related commentary, William J. Hall, M.D., M.A.C.P., of the University of Rochester School of Medicine, Rochester, N.Y., writes: "In short, lower extremity revascularization was relatively ineffective in terms of preserving or enhancing the functional state or the ability to walk of nursing home residents and was associated with a high likelihood of dying within 12 months."
"Most of these nursing home residents were not walking to begin with: thus it is unlikely that claudication was a primary indication for lower extremity revascularization. Rather, most of the procedures were probably performed for relief of symptoms secondary to ischemic leg pain, nonhealing wounds 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," Hall concludes.