Few nursing home patients benefit from lower limb revascularization

Research puts the value of lower extremity revascularization in nursing home residents with peripheral artery disease in doubt. Overall, 82 percent of these patients at the one-year mark were nonambulatory or had died.

The cohort of 10,784 elderly nursing home patients who underwent lower extremity revascularization between 2005 and 2009 was derived from two large national data sets: Medicare’s Inpatient Files claims data and the Minimum Data Set for Nursing Homes. First author Lawrence Oresanya, MD, from the University of California, San Francisco, and colleagues noted that comorbid disease was common among these patients and only 25 percent were ambulatory prior to surgery.

Of patients who were previously ambulatory, 63 percent died or were nonambulatory by one year following surgery. Among nonambulatory patients, the rate of death or nonambulatory status by one year after surgery was 89 percent.

Thirty-four percent of patients who were previously ambulatory were nonambulatory a year after surgery. Mortality among ambulatory patients was between 43 and 51 percent at one year.

Of patients who were nonambulatory prior to surgery, 24 percent were ambulatory at one year. Mortality among nonambulatory patients was 53 percent at one year.

Overall, patients experienced a significant decline in their ability to perform daily living tasks, with the most prominent decline in functionality around three months following 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,” wrote Oresanya et al. Clinicians’ reasons for surgery was not a part of either data set, making it was difficult to determine whether the purpose of the surgeries was functional status or palliative care.

An editorial response, William J. Hall, MD, of the University of Rochester School of Medicine in New York, wrote that this and other studies “point the way to a more rational clinical approach to the care of frail elders with limited lifespan but with the prospect of constant pain and discomfort.” Hall called for more research into this field.

“Treatment decisions for elderly, frail patients with critical limb ischemia are complex; shared decision-making is needed,” wrote Oresanya. They added that benefits, risks and expected outcomes needed to be balanced in any decision-making process.

The study appeared online April 6 in JAMA Internal Medicine.