lower extremity revascularization in nursing home residents in the united states

• For patients with peripheral arterial disease (PAD), the main goals of lower extremity revascularization (LER) are to prevent limb loss and allow patients to maintain functional independence• Prior studies suggest that patients who are non-ambulatory and functionally dependent have poor outcomes•Outcomes after lower extremity revascularization in the frailest elders – nursing home residents – are poorly understood

Lower Extremity Revascularization in Nursing Home Residents in the United States

• A large number of nursing home residents with relative contraindications to revascularization (non-ambulatory/bedbound) are undergoing lower extremity revascularization in the United States

• Only a small proportion of nursing home residents appear to maintain or improve function after revascularization

• Policies and interventions aimed at improving patient selection are needed to guide use of this potentially morbid and resource intensive intervention in this vulnerable population

Lawrence Oresanya MD Shoujun Zhao MD, PhD

Emily Finlayson MD, MS Phillip R Lee Institute for Health Policy Studies

Department of Surgery, University of California San Francisco, San Francisco CA

Introduction

Methods/Approach• Using data from a national registry of nursing home residents (Minimum Data Set for Nursing Homes (MDS)) and Medicare claims, we identified all nursing home residents who underwent lower extremity revascularization procedures in the United States between 2005 and 2008 (n=10809)• Based on registry data, patients were classified as ambulatory, non-ambulatory (63%) and bed bound (27%)and functional status assessed with the MDS-ADL score• We examined functional trajectories before and after surgery using cubic spline trajectory modeling techniques•The intervention was considered a ‘success’ at 1 year if the resident was alive and had no lower extremity complications (re-intervention and/or above ankle amputation)

Functional Status after Revascularization

ACKNOWLEDGEMENTS:Funding for this project was provided by the Paul Beeson Career Development Award In Aging Research and the Philip R. Lee Post-Doctoral Fellowship in Health Policy

Conclusions

“Success” at One Year after Surgery

0 5 10

26

24

22

20

18

16

14

12

Months

MD

S-A

DL

Sco

re

All residents

Nonambulatory residents

Nonambulatory & unable to transfer

0 2 4 6 8 10 12

02

04

06

08

01

00

Months

Su

rviv

al &

No

-am

pu

latio

n &

No

-re

inte

rve

ntio

n R

ate

(%

)

All residents

Nonambulatory residents

Nonambulatory & unable to transfer

3M. 6M. 9M. 12M.

All residents

Perc

enta

ge (

%)

020

40

60

80

100

3M. 6M. 9M. 12M.

Non ambulatoryP

erc

enta

ge (

%)

020

40

60

80

100

3M. 6M. 9M. 12M.

Bedbound

Perc

enta

ge (

%)

020

40

60

80

100

Techniques for Lower Extremity Revascularization

Surgical Bypass Graft

Endovascular stent (‘minimally invasive’)

DiedDiedDied Died

ADL decline

ADL decline

Died

Died

ADL decline

ADL decline

MaintainADL

MaintainADL

MaintainADL

MaintainADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

ImproveADL

MaintainADL

MaintainADL

MaintainADL

MaintainADL

MaintainADL

MaintainADL

MaintainADL

MaintainADL

ADL declineADL

declineADL

decline

ADL decline

ADL declineADL

declineADL

decline

ADL decline

DiedDiedDied Died

Died DiedDied Died