lower extremity revascularization in nursing home residents in the united states
DESCRIPTION
Lawrence Oresanya MD; Shoujun Zhao MD, PhD; Emily Finlayson MD, MSTRANSCRIPT
• 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