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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 an online report 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 lower-extremity revascularization 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,” according to the investigators.
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.
The recent study by Oresanya et al. is very controversial, especially in light of the recent NY Times article suggesting too many inappropriate procedures are occurring for PAD. However, the study must be looked at in context. This is a database study, which, as such, has inherent limitations. The authors admit they had no data on pain, wound healing, or avoidance of major amputations. Fully one-third of the cases in this study were urgent/emergent, again suggesting the critical nature of impaired perfusion in these patients. The only outcomes assessed were mortality and functional status. Seventy-five percent of the patients were already nonambulatory, again suggesting that the indications for intervention were likely critical limb ischemia. If this is correct, as the authors have also assumed, then the issue is not one of mortality or improving functional status, but rather one of limb salvage, and pain control – issues of quality of life. Further, the finding of endovascular cases being more successful suggests that the endovascular first approach is clearly appropriate in this debilitated population.
It is, unfortunately, not possible from this type of database study to ascertain whether the patients treated with open bypass were candidates for endovascular interventions, or had already failed an endovascular approach. It is also not possible to determine whether “success” was achieved, with pain relief, avoidance of major limb amputation with the inherent increased mortality risk, and wound healing.
However, what we can glean from this study is information to better counsel patients and families regarding functional status and life expectancy, as some families and patients have unrealistic expectations and push surgeons to intervene, despite initial attempts at counseling. Having additional data may allow surgeons to correctly convince some patients, whose pain is controlled and tissue loss is not immediately life or limb threatening, that because of limited life expectancy, medical management alone may be appropriate. This study, like most database studies, should lead to further evaluation in a situation in which clinical outcomes may be better assessed, such as a study of the Vascular Quality Initiative database, which does collect this type of information.
Dr. Linda Harris is professor of surgery and chief, division vascular surgery, University at Buffalo, State University of New York, and an associate medical editor for Vascular Specialist.
The recent study by Oresanya et al. is very controversial, especially in light of the recent NY Times article suggesting too many inappropriate procedures are occurring for PAD. However, the study must be looked at in context. This is a database study, which, as such, has inherent limitations. The authors admit they had no data on pain, wound healing, or avoidance of major amputations. Fully one-third of the cases in this study were urgent/emergent, again suggesting the critical nature of impaired perfusion in these patients. The only outcomes assessed were mortality and functional status. Seventy-five percent of the patients were already nonambulatory, again suggesting that the indications for intervention were likely critical limb ischemia. If this is correct, as the authors have also assumed, then the issue is not one of mortality or improving functional status, but rather one of limb salvage, and pain control – issues of quality of life. Further, the finding of endovascular cases being more successful suggests that the endovascular first approach is clearly appropriate in this debilitated population.
It is, unfortunately, not possible from this type of database study to ascertain whether the patients treated with open bypass were candidates for endovascular interventions, or had already failed an endovascular approach. It is also not possible to determine whether “success” was achieved, with pain relief, avoidance of major limb amputation with the inherent increased mortality risk, and wound healing.
However, what we can glean from this study is information to better counsel patients and families regarding functional status and life expectancy, as some families and patients have unrealistic expectations and push surgeons to intervene, despite initial attempts at counseling. Having additional data may allow surgeons to correctly convince some patients, whose pain is controlled and tissue loss is not immediately life or limb threatening, that because of limited life expectancy, medical management alone may be appropriate. This study, like most database studies, should lead to further evaluation in a situation in which clinical outcomes may be better assessed, such as a study of the Vascular Quality Initiative database, which does collect this type of information.
Dr. Linda Harris is professor of surgery and chief, division vascular surgery, University at Buffalo, State University of New York, and an associate medical editor for Vascular Specialist.
The recent study by Oresanya et al. is very controversial, especially in light of the recent NY Times article suggesting too many inappropriate procedures are occurring for PAD. However, the study must be looked at in context. This is a database study, which, as such, has inherent limitations. The authors admit they had no data on pain, wound healing, or avoidance of major amputations. Fully one-third of the cases in this study were urgent/emergent, again suggesting the critical nature of impaired perfusion in these patients. The only outcomes assessed were mortality and functional status. Seventy-five percent of the patients were already nonambulatory, again suggesting that the indications for intervention were likely critical limb ischemia. If this is correct, as the authors have also assumed, then the issue is not one of mortality or improving functional status, but rather one of limb salvage, and pain control – issues of quality of life. Further, the finding of endovascular cases being more successful suggests that the endovascular first approach is clearly appropriate in this debilitated population.
It is, unfortunately, not possible from this type of database study to ascertain whether the patients treated with open bypass were candidates for endovascular interventions, or had already failed an endovascular approach. It is also not possible to determine whether “success” was achieved, with pain relief, avoidance of major limb amputation with the inherent increased mortality risk, and wound healing.
However, what we can glean from this study is information to better counsel patients and families regarding functional status and life expectancy, as some families and patients have unrealistic expectations and push surgeons to intervene, despite initial attempts at counseling. Having additional data may allow surgeons to correctly convince some patients, whose pain is controlled and tissue loss is not immediately life or limb threatening, that because of limited life expectancy, medical management alone may be appropriate. This study, like most database studies, should lead to further evaluation in a situation in which clinical outcomes may be better assessed, such as a study of the Vascular Quality Initiative database, which does collect this type of information.
Dr. Linda Harris is professor of surgery and chief, division vascular surgery, University at Buffalo, State University of New York, and an associate medical editor for Vascular Specialist.
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 an online report 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 lower-extremity revascularization 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,” according to the investigators.
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.
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 an online report 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 lower-extremity revascularization 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,” according to the investigators.
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.