Lower Extremity Revascularization in Nursing Home Residents in the United States
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Lawrence Oresanya MD; Shoujun Zhao MD, PhD; Emily Finlayson MD, MS
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Lower Extremity Revascularization in Nursing Home Residents in the United States
- 1. Lawrence Oresanya MD Lower Extremity Revascularization in 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 Nursing Home Residents in the United States Introduction • 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 Methods/Approach • Usingdata 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) Techniques for Lower Extremity Functional Status after Revascularization Revascularization All residents Non ambulatory 100 100 Improve Improve Improve Improve Improve Improve Improve Improve Percentage (%) Percentage (%) ADL ADL ADL ADL ADL ADL ADL ADL Surgical Bypass Graft Maintain Maintain Maintain Maintain ADL Maintain Maintain Maintain Maintain ADL 80 ADL ADL 80 ADL ADL ADL ADL ADL ADL 60 decline 60 ADL ADL ADL ADL ADL decline decline decline decline ADL decline decline decline 40 40 20 20 Died Died Died Died Died Died Died Died 0 0 3M. 6M. 9M. 12M. Died 3M. 6M. 9M. 12M. Died Bedbound 12 100 Improve Improve Improve Improve Percentage (%) ADL ADL ADL ADL All residents 14 Nonambulatory residents MDS-ADL Score Maintain Maintain Nonambulatory & unable to transfer 80 Maintain Maintain ADL 16 ADL ADL ADL ADL ADL decline 18 60 ADL decline ADL decline 20 decline 40 22 Survival & No-ampulation & No-reintervention Rate (%) 20 24 Died Died Died Died 26 0 0 5 10 3M. 6M. 9M. 12M. Months 100 Endovascular stent (‘minimally invasive’) 80 “Success” at One 60 Year after Surgery 40 20 All residents Nonambulatory residents Nonambulatory & unable to transfer 0 0 2 4 6 8 10 12 Months Conclusions •Alarge 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 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