Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study

Abstract

Importance: Lower extremity revascularization often seeks to allow patients with peripheral arterial disease to maintain the ability to walk, a key aspect of functional independence. Surgical outcomes in patients with high levels of functional dependence are poorly understood.

Objective: To determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents.

Design: Using full Medicare claims data for 2005 to 2009, we identified nursing home residents who underwent lower extremity revascularization. With the Minimum Data Set for Nursing Homes activities of daily living summary score, we examined changes in their ambulatory and functional status after surgery. We identified patient and surgery characteristics associated with a composite measure of clinical and functional failure-death or nonambulatory status 1 year after surgery.

Setting: All nursing homes in the United States participating in Medicare or Medicaid.

Participants: Nursing home residents who underwent lower extremity revascularization.

Main outcomes and measures: Functional status, ambulatory status, and death.

Results: During the study period, 10,784 long-term nursing home residents underwent lower extremity revascularization. Prior to surgery, 75% of the residents were not walking; 40% had experienced functional decline. One year after surgery, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among 1672 residents who were ambulatory before surgery, 63% had died or were nonambulatory at 1 year; among 7188 who were nonambulatory, 89% had died or were nonambulatory. After multivariate adjustment, factors independently associated with death or nonambulatory status were 80 years or older (adjusted hazard ratio [AHR], 1.28; 95% CI, 1.16-1.40), cognitive impairment (AHR, 1.23; 95% CI, 1.18-1.29), congestive heart failure (AHR, 1.16; 95% CI, 1.11-1.22), renal failure (AHR, 1.09; 95% CI, 1.04-1.14), emergent surgery (AHR, 1.29; 95% CI, 1.23-1.35), nonambulatory status before surgery (AHR, 1.88; 95% CI, 1.78-1.99), and decline in activities of daily living before surgery (AHR, 1.23; 95% CI, 1.18-1.28).

Conclusions and relevance: Of nursing home residents in the United States who undergo lower extremity revascularization, few are alive and ambulatory 1 year after surgery. Most who were still alive had gained little, if any, function.

Figure 1

Mortality After Surgery, Stratified by Ambulatory Status

Figure 2

The Proportion of Residents Who Died, Had Activities of Daily Living (ADL) Score Decline, Maintained ADL Score, or Had ADL Improvement Over Time Functional status was measured using Minimum Data Set for Nursing Homes assessments of self-performance of ADLs. Residents were classified as having functional decline if they had a 2-point or greater increase in their MDS-ADL score, maintenance of functional status was defined as no change or a 1-point change (positive or negative), and improvement in functional status was defined as a 2-point or greater decrease in the MDS-ADL score.