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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