We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Functional Outcomes After Lower Extremity Revascularization in Nursing Home Residents A National Cohort Study

Lawrence Oresanya, MD1; Shoujun Zhao, MD, PhD1; Siqi Gan, MPH2; Brant E. Fries, PhD3; Philip P. Goodney, MD, MS4,5,6; Kenneth E. Covinsky, MD, MPH7,8; Michael S. Conte, MD1; Emily Finlayson, MD, MS1,7,9
[+] Author Affiliations
1Department of Surgery, University of California, San Francisco
2The Fielding School of Public Health, University of California, Los Angeles
3Institute of Gerontology and University of Michigan and VA Ann Arbor Healthcare Systems, Ann Arbor
4Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
5The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
6The VA Outcomes Group, White River Junction, Vermont
7Division of Geriatrics, University of California, San Francisco
8San Francisco Veterans Affairs Medical Center, San Francisco, California
9The Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
JAMA Intern Med. 2015;175(6):951-957. doi:10.1001/jamainternmed.2015.0486.
Text Size: A A A
Published online

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.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Place holder to copy figure label and caption
Figure 1.
Mortality After Surgery, Stratified by Ambulatory Status
Graphic Jump Location
Place holder to copy figure label and caption
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.

Graphic Jump Location





You need to register in order to view this quiz.
Submit a Comment
what about skin conditions from the MDS?
Posted on June 3, 2015
Kathryn Locatell, MD
Conflict of Interest: None Declared
Since the authors had access to the Minimum Data Sets for the study population I'm surprised they didn't include information about the population's skin conditions in the analysis. Section M would have provided valuable information about the presence/absence of arterial ulcers as well as pressure ulcers, although granted the MDS does not include the location of these conditions.In my experience as a forensic geriatrician, nursing home medical director and nursing home attending physician, lower extremity wounds constitute THE primary reason for a revascularization procedure in this population. It would have been interesting to see whether the wounds improved or healed after the procedure in the subsequent serial MDSs. Providing the procedure as palliation to promote wound healing might well be a quality of life-enhancing indication, but if the procedure made the resident worse overall and did nothing to heal the wound then it would represent another illustration that the procedure provided no benefit.
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

3 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Related Multimedia

Author Interview

audio player

Articles Related By Topic
Related Collections

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Peripheral Arterial Disease

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Make the Diagnosis: Peripheral Arterial Disease