Oresanya Lawrence, Zhao Shoujun, Gan Siqi, Fries Brant E, Goodney Philip P, Covinsky Kenneth E, Conte Michael S, Finlayson Emily
Department of Surgery, University of California, San Francisco.
The Fielding School of Public Health, University of California, Los Angeles.
JAMA Intern Med. 2015 Jun;175(6):951-7. doi: 10.1001/jamainternmed.2015.0486.
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.
To determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents.
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.
All nursing homes in the United States participating in Medicare or Medicaid.
Nursing home residents who underwent lower extremity revascularization.
Functional status, ambulatory status, and death.
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).
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.
下肢血管重建术通常旨在让外周动脉疾病患者保持行走能力，这是功能独立的一个关键方面。对于功能依赖程度高的患者，手术效果尚不清楚。
确定疗养院居民下肢血管重建术后的功能状态轨迹、步行状态变化及生存率。
利用2005年至2009年完整的医疗保险索赔数据，我们确定了接受下肢血管重建术的疗养院居民。通过疗养院日常生活活动最小数据集汇总评分，我们检查了他们术后步行和功能状态的变化。我们确定了与术后1年临床和功能衰竭综合指标（死亡或非步行状态）相关的患者和手术特征。
美国所有参与医疗保险或医疗补助计划的疗养院。
接受下肢血管重建术的疗养院居民。
功能状态、步行状态和死亡情况。
在研究期间，10784名长期疗养院居民接受了下肢血管重建术。术前，75%的居民无法行走；40%经历了功能衰退。术后1年，51%的患者死亡，28%无法行走，32%持续出现功能衰退。在术前能够行走的1672名居民中，63%在1年后死亡或无法行走；在术前无法行走的7188名居民中，89%死亡或无法行走。多变量调整后，与死亡或非步行状态独立相关的因素包括80岁及以上（调整后风险比[AHR]，1.28；95%置信区间[CI]，1.16 - 1.40）、认知障碍（AHR，1.23；95% CI，1.18 - 1.29）、充血性心力衰竭（AHR，1.16；95% CI，1.11 - 1.22）、肾衰竭（AHR，1.09；95% CI，1.04 - 1.14）、急诊手术（AHR，1.29；95% CI，1.23 - 1.35）、术前非步行状态（AHR，1.88；95% CI，1.78 - 1.99）以及术前日常生活活动能力下降（AHR，1.23；95% CI，1.18 - 1.28）。
在美国接受下肢血管重建术 的疗养院居民中，术后1年仍存活且能行走的寥寥无几。大多数存活者即便有功能改善，也微乎其微。
