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

Quantification of the Survival Disadvantage Associated with Major Amputation in Patients with Peripheral Arterial Disease

Objective: Despite advancements in vascular surgery, the mortality among peripheral arterial disease (PAD) patients undergoing major amputations remains high. While a large body of evidence has previously covered survival rates after major amputation, there is less evidence regarding the associated survival penalty from an epidemiological perspective. The present analysis aimed at quantifying the survival disadvantage after major lower limb amputation while investigating which factors are associated with mortality in this patient cohort. Methods: Data from 246 PAD patients undergoing major amputations were retrospectively collected and matched with mortality records from the Austrian National Death Registry. Life expectancy was estimated using population-based life tables, and differences between observed and expected survival were analyzed across subgroups. Results: The median follow-up was 492 days (Q1-Q3: 73-1438), and 82.5% (n = 203) of patients died, with cardiovascular events being the leading cause (41%). A profound discrepancy between estimated (4697 days, Q1-Q3: 2962-6236) and observed survival (457 days, Q1-Q3: 73-1438, p < 0.001) was seen. In men, an associated median survival penalty of 11.2 years was observed, equivalent to a proportionate reduction in life expectancy of over 90%, while the difference in women was 8.7 years, equaling a reduction of 84.6%. In a multiple regression model, 1 year in life expectancy was associated with a survival penalty of -0.96 years, thereby affecting younger patients with the highest life expectancies the most. Conclusions: Major amputation in PAD patients is associated with a significant reduction in survival compared to standardized mortality rates in the general population. The survival disadvantage exceeds 70% of estimated survival times in over 70% of patients. Elevated mortality rates after major amputation in PAD patients should not be interpreted as a causal relationship but as a surrogate for impaired systemic cardiovascular health.

Primary care follow-up improves outcomes in older adults following emergency general surgery admission

BACKGROUND

While preoperative optimization improves outcomes for older adults undergoing major elective surgery, no such optimization is possible in the emergent setting. Surgeons must identify postoperative interventions to improve outcomes among older emergency general surgery (EGS) patients. The objective of this cohort study was to examine the association between early follow-up with a primary care physician (PCP) and the risk of nursing home acceptance or death in the year following EGS admission among older adults.

METHODS

Using population-based administrative health data in Ontario, Canada (2006-2016), we followed all older adults (65 years or older) for 1 year after hospital admission for EGS conditions. A multivariable Cox model was used to identify the association between early postdischarge follow-up with a patient's PCP and the time to nursing home acceptance or death while adjusting for confounders.

RESULTS

Among 76,568 older EGS patients, 32,087 (41.9%) were seen by their usual PCP within 14 days of discharge, and 9,571 (12.5%) were accepted to a nursing home or died within 1 year. Primary care physician follow-up was associated with a 13% reduced risk of nursing home acceptance or death compared with no follow-up (hazard ratio 0.87; 95% confidence interval 0.84-0.91). This effect was consistent across age and frailty strata, patients managed operatively and nonoperatively, and patients who had both high and low baseline continuity of care with their PCP.

CONCLUSION

Early follow-up with a familiar PCP was associated with a reduced risk of nursing home acceptance or death among older adults following EGS admission. Structures and processes of care are needed to ensure that such follow-up is routinely arranged at discharge.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Analysis of in-hospital deaths in patients with critical limb ischemia necessitating invasive treatments: based on a Japanese nationwide database

Critical limb ischemia (CLI) is associated with systemic cardiovascular and non-cardiovascular diseases. Treatments primarily targeting limb-related outcomes may not improve overall life prognosis. We aimed to describe in-hospital mortality and the underlying etiologies in Japanese patients with CLI. We analyzed the Diagnosis Procedure Combination (DPC) database from approximately 1200 Japanese acute-care hospitals between April 2018 and March 2020. The definition of patients with CLI was based on the diagnostic codes listed as the most resource-intensive diagnosis and information regarding invasive procedures (endovascular treatment, bypass, or amputation). The DPC database provides information on whether in-hospital death was caused by the most resource-intensive diagnosis. Among 15,228 distinct patients with CLI, we identified 18,970 records, including 5,378 amputations. In-hospital death occurred in 1238 (6.5%) patients. Among them, 811 (65.5%) were due to causes unrelated to CLI. In patients who underwent amputation (n = 5378), causes unrelated to CLI accounted for 70.0% of in-hospital deaths, whereas among patients who did not undergo amputation (n = 13,592), this proportion was 60.1%. When compared to patients who died due to causes related to CLI, the prevalence of male patients was higher (62.6% vs 52.7%, p = 0.001), and amputation was more frequently performed (58.0% vs 47.1%, p < 0.001) in those who died due to causes unrelated to CLI. The majority of in-hospital deaths among patients with CLI necessitating endovascular treatment, bypass, or amputation were attributable to factors unrelated to the primary condition of CLI. Managing systemic cardiovascular and non-cardiovascular diseases beyond the affected limb is crucial to improve the prognosis of these patients.

Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease

BACKGROUND

Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there are little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized.

METHODS

Cognitive impairment screening was prospectively performed for veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment.

RESULTS

Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, P = 0.03), Black versus White race (94% vs. 54%, P < 0.01), hypertension (66% vs. 31%, P = 0.01), prior stroke/TIA (79% vs. 58%, P = 0.03), diabetes treated with insulin (79% vs. 58%, P = 0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, P = 0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥70 years, diabetes treated with insulin, PTSD, and Black race.

CONCLUSIONS

Many veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.

Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study

BACKGROUND

Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement.

METHODS

We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models.

RESULTS

From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores.

CONCLUSIONS

Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.

Long-term survival in high-risk older adults following emergency general surgery admission

BACKGROUND

Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions.

METHODS

We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups.

RESULTS

A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation.

CONCLUSION

Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients.

LEVEL OF EVIDENCE

Epidemiological, level III.

An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults

BACKGROUND

Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution.

METHODS

This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night.

RESULTS

During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline.

CONCLUSIONS

A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.

The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.

Factors Associated With Functional Recovery Among Older Survivors of Major Surgery

OBJECTIVE

The objectives of the current study were 2-fold: first, to evaluate the incidence and time to recovery of premorbid function within 6 months of major surgery and second, to identify factors associated with functional recovery among older persons who survive a major surgery with increased disability.

BACKGROUND

Most older persons would not choose a surgical treatment resulting in persistently increased postsurgical disability, even if survival was assured. Potential predictors of functional recovery after major surgery have, however, not been well-studied among geriatric patients.

METHODS

It is a prospective longitudinal study of 754 community-living persons 70 years or older. The analytic sample included 266 person-admissions in which participants survived major surgery with increased disability and were monitored on a monthly basis for 6 months.

RESULTS

Of the 266 person-admissions assessed, 174 (65.4%) recovered to their presurgical level of function, with median time to recovery of 2 months (interquartile range, 1-3), whereas 16 (6.0%) died. Two factors were significantly associated with an increased likelihood of functional recovery: being nonfrail (hazard ratio 1.60; 95% confidence interval 1.03-2.51; P = 0.038) and having elective surgery (hazard ratio 1.72; 95% confidence interval 1.14-2.59; P = 0.009). Three factors were associated with a reduced likelihood of functional recovery: hearing impairment, greater increase in postsurgical disability in the month after hospital discharge, and years of education.

CONCLUSIONS

Among older persons, nonfrailty and elective surgery were positively associated with functional recovery, whereas hearing impairment, greater increases in postsurgical disability, and years of education were associated with higher risk of protracted disability.

Limb Salvage in Patients With Severe Critical Limb Ischemia (CLI) After Referral for a Second Opinion to a Dedicated CLI Center

The complexity of critical limb ischemia (CLI) requires dedicated multidisciplinary teams of different care providers, who will supervise the full cycle of CLI care. Until CLI treatment is fully centralized, such dedicated teams may work as second-opinion tools before major amputation is undertaken in CLI patients. The aim of the study is to assess the effectiveness of a well-timed referral to a dedicated CLI-center of patients scheduled to major amputation elsewhere. A retrospective analysis of all CLI-patients treated in our department between January 2019 and March 2020 was conducted. Only patients scheduled for a major amputation elsewhere and referred to our clinic were included. Primary endpoint was amputation-free survival, whereas technical success, limb salvage, minor amputation rate, re-admission at 30 days, and frequency of medication change from other disciplines were the secondary endpoints. Sixteen patients with 19 treated limbs were identified and included in this analysis. The WIfI (wound, infection and foot ischemia) clinical stage on admission was 2 in 4 limbs (21%), 3 in 5 limbs (26%), and 4 in 10 limbs (53%). All patients underwent advanced endovascular revascularization. Minor amputation was performed in 8 patients (42%). Amputation-free survival at 6 months was 93% with limb salvage rate of 100%. Technical success and re-admission rates at 30 days was 95% and 6%, respectively. There was a medication adjustment from other specialties in 13 (81%) patients. Patients in severe stages of CLI scheduled to major amputation reached high limb salvage and survival rate, since they are referred for a second opinion to a dedicated multidisciplinary CLI team.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

Defining Serious Illness Among Adult Surgical Patients

CONTEXT

Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context.

OBJECTIVES

The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts.

METHODS

We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement.

RESULTS

All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V.

CONCLUSION

We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.

Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents

Importance

Breast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood.

Objective

To assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type.

Design, Setting, and Participants

This study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018.

Main Outcomes and Measures

Functional status and death.

Results

From 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups.

Conclusions and Relevance

For female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.

Postoperative Delirium as a Target for Surgical Quality Improvement

OBJECTIVE

To explore hospital-level variation in postoperative delirium using a multi-institutional data source.

BACKGROUND

Postoperative delirium is closely related to serious morbidity, disability, and death in older adults. Yet, surgeons and hospitals rarely measure delirium rates, which limits quality improvement efforts.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot (2014 to 2015) collects geriatric-specific variables, including postoperative delirium using a standardized definition. Hierarchical logistic regression models, adjusted for case mix [Current Procedural Terminology (CPT) code] and patient risk factors, yielded risk-adjusted and smoothed odds ratios (ORs) for hospital performance. Model performance was assessed with Hosmer-Lemeshow (HL) statistic and c-statistics, and compared across surgical specialties.

RESULTS

Twenty thousand two hundred twelve older adults (≥65 years) underwent inpatient operations at 30 hospitals. Postoperative delirium occurred in 2427 patients (12.0%) with variation across specialties, from 4.7% in gynecology to 13.7% in cardiothoracic surgery. Hierarchical modeling with 20 risk factors (HL = 9.423, P = 0.31; c-statistic 0.86) identified 13 hospitals as statistical outliers (5 good, 8 poor performers). Per hospital, the median risk-adjusted delirium rate was 10.4% (range 3.2% to 27.5%). Operation-specific risk and preoperative cognitive impairment (OR 2.9, 95% confidence interval 2.5-3.5) were the strongest predictors. The model performed well across surgical specialties (orthopedic, general surgery, and vascular surgery).

CONCLUSION

Rates of postoperative delirium varied 8.5-fold across hospitals, and can feasibly be measured in surgical quality datasets. The model performed well with 10 to 12 variables and demonstrated applicability across surgical specialties. Such efforts are critical to better tailor quality improvement to older surgical patients.

How Did We Get Here? A Broader View of the Postoperative Period

The decision to offer surgery to an older adult with medical comorbidities involves candid conversations between the surgeon, patient, and caregivers. Tools are available to physicians that facilitate patient empowerment. Beyond short-term risks, the conversation should include the potential for institutional discharge, functional and cognitive decline, and longer term mortality.

Functional Trajectories Before and After Major Surgery in Older Adults

OBJECTIVES

We hypothesized that distinct sets of functional trajectories can be identified in the year before and after major surgery, with unique transition probabilities from pre to postsurgical functional trajectories, and that outcomes would be better among participants undergoing elective versus nonelective surgery.

BACKGROUND

Major surgery is common and can be highly morbid in older persons. The relationship between the course of disability (ie, functional trajectory) before and after surgery in older adults has not been well-studied for most operations.

METHODS

Prospective cohort study of 754 community-living persons 70 years or older. The analytic sample included 250 participants who underwent their first major surgery during the study period.

RESULTS

Before surgery, 4 functional trajectories were identified: no disability (n = 60, 24.0%), and mild (n = 84, 33.6%), moderate (n = 73, 29.2%), and severe (n = 33, 13.2%) disability. After surgery, 4 functional trajectories were identified: rapid (n = 39, 15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%), and little (n = 57, 22.8%) improvement. Rapid improvement was seen for n = 31 (51.7%) participants with no disability before surgery, but was uncommon among those with mild disability (n = 8, 9.5%) and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (n = 46, 54.8%) and partial improvement (n = 36, 49.3%) were most common. Most participants with severe disability (n = 27, 81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus nonelective surgery.

CONCLUSIONS

Functional prognosis in the year after major surgery is highly dependent on premorbid function.

Toll-like receptors 2 and 6 mediate apoptosis and inflammation in ischemic skeletal myotubes

Critical limb ischemia (CLI) is associated with skeletal muscle damage. However, the pathophysiology of the muscle damage is poorly understood. Toll-like receptors (TLR) have been attributed to play a role in ischemia-induced tissue damage but their role in skeletal muscle damage in CLI is unknown. TLR2 and TLR6 expression was found to be upregulated in skeletal muscle of patients with CLI. In vitro, ischemia led to upregulation of TLR2 and TLR6 by myotubes, and activation of the downstream TLR signaling pathway. Ischemia-induced activation of the TLR signaling pathway led to secretion of the pro-inflammatory cytokine interleukin-6 and muscle apoptosis, which were abrogated by neutralising TLR2 and TLR6 antibodies. Our study demonstrates that TLR2 and TLR6 are upregulated in ischemic muscle and play a role in ischemia-induced muscle damage. Thus, manipulating the TLR pathway locally may be of potential therapeutic benefit.

Use of Functional Assessment to Define Therapeutic Goals and Treatment

This article summarizes the presentations and discussions from a workshop, "Using Functional Assessment to Define Therapeutic Goals and Treatment," which took place on November 30 to December 1, 2017. This workshop brought together transdisciplinary leaders in the fields of function and disability and clinical investigators engaged in research on geriatric populations to outline opportunities and challenges for incorporating measures of function in clinical research. Topics addressed included reliable and clinically feasible measures of function and key domains of health (eg, musculoskeletal, cognitive, and sensory) that are most strongly associated with patients' perceptions of well-being, independence, and quality of life across a wide array of diseases and interventions. The workshop also focused on the importance of function in medical decision making to inform communications between specialty physicians and patients about prognosis and goals of care. Workshop participants called for more research on the role of function as a predictor of an intervention's effectiveness and an important treatment outcome. Such research would be facilitated by development of a core set of simple, short, functional measures that can be used by all specialties in the clinical setting to allow "big data" analytics and a pragmatic research. J Am Geriatr Soc 67:1782-1790, 2019.

Using the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification to identify patients most likely to benefit from revascularization

BACKGROUND

The Society of Vascular Surgery Wound Ischemia foot Infection (WIfI) classification system for chronic limb-threatening ischemia was intended to predict 1-year major lower extremity amputation (LEA) risk and to identify which patients benefit most from revascularization. We aimed to identify which WIfI presentations benefited most from revascularization to explore whether a cluster analysis could identify a more data-driven WIfI score, and to quantify which component of the WIfI score was most strongly associated with 1-year LEA after revascularization.

METHODS

Composite multi-institutional nested cohort data from centers who previously validated WIfI were reviewed retrospectively. We collected each patient's WIfI component grades and whether LEA was performed. To examine the benefit of revascularization, the predicted LEA rates were subtracted from observed LEA rates. We used k-means cluster analysis to model predicted vs observed LEA rates after revascularization. Multivariable linear regression analysis was performed to quantify which WIfI score component(s) best predicted LEA.

RESULTS

Data from 10 centers, accumulated between 2005 and 2015 were collated (2878 limbs at risk; 314 LEAs performed). The subset of patients who underwent revascularization comprised the study base (1654 limbs; 169 LEAs). Of 64 potential WIfI grade combinations, 15 were never reported and were excluded from the analysis. By original WIfI stages, the observed LEA rate after revascularization was: stage 1, 10.8% (14/130); stage 2, 4.9% (5/103); stage 3, 5.1% (25/487); and stage 4, 13.4% (125/934). Based on the difference between predicted and observed LEA risk for those who underwent revascularization, the WIfI scores were placed into quartiles from greatest to no benefit of revascularization. Cluster analysis identified four clusters with the following 1-year LEA rates: cluster 1, 4.4% (46/1038); cluster 2, 14.8% (66/447); cluster 3, 28.1% (36/128); and cluster 4, 51.2% (21/41). The between sum of squares/total sum of squares was 93.9%. Multiple linear regression revealed the wound grade most strongly predicted LEA (F-value, 17.25; P < .001). Ischemia (F-value, 6.51; P = .001) and infection (F-value, 5.7; P = .003) were similarly associated with LEA risk. Interaction terms between each component of the WIfI score were not statistically significant.

CONCLUSIONS

WIfI can identify which patients with chronic limb-threatening ischemia are most likely to benefit from revascularization and may provide improved prognostication, risk stratification, and equitable outcome assessments. After revascularization, wound severity is most strongly associated with LEA risk. Ischemic and infectious grades confer additive, but not synergistic, risk. Future cluster analyses comparing specific WIfI presentations treated with and without revascularization will be required to further refine WIfI.

Determinants of Long-Term Outcomes and Costs in the Management of Critical Limb Ischemia: A Population-Based Cohort Study

Background The optimal treatment for critical limb ischemia remains controversial owing to conflicting conclusions from previous studies. Methods and Results We obtained administrative claims on Medicare beneficiaries with initial critical limb ischemia diagnosis in 2011. Clinical outcomes and healthcare costs over 4 years were estimated among all patients and by first treatment (endovascular revascularization, surgical revascularization, or major amputation) in unmatched and propensity-score-matched samples. Among 72 199 patients with initial primary critical limb ischemia diagnosis in 2011, survival was 46% (median survival, 3.5 years) and freedom from major amputation was 87%. Among 9942 propensity-score-matched patients (8% rest pain, 26% ulcer, and 66% gangrene), survival was 38% with endovascular revascularization (median survival, 2.7 years), 40% with surgical revascularization (median survival, 2.9 years), and 23% with major amputation (median survival, 1.3 years; P<0.001 for each revascularization procedure versus major amputation). Corresponding major amputation rates were 6.5%, 9.6%, and 10.6%, respectively ( P<0.001 for all pair-wise comparisons). The cost per patient year during follow-up was $49 700, $49 200, and $55 700, respectively ( P<0.001 for each revascularization procedure versus major amputation). Conclusions Long-term survival and cost in critical limb ischemia management is comparable between revascularization techniques, with lower major amputation rates following endovascular revascularization. Primary major amputation results in shorter survival, higher risk of subsequent major amputation, and higher healthcare costs versus revascularization. Results from this observational research may be susceptible to bias because of the influence of unmeasured confounders.

Outcomes in nursing home patients with traumatic brain injury

BACKGROUND

Traumatic brain injury is a leading cause of death and disability in the United States. In survivors, traumatic brain injury remains a leading contributor to long-term disability and results in many patients being admitted to skilled nursing facilities for postacute care. Despite this very large population of traumatic brain injury patients, very little is known about the long-term outcomes of traumatic brain injury survivors, including rates of discharge to home or risk of death in long-term nursing facilities. We hypothesized that patient demographics and functional status influence outcomes of patients with traumatic brain injury admitted to skilled nursing facilities.

METHODS

We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries aged 65 and older discharged alive and directly from hospital to a skilled nursing facility between 2011 and 2014 using the prospectively maintained Federal Minimum Data Set combined with Medicare claims data and the Centers for Medicare and Medicaid Services Vital Status files. Records were reviewed for demographic and clinical characteristics at admission to the skilled nursing facility, including age, sex, cognitive function, ability to communicate, and motor function. Activities of daily living were reassessed at discharge to calculate functional improvement. We used robust Poisson regression with skilled nursing facility fixed effects to calculate relative risks and 99% confidence intervals for mortality and functional improvement associated with the demographic and clinical characteristics present at admission. Linear regression was used to calculate adjusted mean duration of stay.

RESULTS

Overall, 87,292 Medicare fee-for-service beneficiaries with traumatic brain injury were admitted to skilled nursing facilities. The mean age was 84 years, with 74% of patients older than age 80. Generally, older age, male sex, and poor cognitive or functional status at admission to a skilled nursing facility were associated with increased risk for poorer outcomes. Older patients (age ≥80 years) with traumatic brain injury had a 1.5 times greater risk of death within 30 days of admission compared with adults younger than 80 years (relative risk = 1.49, 99% confidence interval = 1.36, 1.64). Women were 37% less likely to die than men were (relative risk = 0.63, 99% confidence interval = 0.59, 0.68). The risk of death was greater for patients with poor cognitive function (relative risk = 2.55, 99% confidence interval = 2.32, 2.77), substantial motor impairment (relative risk = 2.44, 99% confidence interval = 2.16, 2.77), and patients with impairment in communication (relative risk = 2.58, 99% confidence interval = 2.32, 2.86) compared with those without the respective deficits. One year after admission, these risk factors continued to confer excess risk for mortality. Duration of stay was somewhat greater for older patients (30.1 compared with 27.5 average days) and patients with cognitive impairment (31.7 vs 27.5 average days). At discharge, patients with cognitive impairment (relative risk = 0.86, 99% confidence interval = 0.83, 0.88) and impairment in the ability to communicate (relative risk = 0.67, 99% confidence interval = 0.54, 0.82) were less likely to improve in physical function.

CONCLUSION

Our results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode.

Long-term outcomes after autogenous versus synthetic lower extremity bypass in patients on hemodialysis

BACKGROUND

Hemodialysis dependence confers unique physiologic conditions. Prior reports of outcomes after infrainguinal open bypass operations in patients on hemodialysis have been based on relatively small sample institutional series. In this study, we evaluate long-term outcomes after open bypass operations in a large contemporary population-based cohort of hemodialysis patients. We studied all hemodialysis patients who underwent infrainguinal open operation using autogenous versus prosthetic conduits in the United States Renal Data System between January 2007 and December 2011.

METHODS

Univariate methods (χ², analysis of variance) were used to compare the characteristics of the patient and type of bypass. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were used to evaluate 30-day postoperative outcomes as well as patency, limb salvage, and mortality in the long term.

RESULTS

There were 9,739 (autogenous: 59%, prosthetic: 49%) infrainguinal open bypass operations performed in this cohort. Of these, 4,717 (48%) were femoral-popliteal, 3,321 (34%) were femoral-tibial, and 1,701 (18%) were popliteal-tibial bypasses. Bypass operations were performed most commonly for critical limb ischemia (72%). Primary patency was 18% for both types of conduits at 5 years (P = .16). Comparing autogenous versus prosthetic conduits, primary-assisted patency was 23% vs 20% at 5 years (P = .98), while secondary patency was 30% for both conduits at 5 years (P = .05). Limb salvage was 35% vs 41% at 5 years (P < .001). Multivariable analyses demonstrated greater patency (adjusted hazard ratio [aHR]: 1.16; 95% confidence interval, 1.05-1.28; P = .003) and limb salvage (aHR: 1.12; 95% confidence interval, 1.01-1.24; P = .03) for autogenous compared to prosthetic bypasses. The advantage conferred by autogenous conduits was most clinically relevant for femoral-tibial (aHR: 1.34; 95% confidence interval, 1.17-1.55; P < .001) and popliteal-tibial (aHR: 1.55; 95% confidence interval, 1.09-2.21; P = .014) configurations.

CONCLUSION

This large study evaluated the long-term outcomes of open bypass operations in patients on hemodialysis. The data confirm the long-term benefits of autogenous conduits compared with prosthetic conduits in this high-risk population of patients, especially for the treatment of distal lesions. Individual patient life expectancy, availability of adequate autogenous conduit options, indication for operation, level of disease, as well as potential need for future options for additional access for dialysis should be taken into consideration when deciding to construct an open bypass in a hemodialysis patient.

Functional Outcomes After Transurethral Resection of the Prostate in Nursing Home Residents

OBJECTIVES

To understand outcomes of transurethral resection of the prostate (TURP) or transurethral laser incision of the prostate (TULIP) for the treatment of bladder outlet obstruction in men with high levels of functional dependence, which are poorly understood.

DESIGN

Retrospective cohort study.

SETTING

U.S. nursing homes (NHs).

PARTICIPANTS

Male NH residents aged 65 and older who underwent TURP or TULIP in the United States between 2005 and 2008 (N = 2,869).

MEASUREMENTS

Changes in activities of daily living (ADLs), Foley catheter status, and survival up to 12 months after surgery were examined. Multivariate regression was used to determine risk of having a Foley catheter 1 year after surgery.

RESULTS

Sixty-one percent of the cohort had a Foley catheter before the procedure. Of men with a Foley catheter at baseline, 64% had a Foley catheter, 4% had no Foley catheter, and 32% had died by 1-year after the procedure. Having a Foley catheter at baseline (risk ratio (RR) = 1.39, 95% confidence interval (CI) = 1.29-1.50) and poor baseline functional status (RR = 1.34, 95% CI = 1.18-1.52 for individuals in the worst quartile of function) were associated with greater risk of having a Foley catheter at 1-year.

CONCLUSION

Poor baseline functional status and having a Foley catheter preoperatively were associated with greater risk of TURP or TULIP failure, as measured by the presence of a Foley catheter at 1 year. Preoperative measurement of ADLs may aid in surgical decision-making in this population.

Management of Critical Limb Ischemia

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Postoperative Functional Outcomes in Older Adults

As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.

Controversies in anaesthesia for noncardiac surgery in older adults

As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing. Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical issues specific to older surgical patients are reviewed, with a special emphasis on areas of debate related to anaesthesia care in this group. These issues include the role of frailty and disability in preoperative assessment, choice of anaesthesia technique for hip fracture, postoperative delirium, and approaches to shared decision-making before surgical procedures.