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Hip Fracture Setting Priorities for Effectiveness Research Report of a Study by a Committee of the INSTITUTE OF MEDICINE Division of Health Care Services Kim ~ Heithoff and Kathleen N. Lohr, editors NATIONAL ACADEMY PRESS Washington, D.C. 1990

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This workshop was supported by the Health Care Financing Administration, U.S. Department of Health and Human Services, under Basic Ordering Agreement Contract No. 500-89-0008. Library of Congress Catalog Card No. 90-61984 International Standard Book No. 0-309-W299-2 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 S188 Printed in the United States of America

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INSTITUTE OF MEDICINE Division of Health Care Services HCFA Effectiveness Initiative Hip Fracture Research Workshop Committee KENNETH I. SHINE, Chair, Dean, School of Medicine, University of California, Los Angeles CHRISTINE K CASSEL, Chief, Section of General Internal Medicine, University of Chicago, Chicago, Illinois JOHN F. FITZGERALD, Assistant Professor of Medicine, Indiana University School of Medicine, Indianapolis HOWARD S. FRAZIER, Professor of Medicine, Harvard Medical School, Boston, Massachusetts JOHN J. GARTLAND, Director, Center for Research, Medical Education and Health Care, Jefferson Medical College, Philadelphia, Pennsylvania MAUREEN M. HENDERSON, Professor of Epidemiology and Medicine, University of Washington, Seattle CAROL CLARKE HOGUE, Associate Professor, University of North Carolina, Chapel Hill C. CONRAD JOHNSTON, Chief of Endocnnology, Indiana University School of Medicine, Indianapolis ROSALIE ~ KANE, Professor, School of Public Health and School of Social Work, University of Minnesota, Minneapolis EMMETT B. KEELER, Senior Mathematician, Economics Department, The RAND Corporation, Santa Monica, California ROBERT B. KELLER, Executive Director, Maine Medical Assessment Foundation, Belfast ROBERT J. LLOYD, Arthritis Rehabilitation Center, Washington, D.C. BARBARA J. MCNEIL, Head, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts JOHN L. MELVIN, Professor and Chair, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee JANA M. MOSSEY, Professor, Medical College of Pennsylvania, Philadelphia DAVID G. MURRAY, Professor of Orthopedic Surgery, State University of New York Health Sciences Center, ALAN R. NELSON, Associate, Memorial Medical Center, Salt Lake City, Utah RAYMOND J. RABIDOUX, President, Henry Ford Continuing Care Corporation, Detroit, Michigan . . .

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WAYNE ~ RAY, Associate Professor of Biostatistics and Director, Division of Pharmacoepidemiology, Vanderbilt University School of Medicine, Nashville, Tennessee J. SANFORD SCHWARTZ, Executive Director, The Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania G. RICHARD SMITH, Associate Professor of Psychiatry, Department of Psychiatry, University of Arkansas for the Medical Sciences, Little Rock HAROLD C. SOX, Professor and Chairman, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire STUDY STAFF Division of Health Care Services KARL D. YORDY, Director KATHLEEN N. LOHR, Senior Professional Associate RICHARD ~ RE11IG, Senior Staff Officer KIM A. HEITHOFF, Research Assistant Division of Health Promotion and Disease Prevention MARIA ELENA LARA, Program Officer IV

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Acknowledgments The contributions of several members of the Institute of Medicine staff deserve special mention. Among them are H. Donald Tiller, administrative associate, and Theresa Nally, project secretary. Maria Elena Lara assisted with the development of workshop materials. Richard ~ Rettig and Karl D. Yordy provided steady support and leadership throughout the entire project. The committee is particularly indebted to several of the anonymous reviewers of the draft of this report for comments and suggestions that have been incorporated into the text. Support for this study was provided by the U.S. Department of Health and Human Services, Health Care Financing Administration. We partic- ularly wish to acknowledge the unflagging assistance and guidance of the government's project officer, John Spiegel, of the Health Standards and Quality Bureau. v

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Contents ACKNOWLEDGMENTS ........ SUMMARY ............. INTRODUCTION.............................................. EDectiveness Initiative, 5 The IOM Clinical Workshop, 5 Condition-specific Research Workshops, 6 THE KNOWLEDGE BASE FOR KEY CLINICAL ISS U ES IN HIP E]R1iCI1JR E ......................................... Definitions, 8 Epidemiologic and Clinical Aspects of Hip Fracture, 10 FACTORS IMPORTANT FOR THE SELECTION OF KEY PATIENT MANAGEMENT ISSUES AND RELATED RESEARCH ACI~INIITIES............................... Selecting Patient Management Issues, 21 Selecting Research Topics and Activities, 22 KEY PATIENT MANAGEMENT TOPICS FOR EtLL;CTIVENESS RESEARCH IN HIP FRACTURE. Preliminary Discussion and Selection of Major Topics, 25 Summary of Recommendations, 25 Methods Issues, 26 Patient Management Issues, 32 CONCLUSIONS ............................................. BIBLIOGEtAUPElY ........................................ APPENDIX: Background and Conduct of the Workshop . . . vie . v ..... 8 ........ 21 25 .41 ....43 .49

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