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Summary In late 1988, as part of planning an "Effectiveness Initiative," the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services asked the Institute of Medicine (IOM) to conduct three research workshops one each on breast cancer, acute myocardial infarction, and hip fracture. These research workshops had three objectives: (1) to examine each clinical condition in detail; (2) to identify key patient management topics for each condition that deserve further "effectiveness" investigation, as contrasted with "efficacy"; and (3) to propose appropriate research strategies or approaches to be used by HCFA and other public and private organizations that conduct effectiveness research. This report presents the IOM committee's recommendations from the workshop on hip fracture. The committee recommends that explicit attention be given to four methodologic issues in hip fracture effectiveness research. First, currently available health and functional status measures must be synthesized and "disease-specific" measures developed for the study of hip fracture risk and prognosis. These measures should include indices of frailty; activities of daily living (AD Ls) and "instrumental" activities of daily living (IADLs); cognitive functioning; sociodemographic variables; physiologic parameters; and predisposing causes of fractures. Second, the committee recommends that HCFA focus on two outcome issues: (1) a more comprehensive definition of outcomes, in line with recent developments in health status assessment and quality-of-life measurement; and (2) techniques for acquiring data that cross the full spectrum of care delivery sites. HCFA should continue to seek expert assistance to develop outcome measures other than mortality, including guidance for selecting the instruments for general electiveness use as well as for hip fracture. The 1

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2 EFFECTIVENESS INITIATIVE

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HIP FRACTURE 3 community physicians, to evaluate the acquisition and use of this knowledge by community physicians, and to evaluate the effectiveness of these inter- ventions in a community setting. Cost and benefit analyses of prevention interventions should be done before and after enrollment in Medicare. Considerable professional uncertainty exists about alternative treat- ment options. Research is needed to address the effectiveness of selected surgical interventions, the appropriateness of nonsurgical (medical and supportive) management, and other treatment issues that predict very high costs of care. Effectiveness research on hip fracture treatment alternatives should be aimed at developing scientifically based indications to determine which patients should have open or closed reduction with internal fixation, prosthetic replacement of the femoral head, or primary total hip replace- ment. Four other clinical treatment effectiveness issues recommended for investigation include: impact of comorbidity, patient predictors of exces- sively long lengths of stay or high costs of care, better clinical data sets, and payment incentives affecting clinical decision making. Studies in rehabilitation should focus on three areas: (1) appropriate rehabilitation programs for different kinds of hip fractures; (2) appropriate rehabilitation programs for different kinds of patients; and (3) examination of sites for delivery of rehabilitation services to determine which are most effective. HCFA should concentrate its effectiveness research for rehabil- itation on four areas: (1) a minimal data set; (2) timing and intensity issues; (3) longitudinal follow-up across settings of care; and (4) hypothesis generation.

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