|
Items in cart [0] |
Questions? Call 888-624-8373 |
PAPERBACK PDF BOOK Free Resources |
||||||||||||||||
|
||||||||||||||||
|
|
|||||||||||||||
| ||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 21
Factors Important for the Selection of Key
Patient Management Issues and Related
Research Activities
Hip fracture was selected for the Effectiveness Initiative research pro-
gram because of its high concentration among elderly people and strong
relationship to age; its high mortality, morbidity, and disability rates; con-
siderable disagreement about surgical approaches in at least some classes
of hip fracture; appreciable concern about whether the standard therapy—
surgery is appropriate in all cases (especially for patients whose prefrac-
ture status was poor); wide variation in approaches to rehabilitation; and
high costs of care that will increase in the future as the population ages.
The committee agreed, in principle, that the HCFA data banks should
be used to develop preliminary information on the costs and effectiveness of
prevention, treatment, and rehabilitation of hip fracture. It also endorsed
the general concept that analysis of variations in patterns of care and
outcomes by geographic area, institution, type of provider or practitioner,
and other factors could be a useful component of any effectiveness research
program. Finally, it concluded that separate studies to determine the
outcomes of care provided to the Medicare population will be valuable,
especially if those analyses advance the understanding of the effectiveness
of prevention strategies, Claris whether interventions offered to the elderly
reduce the incidence of hip fracture at any given age, and identify preferred
patient management regimens.
SELECTING PATIENT MANAGEMENT ISSUES
Several factors affect the selection of patient management issues for
effectiveness research into hip fracture. Although not equally well docu-
mented in the clinical or health policy literature, the committee believed
21
OCR for page 22
22
EFFECTIVENESS INITL24TIVE
that all these factors deserved to be considered in choosing specific study
topics:
· epidemiologic aspects of hip fracture (e.g., the relative incidence of
osteoporosis, falls, fractures, and repeat fractures in particular subgroups)
· health status and quality-of-life aspects of both the illness itself and
different treatment options for elderly people
different treatment options characterized by the likelihood of pro-
longing survival, producing major impairment and disability, or improving
the patient's physical functioning and mobility, emotional well-being and
social interaction, and independence
· high degree of professional and clinical uncertainty or disagreement
about alternative strategies for managing the care of hip fracture patients
· substantial variation across geographic areas in the per-person use
of services for hip fracture, including those for prevention and management
of risk factors, beyond that explained by differences in patient characteristics
or health resources
· substantial variation across geographic areas or institutions in the
outcomes of care for patients with hip fractures, beyond that explained by
the differences in the severity or type of fracture or the sociodemographic
characteristics of patients
· relatively high costs to the Medicare program for the services to
prevent hip fractures and to treat and rehabilitate hip fracture patients
· relatively high out-of-pocket costs to Medicare beneficiaries for hip
fracture prevention, treatment, and follow-up care.
SELECTING RESEARCH TOPICS AND ACTIVITIES
Content, Conduct, and Use of Research
For high priority hip fracture research, the committee raised three
additional points. First, it endorsed four generic subjects identified by
the October 1988 workshop: prevention, generation and use of outcomes
measures that include functional status and quality of life, analysis of men-
tal and emotional dimensions of an illness (cognitive functioning, anxiety
and depression), and clarification of the difference between efficacy and
effectiveness.
Second, the research strategy adopted should be the one that is
most appropriate for the specific question being asked. For effective-
ness research, the choice of strategies include monitoring through analy-
sis of administrative data; observational (cross-sectional, case-control, or
longitudinal-cohort) studies; quasi-experimental studies and demonstra-
tions; and, potentially, Reins. The choice is often determined by the
research question, but if the question can be addressed by more than one
OCR for page 23
HIP FIUCTURE
23
approach, then the complexity, rigor, and expense of alternative research
designs should be examined. Plans to use more than one strategy either
simultaneously or sequentially should also be considered.
In addition, projects based on newer, more sophisticated, nonexper-
imental techniques, such as meta-analysis and cost-effectiveness analysis,
should be included among the research options. Furthermore, the Medi-
care claims databases might yield information that is useful for developing
decision-analytic methods (which incorporate data-based probabilities). In
short, the committee concurred that all these approaches should be con-
sidered potential investigational methods for effectiveness research and
cautions that there is no single appropriate strategy. The committee also
wishes to emphasize the importance of evaluating beforehand the trade-off;
implicit in selecting one approach over another and in mounting combined
approaches.
Third, the committee stressed the contributions that studies of partic-
ular illnesses can have as prototypes for examining other conditions. Hip
fracture research should be seen as an opportunity to address conceptual
and methodologic issues relevant to other conditions or functional im-
pairments that are prevalent in the Medicare population and that call for
attention to prevention, rehabilitation, or situations in which standard ther-
apy (e.g., surgery in a patient who suffers from dementia or is bedridden)
may not be in that patient's best interest.
Data Issues
The October 19~ worl~;hop committee questioned the adequacy and
availability of data to investigate key effectiveness questions through HCFA's
existing (or anticipated) administrative data files. As effectiveness research
proposals depend on the quality of the data collected and used, the hip
fracture committee reiterated this general concern with respect to hip
fracture.
First, adequate data on health and functional status of patients with
hip fracture must be available before any longitudinal studies of alternative
therapies (surgical and rehabilitative) are undertaken with the Medicare
files. Second, accurate case identification and coding must be assured.
Problems with the Medicare files include inaccurate descriptions of race,
discrepancies in numbers of identifiable cases based on diagnosis versus
those derived by summing over appropriate procedures, inability to identify
reliably the type or stage of fracture, and inability to differentiate left
from right hip fracture (meaning that it is also difficult to distinguish
a reoperation on one hip from a first operation on the other). 1b the
extent that information about hip fracture from the administrative data
OCR for page 24
24
EFFECTIVENESS INITLi4TIVE
bases lacks reliability and validity, data analysis and interpretation will be
severely restricted; this limitation must be acknowledged and overcome.
Third, extensive and high quality data are necessary for the analysis of
comorbidity (or case mix). Analyses of hip fracture, for instance, should
not combine (or confuse) patients who were healthy before the fracture
with those for whom the fracture is a culmination of numerous chronic
conditions. Adequate case mix data are needed-both for interpreting prac-
tice variations and, more critically, for investigating outcomes (especially
those with strong quality-of-life components).
Notwithstanding the above caveats, the committee endorsed the view
that the existing administrative data sets even now can provide information
on several important topics, such as the site of service, shifts in the choice
of procedures over time (e.g., from pinning to total hip replacement),
and geographic variations in broad patterns of care. They can also be
used to evaluate in-hospital survival, time-based survival (30 days, six
months, one year), readmissions, some complications, and other simple
outcome measures. Thus, although the discussion emphasized the necessity
of obtaining richer clinical and patient outcome data through, for instance,
Medicare PROs or primary data collection, the potential of the existing
data sets to answer some questions was acknowledged.
Representative terms from entire chapter:
patient management
