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Key Patient Management Topics
for Effectiveness Research in Hip Fracture
PRELIMINARY DISCUSSION AND SELECTION OF MAJOR TOPICS
The high priority patient management topics nominated by the commit-
tee- primely prevention, treatment selection, and rehabilitation remained
essentially unchanged from a homework exercise conducted before the
workshop (see the appendix). Specific study topics within each group, how-
ever, were quite broad in scope. In addition, prevention and management
of secondary complications of hip fractures were noted by a few committee
members as patient management topics suitable for effectiveness research.
Issues of cost, cost-effectiveness, and cost-efficiency were noted with some
frequency across all categories. In the second round of voting, a consen-
sus by the committee to focus on prevention of hip fracture, selection of
treatment alternatives, and rehabilitation was virtually unanimous.
Bible N2 of the appendix summarizes the topics listed by the commit-
tee in the preworkshop homework exercise. Methodologic and data issues
related to the study of these topics are discussed in the next section of this
report.
SUMMARY OF RECOMMENDATIONS
The workshop discussion did not propose testable hypotheses or spe-
cific research questions. Rather, it was meant to arrive at a broader set of
issues whose exploration would depend critically on the data that might be
available through the Medicare files or that could be collected by indepen-
dent effectiveness research projects. Even with this limitation, many useful
subjects might be addressed, and the major questions that the committee
thought belonged in an effectiveness research agenda are discussed here.
25
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26
EFFECTIVENESS INITIATIVE
The committee made recommendations that were specific to HCFAs
existing capabilities as well as those related to the larger, evolving DHHS
program of effectiveness and outcomes research. The administrative data-
bases, by themselves, are limited in the type of effectiveness research ques-
tions that they can address, but they provide some unique opportunities
when combined with other data sources and research efforts.
The committee recommended that explicit attention be given to four
methodologic issues in hip fracture effectiveness research:)
1. health and functional status assessment;
2. definitions of outcomes and comparability of outcome measures;
3. the need for longitudinal data; and
4. risk stratification and classification by comorbidity.
A methodologic issue that was not addressed by the hip fracture
committee explicitly but was judged by the core committee to be integral
to effectiveness research was:
5. patterns of care and variations in those patterns.
The committee also recommends three clinical or patient management
topics for initial study in an effectiveness research program:
1. prevention of hip fracture;
2. treatment options for hip fracture, particularly as a function of
age, frailty, comorbidities, and provider characteristics; and
3. rehabilitation, particularly as a function of type and intensity of
service, site of care, and provider characteristics.
Finally, the committee noted that age cuts across all effectiveness
and outcomes research affecting elderly people. In hip fracture, as with
many other clinical conditions, age and the degree of frailty have profound
implications for treatment choice and outcome. These issues are discussed
below and mentioned throughout the report.
METHODS ISSUES
Health and Functional Status Assessment
Recent work in measuring health status and functional capabilities is
quite extensive. There is little consensus, however, as to formats that should
be adopted by a government agency or by private researchers to measure
iAll four methodologic issues noted in this report pertain as well to breast cancer and acute
myocardial infarction research strategies, and they are discussed in the companion reports with
modifications pertinent to the diseases under consideration.
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HIP FRACTURE
27
either prognostic indicators or outcomes in effectiveness research. Many
current measures are too long and are not specific to the clinical condition
under consideration.
~ move forward in effectiveness research, the recent work on health
and functional status assessment must be synthesized; the committee cau-
tioned against "reinventing the wheel" in this area. The use of "generic"
health status measures (e.g., the Sickness Impact Profile, the Visual Ana-
logue Pain rating scales, or the Index of Independence in Activities of
Daily Living), augmented by selected "disease-specific" measures (e.g., the
Arthritis Impact Measurement Scale), is increasingly recognized as an ap-
propriate research strategy (see the citations in the bibliography). The
committee noted, for example, that the concept of frailty must be incor-
porated into health and functional status assessments of patients with hip
fractures. The committee supports funding of methodologic research that
would construct a geriatric assessment instrument that includes the concept
of frailty.
Effectiveness research on hip fracture will require that baseline and
follow-up data on health status be collected for several purposes: prognos-
tic risk stratification, physician and patient decision making about treatment
options, defining and understanding short- and long-term outcomes, and
appropriate characterization of the patient populations being studied. Stan-
dard patient-based measures of acceptable reliability and validity should, in
the long run, become an integral part of the effectiveness research program.
Regarding data sources, much health and functional status information
will have to be obtained directly from patients (or their proxies); existing
HCFA databases lack measures of functional status.2 The committee rec-
ommends that HCFA develop health and functional status measures that
can be linked longitudinally to the Medicare Part A and Part B files and
to medical record data. Health and functional status information is needed
on a broad population base and should be assessed periodically. Studies
must be funded to determine the most effective way to implement such
questionnaires to obtain consistent, reliable, and valid data. Eventually,
this database could serve as a source of information for predicting future
events (i.e., determining risk) and for measuring response to interventions.
The committee further recommends that HCFA consider introducing
a health assessment mechanism or questionnaire to patients on their entry
to the Medicare system before any illness even for a limited sample of
2At the time of the workshop, HCFA was attempting to add a physician-based functional sta-
tus measure to the Medicare insurance claims forms. Depending on the adequacy of any such
measure, appropriate information for hip fracture (or for the other conditions recommended
for the Effectiveness Initiative) may still need to be obtained directly. Presumably the reliability,
validity, and cost-effectiveness of adding functional status information to the claims forms will
be evaluated, but these issues were not addressed by the committee.
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28
EFFECTIVENESS INITL~4T~E
beneficiaries.3 As implied above, this additional information should include
physiologic parameters and risk factors as well as the health and functional
concepts noted above. This registry, if implemented over time, could reveal
information about change in health status in the Medicare population as
people age and the prevalence of chronic disease increases.
Ultimately, a component of this health status assessment would de-
scribe very high risk individuals. These individuals are called frail for
the purposes of hip fracture, but other categories might emerge from
population-based health status assessments. Such a data set would be valu-
able to effectiveness and outcomes research across many clinical conditions
important in the Medicare population. It may also provide insights into
clinical issues that emerge in late middle age and that ultimately impinge
heavily on the Medicare program.
~ A ~
It was beyond the charge of this committee to specify components of
a geriatric health and functional status assessment instrument suitable for
hip fracture research. In general, however, the committee believed that
this assessment instrument should include components of what has classi-
cally been called functional capabilities (including Activities of Daily Living
[AD Ls] and Instrumental ADLs [IADLs]), cognitive functioning' sociode-
mographic variables, physiologic parameters, and prognostic indicators. A
comprehensive assessment incorporating these various perspectives might
aid in defining a category of people considered to be frail. This frailty index
could be factored into treatment decision making. Incorporating a frailty
dimension into assessment of elderly people is one aspect of recognizing
the heterogeneity of the elderly population for purposes of research and
patient care.
Because hip fracture seems to be so intimately tied to the development
of mobility and cognitive problems that come under the rubric of frail~,
this clinical condition can potentially be used to understand and perhaps
separate disease processes from the process of aging. The interest, energy,
and financial resources that are focused on the study of hip fracture will
therefore carry over to effectiveness research of other clinical conditions.
Outcomes
The committee recommends that HCFA focus on two outcomes issues,
(1) a more comprehensive definition of outcomes, in line with recent
developments in health status assessment and quality-of-life measurement,
3At the time of the workshop, very preliminary plans were being discussed at HCFA about de-
veloping a Medicare "registry" perhaps involving a 5 percent sample of newly enrolled Medicare
beneficiaries. Ibis recommendation was meant to support further exploration of this idea.
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HIP FRACTURE
29
and (2) techniques for acquiring data that cross the full spectrum of care
delivery sites.
Mortality rates are often used as outcome measures. Although the
mortality rate at one year for hip fracture is substantial, mortality alone
is not the only appropriate outcome measure for hip fracture. The 30~ay
mortality rate for hip fracture, for instance, is 7 percent and does not reflect
the often rapid decrease in functional and health status that follows injury.
Various clinical and surgical outcomes are important, such as stability of
the joint, healing of the fracture, and prevention of acetabular erosion.
The committee wishes to emphasize that for hip fracture (more than for
breast cancer or acute myocardial infarction), health and functional status
assessment before the adverse clinical event is necessary to interpret these
and other outcome measures appropriately.
For all patients, measures of morbidity (including pain and other symp-
toms), functional status (including physical capacity and ability to function
In daily life), psychological and emotional well-being, social functioning and
support networks, and general outlook on health are important. Adequate
ascertainment of these health and functional status levels should affect the
choice of surgical procedure (or, in a subset of frail elderly people, the de-
cision to treat the fracture nonsurgically) and may determine the type and
site of rehabilitative services needed and offered. Thus, it is important to
differentiate between outcomes and patient preferences for outcomes and
to encourage the acquisition and use of information on patient preferences
for different outcomes.
The committee recommends that HCFA continue to seek expert as-
sistance to develop outcome measures other than mortality, including
guidance for selecting the instruments for general effectiveness use as well
as for hip fracture. This committee draws special attention to the emerging
evidence that the use of "generic" health status measures augmented by
selected "disease-specific" measures is an appropriate, desirable, and prac-
tical research strategy. The committee does not, however, advocate that a
single outcome measure (or even a single set of measures) be mandated for
effectiveness research; the goal is to obtain comparable information across
studies by using measures whose elements can be mapped to one another.
For hip fracture, a definition of poor outcome would include several
variables: increased length of hospital stay (not explained by provision
of comprehensive rehabilitation services), increased rates of institutional
placement, continued pain, lower health and functional status along sev-
eral dimensions (mobility and physical activity, mental distress, reduced
social interaction, inability to conduct activities of daily living), and pre-
mature mortality. Short- and long-term outcomes for patients with hip
fractures (controlling for the type of surgical procedure and comorbidity at
admission) must be determined.
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30
EFFECTIVENESS INITLi4TIVE
One outcomes assessment strategy, cited by the committee as a poten-
tial model for a multifaceted assessment, is Ellwood's Outcomes Manage-
ment approach. HCFA has funded Quality Quest to work with the PROs
in three states to assess systematically outcomes of large groups of peo-
ple using information in addition to billing data. The research instrument
includes measures of functional status, patient satisfaction, and other indi-
cators of health status. The committee recommends that HCFA continue
to support this kind of effort.
Longitudinal Follow~up
The committee recommends that hip fracture outcomes be measured
longitudinally, for instance, at the time of hospital discharge and at six
weeks, six months, and one year after discharge. As noted earlier, pre-
fracture health status should also be obtained. Outcomes as a function of
living arrangements should, for example, be examined in detail to deter-
mine the variables that permit individuals to return to the community (e.g.,
utilization of a skilled nursing facility, living with family or a paid caretaker,
Medicare home health service). Short-, mid-, and long-term outcomes can
be contrasted with prefecture status and correlated with type of treatment,
length of stay, and type, site, and intensity of rehabilitation.
Research currently being conducted on hip fracture outcomes by in-
vestigators at the University of Minnesota School of Public Health was
identified as an example of a follow-up study that will yield health and func-
tional status information across various settings. In that study, prehospital
functioning was assessed retrospectively; functional status was measured at
the time of discharge and at two weeks, six weeks, six months, and one
year after discharge. Patients are followed as they move from hospital to
rehabilitation facility to nursing home to a community setting, sometimes
all within the span of six weeks.
Risk Stratification and Classification of Comorbidities
The committee recommends that case mix indices for hip fracture
be developed (including a measure of prefecture frailty, to predict, for
example, cost, mortality, and ADL functioning sur months postfracture.
Attention should be given to the minimum clinical data needed and the
procedures for acquiring such data. The importance of good risk stratifi-
cation is obvious; a vigorous 70-year-old tennis player who breaks a hip,
for instance, is in a vein different category than a 70-year-old resident of a
nursing home.
Categorizing patients in terms of prognosis becomes very critical in un-
derstanding the effectiveness of treatment. Risk stratification, for example,
OCR for page 31
HIP P~C=~
31
may suggest that the intervention that will achieve the "best" outcome for
some patients is nonsurgical management. This difficult ethical question
can only be addressed satisfactorily with accurate risk stratification. Again,
for HCFA, this type of analysis will depend on linking administrative data
to primary data collection by the PROs or other research efforts.
Information about the presence of comorbid conditions is also im-
portant, such as kidney failure secondary to atherosclerotic cardiovascular
disease, diabetes with severe peripheral vascular disease, or stroke with
cognitive impairment or necrologic conditions. Knowing the medications
the patient was taking before the hospitalization can also contribute signif-
icantly to the risk stratification and classification process. A scale could be
developed that would enable researchers to stratify (or grade) the patient
population into various classes resecting their baseline functional status.
If four or five different classes of patients were identified, more realistic
outcome goals for each class of patient could be developed.
Patterns of Care and Variations
Analysis of the change of patterns of care over time and as a function
of epidemiologic, clinical, and health care factors has emerged as a major
dimension of effectiveness research. This is true because evidence has
revealed (1) wide variations in rates of use of services (in hip fracture, pri-
marily surgery and rehabilitation), (2) variations in use and site of services
(especially for rehabilitative care), and (3) differences in practice styles that
appear to reflect professional disagreement. The committee supports the
use of the HCFA databases, augmented as appropriate by information from
patient records, to analyze patterns of care for hip fracture. This could be
done partly for policy and epidemiologic purposes and partly to help design
good follow-up studies of groups of hip fracture patients.
Patterns-of-care studies should be linked expressly to issues of preven-
tion, treatment options, and rehabilitation. Several variables should be a
part of a comprehensive set of analyses of patterns of care and variations.
Geographic region (even at the level of major census divisions) may prove
to be a crucial element in understanding who experiences hip fractures
and what type of treatment option (e.g., surgical or nonsurgical; type of
surgical interventions is chosen. Small-area analysis should also yield use-
ful information on different patterns of care. Differences by institutional
providers (e.g., types of hospitals; rehabilitation settings) and by professional
characteristics of physicians and various types of therapists should also be
studied, as they may shed light on differences in organizational factors
or professional training and practice styles that might be used to explain
or to change performance patterns. Other variables (e.g., prepaid versus
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32
EFFECTIVENESS INITL24TIVE
fee-for-service practice) may also prove to be important, especially for the
frail elderly population.
PATIENT MANAGEMENT ISSUES
Prevention
Prevention of hip fracture was identified as a priority patient manage-
ment issue because of the high social costs and grim personal consequences
for elderly victims in terms of pain, disability, functional limitations, and
displacement from community living. Prevention is a very promising area
of study. For the person 65 years of age, the incidence of hip fracture
doubles every five to seven years, with the risk increasing 8-fold to 16-fold
between the ages of 65 and 85. Even from the time that a person enters
the Medicare system, certain preventive interventions may modify the risk.
If the onset of a hip fracture could be delayed five years, the incidence of
hip fracture could be reduced by as much as 50 percent, with considerable
savings in patient suffering and costs.
The committee identified osteoporosis and falls as priority targets for
prevention research, because they are major risk factors for hip fracture.
Prevention research for falls should include preventing falls per se and
reducing fracture risk for falls that do occur. Studies on medications
should also be pursued as corollary to understanding prevention issues.
Osteoporosis
Because of the intricate relationship of osteoporosis, bone strength,
falls, and hip fracture, the committee recommends that osteoporosis be
made a focus of prevention research. Several prevention strategies for this
risk factor are probably most effective if they are implemented before the
person enters the Medicare system (i.e., reaches age 65~. Consideration
should be given to the impact that third party payer denial of preventive
services before age 65 has on shifting costs of these sequelae after age 65
onto the public sector.
One example of work that might be done in this area involves medi-
cations that are believed to have a protective effect. Observational studies
suggest that thiazide diuretics reduce the risk of hip fractures if they are
used for a period of several years; this is consistent with their known effects
on reducing calcium excretion. Replacement estrogens are protective for
newly postmenopausal women; it is unknown if starting these medications
for women age 65 and older will delay osteoporosis. Calcium supplements,
calcitonin, biphosphonates, and coherence therapy are all potential drug
treatments for osteoporosis whose efficacy for preventing hip fractures is
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HIP FRACTURE
33
unknown.4 Life-style changes such as an increase in the level of physical
activity may also preserve bone mass. There is an urgent need both for
efficacy and effectiveness research to clarify the clinical utilibr of these
potential preventive measures.
Thus, because this topic is clinically, epidemiologically, and adminis-
tratively important, we advise that those planning the effectiveness research
programs reach beyond the Medicare eligible population and ask what
studies can be done now for those 65 years of age and older and what can
be initiated for those under 65.
Falls
Falls are the leading cause of death from injury in the United States
for people age 65 and older. As noted earlier, approximately 260,000 hip
fractures occur among the elderly each year, with an associated medical
cost estimated at over $6 billion, and falls are clearly a major factor in this
picture.5
The committee recommends that effectiveness research efforts ad-
dress pathophysiologic processes, the primary aging processes, and behav-
ioral and environmental factors associated with falls. Outcomes and the
cost-effectiveness of various prevention strategies must be evaluated. The
mechanisms of falls and their role in hip fracture etiology should also be
addressed.
Administrative databases can make only limited contributions to these
questions, but certain uses should not be overlooked. For instance, such
data might be used to evaluate programs to prevent falls, such as a demon-
stration project comparing an intervention in one community (a city- or
state-wide program in which benefits include assessment of the home en-
vironment for hazards such as throw rugs on polished floors, inadequate
lighting, and lack of handrails on stairs) and no intervention in another.
Another potential contribution that the HCFA data might make Is
to develop a risk profile for fall-related fractures. Differences in fracture
related to race, body weight, and the like can be examined. The validity of
this kind of analysis requires that the presence or absence of comorbidity
be explicitly recognized. Although this type of analysis is not currently
possible, diagnosis-related group (DRG) data will become much more
useful if the codes account for the presence or absence of complications
or comorbidities. This change, if implemented by HCFA, would help
4 Coherence therapy is a cyclic combination of therapies stimulating the rate of bone remodeling
and depressing resorption.
5A relatively small proportion of falls in old people result in fracture (4-6 percent), but nearly
all hip fractures are consequent to falls.
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34
EFFECTIVENESS INlTLATIVE
researchers obtain a clean sample of patients, that is, one with similar
complications or comorbidities; this risk stratification would then permit
useful comparisons.
Medication Usage
Effectiveness research should include work on medications thought to
be helpful in preventing osteoporosis (and, hence, falls and fractures) and
on those believed to be harmful.6 One example of the former thiazide
diuretics- was noted earlier. Possibly more important, however, is improve-
ment in the understanding of which medications (including combinations
of medications) may foster osteoporosis (and indirectly increase the risk
of fractures) and which may affect balance or cognition and, thus, more
directly increase the risk of falls and fractures.
Psychotropic medications are a class of drugs that constitute a signif-
icant risk factor for falls and fractures. Certain psychotropic medications
(e.g., hypnotic-an~olytics with long elimination half-lives, tricyclic antide-
pressants, and antipsychotics) produce about a twofold increase in the risk
for hip fracture. An estimated 20 percent of Medicare beneficiaries are cur-
rently being prescribed psychotropic medications (although the Medicare
program will not provide reimbursement for them when they are prescribed
on an outpatient basis). The potential for effective prevention intervention
by changing practice patterns and refining indications for drugs is great.
Thus, clarification of how widely and how appropriately these agents are
used and their role in falls or fractures is badly needed.
Treatment Options
The committee recommends that three questions be addressed con-
cerning choices of treatment: (1) electiveness of selected surgical in-
terventions, (2) appropriateness of nonsurgical (medical and supportive)
management, and (3) other treatments that pose high costs of care.
6 Medicare does not cover outpatient prescription drugs at present. The Medicare Catastrophic
Coverage Act, which would have instituted an outpatient drug provision, was repealed in late
1989. The committee noted, however, that the absence of outpatient medication information
will limit effectiveness research that otherwise might be conducted using the Medicare insur-
ance claims files. That is, HCFA databases currently offer little assistance in this area because
Medicare does not cover outpatient prescription drugs. One possible way around this might be
to link Medicare data to Medicaid data for those states that provide ambulatory medication in-
formation for the subsample of Medicare patients dually covered by Medicaid (i.e., the poor and
disabled elderly population). By and large, however, effectiveness research directed at issues
involving medications, which for hip fracture may be fairly important, will have to be done based
on data collected through means other than the HCFA files.
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HIP FRACTURE
Effectiveness of Surgical Interventions
35
The committee recommends that electiveness research on hip fracture
treatment alternatives develop scientifically based indications to determine
which patients should have the following: (1) open or closed reduction
with internal fixation, (2) prosthetic replacement of the femoral head, or
(3) primary total hip replacement.
Nonsurgical Management
Many- questions remain unanswered in the treatment of hip fracture
for the oldest old and the frail elderly populations. Anecdotal experience
suggests that a category of patients exists for whom standard care (i.e.,
surgical treatment) may not be indicated. Those who were minimally
functional before the fracture often remain so afterward. They undergo
a major operation at a very high cost (in physical, mental, and perhaps
financial terms), yet they return to their previous functional status and face
an extremely high probability of death within three to six months. Research
is needed to determine whether there is a subset of patients who sustain hip
fractures who are so disabled that the usual operative intervention offers
little if any functional gain. Recommendations for the treatment of the
frail elderly population, therefore, must be developed consistent with the
purposes of treatment. These include return to previous function, control
of pain, ease of nursing management at the site to which the patient will be
discharged, and the speed with which mobilization can be accomplished.
Current predictors of hip fracture treatment by nonsurgical means ap-
pear to include: inability to walk three months before the fracture, low
ADL status before admission, an impacted (i.e., compressed) fracture, and
cancer of the hip.7 It is possible now to analyze the HCFA administrative
databases (mainly in terms of mortality and some simple morbidity vari-
ables) to generate hypotheses regarding this ethical question. Information
not available from these existing files might be obtained through medical
record abstraction or other activities of the Medicare PROB. In the future,
health and functional status information should be matched with Medicare
Part A and Part B data.
~ These factors for predicting selection of nonsurgical treatment options are based on preliminary
results of a study being conducted by investigator at Lee RAND Corporation. Approximately
2,800 patients with hip fractures were selected from the Medicare files and their medical records
were abstracted to obtain information to clarify treatment selection factors. Approximately 5
percent of the patients with hip fracture were managed nonsurgically.
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36
Other Treatment Issues
EFFECTIVENESS INlTLt4TWE
The committee recommends that HCFA address four other clinical
treatment effectiveness issues: impact of comorbidity, patient predictors of
excessively long lengths of stay or high costs of care, better clinical data
sets, and payment incentives affecting clinical decision making. First is the
question of comorbidity and its observed effects on treatment choices and
outcomes. As noted elsewhere in this report, work is needed on patient
classification and risk stratification problems. One instrument cited by
the committee that might be used in effectiveness research to monitor the
impact of comorbidity is the Gonnella disease staging system. This severity-
of-illness classification system, which is based chiefly on the presence of
comorbid conditions, uses data that already appear in the HCFA Medicare
Part A files; thus, it might be useful now for risk stratification purposes.
Stratification by comorbidities may enable researchers to pose more precise
questions regarding timing and intensity of rehabilitation.
Second, work should be done to identify the clinical and demographic
variables that predict cost and utilization outliers, that is, those patients
who greatly exceed the average costs or institutional lengths of stay for
treatment of their hip fractures. Such research may provide important
clues to treatment effectiveness.
Third, the committee recommends that HCFA continue its efforts to
establish a valid and reliable clinical data sets for use in effectiveness
research. Additional mechanisms should be developed by which all data
sets (i.e., the administrative claims files and the files containing inpatient
clinical information) might be linked. Survey data, containing functional
and health status information, when linked to inpatient and outpatient
data, may ultimately provide an additional powerful input into treatment
effectiveness and outcomes research. The barriers that exist to linking
person-specific data bases from different sources are very great, however,
and issues of confidentiality and privacy must be addressed. In the near
future, therefore, the likely "linkage" will be on a population basis.
Finally, many committee members expressed concern that the payment
system may drive decision making for treatment choice. Monitoring utiliza-
tion trends can highlight odd or perverse patterns of use and direct policy
attention in such a way that treatment decisions will in future be made on
the basis of desired outcomes and not on the level of reimbursement.
Cone need for a minimal data set shared by all effectiveness research is implicit throughout these
recommendations. The appendix contains additional information on the Uniform Clinical Data
Set.
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HIP FRACTURE
i]
37
Rehabilitation
The committee recommends that three rehabilitation questions receive
priority consideration in effectiveness research because of their importance
to health status and quality of life:
1. What are the appropriate rehabilitation programs for different
kinds of hip fractures?
2. What rehabilitation programs are most appropriate for different
kinds of patients?
3. Which sites for delivery of rehabilitation services are most effective
n outcomes and cost?
Professional uncertainty exists in matching rehabilitation programs to
type of fracture. There is no firm consensus on extensiveness, for example,
intensity of physical or occupational therapy or emotional counseling as a
function of type of fracture.
Rehabilitation after hip fracture is highly sensitive to cognitive, phys-
ical, and functional status before the fracture. Some elderly people who
fracture a hip are healthy and have no ADL or IADL impairments; others
have numerous problems that predispose them to falls and fractures. The
increased prevalence of chronic conditions in those most at risk for hip
fracture make the issues of data reliability, validity, and comprehensiveness
particularly important. Certain coexisting ailments (e.g., dementia, depres-
sion, and chronic infections) may also inhibit the rehabilitation process.
Assessment must not only determine the presence and severity of these
conditions but also monitor their impact on the outcome of hip fracture
treatment. The proper management of coexisting illnesses is potentially as
important in rehabilitation as the type of fracture or the surgical procedure
elected.
Again, information on cognitive and physical function is generally not
available from the administrative data set and often not from the medical
record. The committee noted that a long-range goal for HCFA should be
to incorporate this information into the medical record and claims data. In
the short run, primary data collection will be required.
Rehabilitation outcomes may also depend on the availability and uti-
lization of appropriate services following acute care. The density of avail-
able rehabilitation beds per population, the availability of appropriate
personnel in home health agencies, and access to outpatient physical and
occupational therapy are all important.
The committee recommends that HCFA concentrate its effectiveness
research for rehabilitation on four areas: (1) minimal data set, (2) timing
and intensity, (3) longitudinal follow-up across settings of care, and (4)
hypothesis generation.
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38
Establishment of a Minimal Data Set
EFFECTIVENESS INITLfT[VE
Section 9305(h) of the Omnibus Budget Reconciliation Act (OBRA) of
1986 mandated the development (but not the implementation) of a uniform
needs assessment instrument by the Secretary of DHHS. Its content will
include measures of functional capacities, nursing care requirements, and
the social and family supports that are available. The instrument would be
used to evaluate the needs of patients for posthospital extended-care ser-
vices, home health services, and long-term-care sentences of a health-related
or supportive nature, and the data would be used by hospital discharge
planners, home health care agencies, other health care providers, and
Medicare fiscal intermediaries and carriers. It might also be used to deter-
mine whether payment for long term care should be approved. A different
requirement item from OBRA 1987 is for a uniform minimum data set
for nursing homes.9 The committee strongly supports these developmental
efforts and further field testing.
Timing and Intensity Issues in Rehabilitation
Medicare currently covers 100 days of rehabilitation services and nurs-
ing home care when a potential for improvement can be demonstrated.
Electiveness research could help define appropriate services and time
frames for benefits that are effective in terms of both health status and
cost. Sites appropriate for analysis include acute care hospitals, reha-
bilitation hospitals, extended-care facilities, home settings when the care
is rendered through home health agencies, and other settings delivering
relevant outpatient care. Medicaid files might also be used to capture
intermediate care facility utilization.
Longitudinal Follow-up
A major deficit in the knowledge of hip fracture rehabilitation is
outcomes over time. Detailed health status information before fracture
is not usually available. The current Medicare benefit structure permits
tracking of patients across only a limited number of settings, for example,
in acute and rehabilitation hospitals but not skilled nursing facilities after
100 days.
9An advisory panel appointed by the Secretary of DHHS has developed a draft of the uniform
needs assessment instrument that was reviewed by interested organizations, associations, and
provided. As of November 1989, a final instrument had been prepared but not yet transmitted
to the U.S. Congress by the Secretary of DHHS. Both this effort and the uniform minimum data
set for nursing homes are being coordinated by the Office of Survey and Certification, Health
Standards and Quality Bureau, HCF~
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HIP FRACTURE
39
Nevertheless, the results of rehabilitative care should be examined in
different settings to determine whether Medicare program operations and
coverage benefits limit those outcomes. Such outcome information obtained
over time is critical if appropriate and effective alternatives for rehabilitation
are to be identified. Put another way, this information is needed to decide
what services should be made available to Medicare beneficiaries, and to
avoid policies that may make outcomes worse. Governmental behavior, as
well as provider and patient behavior, need to be critically evaluated in this
regard.
Hypothesis Generation
The possibility that the HCFA databases can be used to generate
hypotheses should not be overlooked. Often, a hip fracture signals a rapid
decline in health status and functional capabilities. Through the HCFA
data, variations within geographic areas and among different practitioners
might be examined to generate hypotheses regarding type, site, and intensity
of rehabilitation services; for instance, about the relative merits of providing
rehabilitation in the acute setting, a rehabilitation hospital, or at home.
These hypotheses could then be examined by linking HCFA data files to
other data bases or by funding experimental and quasi-experimental studies.
Hip Fracture in the Context of Aging
Few data are directed specifically to understanding what a hip fracture
actually represents biologically, that is, in terms of aging per se. If hip
fracture represents the accumulation of risk factors and therefore is a
clinical manifestation of decline, then it may be inappropriate (if the rate
of decline is moderate or rapid) to expect many individuals to return to
prefecture levels of functioning. If, on the other hand, the fracture is an
acute injury that itself can precipitate a major decline in an otherwise intact
individual, then treatment strategies must be developed to minimize side
effects or inadequate rehabilitation. Some experts suspect that, for some
people, hip fracture is a precipitating event and that, for others, it signals
a decline that is well in progress. Research is needed to determine how
to classify individual patients and how to apportion resources so that the
maximum recovery level for each person suffering a hip fracture can be
achieved at a reasonable cost.
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Representative terms from entire chapter:
effectiveness research
