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Conclusions Aside from the recommendations already cited, the hip fracture com- mittee reached three main conclusions. First, as in the breast cancer and acute myocardial infarction clinical workshops, the committee believes that the HCFA data sets, as presently constituted, can be best used to describe, track, and compare broad patterns of care for hip fracture according to subgroups of providers, practitioners, and patients. The committee fully supports these goals of the Effectiveness Initiative. The patient management areas identified as highest priority for effec- tiveness research prevention, treatment options, and rehabilitation reach beyond the capacity of the current HCFA databases. The scarcity of out- come measures (other than mortality) and of health and functional status information (both pre- and post-fracture) in the Medicare administrative databases makes them inadequate to adjust for case mix, to ascertain risk, or to determine the effectiveness of prevention, treatment, or rehabilitation interventions. These limitations, among others, emphasize the importance of developing strategies to acquire needed outcome and health and func- tional status data, either for the standard data sets themselves or for special projects and studies. Second, the Medicare files pose problems of data reliability and va- lidity. These limitations include inadequate descriptions of race, the im- possibility of expressing which one of a paired body part is involved in a procedure, and discrepancies between the numbers of identifiable cases based on the diagnosis and those identified by summing over the appropri- ate procedures. These and other difficulties obligate external users of these files to consult experts within HCFA during extramural research projects and to incorporate validity studies in all effectiveness research. 41
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42 EFFECTrVENESS INITL24TWE Third, the committee emphasized the need for coordination among DHHS agencies that are responsible for effectiveness research. This should minimize duplication of efforts and maximize current knowledge (e.g., in the development of a health and functional status measure that includes the concept of frailty). DHHS should develop a mechanism (e.g., a task force, requests for proposals, contracting, and grants) to accomplish this coordination. DHHS should also consult widely and continuously with clinicians and technical experts in these efforts. ~ this end, DHHS might empanel a high-level advisory committee of experts to provide oversight for effectiveness and outcomes research. This workshop represents an important step in hip fracture effective- ness research. Problems of patients, practitioners, and payers are addressed from a very broad perspective. Effectiveness research, done well, will have several benefits beyond its immediate scope: it will generate hypotheses for clinical and biomedical studies; it will provide a focusing mechanism for such research that is derived from the epidemiology of disease and its treatment, not simply from the science base; and it will stimulate a more comprehensive orientation to research that will in turn support clinical practice.