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Appendix
Background and Conduct of the Workshop
STRUCTURE OF THE WORKSHOP
This appendix describes the hip fracture workshop project and docu-
ments the materials developed or used as background for the committee
discussions. Before the workshop, the Institute of Medicine (IOM) staff
distributed a set of background materials to the committee to familiarize
them with the Electiveness Initiative and the issues to be discussed. These
materials included information on the Medicare data files; current research
funded by the National Institute on Aging, the Centers for Disease Control,
the National Center for Health Services Research, and the Health Care
Fincancing Administration (HCFA); and abstracts from recently published
articles and presentations on hip fracture research relating to the use of ser-
vices, risk factors, prevention interventions, reimbursement, and efficacies
of various treatment regimens (see Bibliography, this volume).
In addition, IOM staff developed a brief exercise, which the committee
completed and returned before the workshop, to determine the committee's
views about high-priority research questions for hip fracture. Before the
workshop, committee members were asked to list three patient management
topics that should be given highest priority and, for each of the topics
nominated, to specify the types of studies that should be undertaken or
sponsored. The results of this exercise were presented at the outset of the
meeting.
The committee also received estimates on the incidence of hip fractures
in the elderly population of the United States and case-fatality rates for
those people. These data were compiled, in part, from the HCFA Medicare
49
OCR for page 50
so
APPENDIX
Provider Analysis and Review (MEDPAR) files and taken from preliminary
results of an ecologic study of factors associated with hip fracture.)
The workshop featured four background presentations: Rose Conner-
ton of HCFA, on the Medicaid/Medicare Decision Support System; Alfred
Rimm of the Medical College of Wisconsin, on risk factors and inci-
dence rates obtained from the administrative databases; Kenneth I. Shine
of UCLA (chair of the committee), on factors that the committee should
consider in recommending patient management topics; and Kim ~ Hei-
thoff of the IOM, on the results of the homework exercise. After extensive
discussion, the committee selected (by voting) the priority patient manage-
ment and methodologic issues and further delineated the primary research
strategies related to those issues. The executive session refined the final
recommendations of the committee.
HCFA DATA
Medicare/Medicaid Decision Support System
The description of the Medicare decision support system included a
simplified version of the flow of data into the Medicare systems. That flow
starts with entitlement and demographic data for about 33 million Medicare
beneficiaries that are obtained initially by the Social Security Administration
(SSA). Health care providers and contractors are the primary sources of
Medicare utilization data. Providers (e.g., institutional providers, home care
agencies, suppliers, and physicians) submit bills to fiscal intermediaries (for
Medicare Part A) and carriers (for Medicare Part B); they in turn adjudicate
and then pay the bills and pass them on to the system. These utilization
data are merged with the SSA demographic information. From these main
sources, several basic record groups are developed.
Basic Record Groups
The first record group is the Health Insurance Master (HIM) Enroll-
ment record, developed from the SSA file; these data, which are updated
daily, include dates of birth and death, sex, race, residence, dates of entitle-
ment, and dates of enrollment into health maintenance organizations. This
is a rich source of data for identifying beneficiaries and drawing samples for
follow-up research studies. The second file, the Provider of Service (POS)
Record, contains considerable information on hospitals, skilled nursing fa-
cilities, home health care agencies, independent laboratories, ambulatory
~ Requests for copies of these preliminary findings should be directed to Alfred A. Rimm, Med-
ical College of Wisconsin, Milwaukee.
OCR for page 51
APPENDIX
51
surgical centers, and similar providers for Medicare. The third and fourth
files are the Utilization Records for Medicare Parts A and B billing in-
formation, including hospital days of care, diagnoses, surgical procedures,
physician visits, charges, and payments. The fifth main record group is the
Provider Cost Report Record, which has cost, accounting, and other data
from participating institutional providers.
For effectiveness research, other "derivative" files may be important
sources of information: MEDPAR (Medicare Provider Analysis and Re-
view file), MADRS (Medicare Automated Data Retrieval System), and
BMAD (Medicare Annual Data System for Part B). The SSA-based HIM
file provides the beneficiary identification number and demographic infor-
mation; that information can be used to enter these files for more detailed
utilization information.
MEDPAR is a 100 percent file of Part A inpatient care (about 10
million admissions a year). Because it has person-level data with unique
identifiers, it can be used to identify individuals who have received inpatient
services related to the diagnosis of hip fracture. Among the information
elements on this file are principal and secondary diagnoses and surgical
procedures (ICD-9-CM [International Classification of Disease, ninth revi-
sion, clinical modification] codes), days of care, charges, and provider. This
file is updated quarterly.
MADRS is a newer 100 percent file that links Part A and Part B
data for all persons receiving inpatient hospital care; it currently exists for
1986, 1987, and 1988 and is updated monthly. It allows the creation of
episodes of care; Medicare-covered inpatient and outpatient care given to
a beneficiary before and after a hospitalization can be identified. For this
file, which contains about 250 million records per year, Part B (outpatient)
data are in summary form only.
The B MAD file is built on a 5 percent sample of beneficiaries and
contains about 21 million records, which are updated annually. It contains
somewhat more information than the MADRS file on all outpatient services
for this sample, such as expenditures, place and type of service, visits, and
procedures; the latter are coded using the HCFA Common Procedure
Coding System (HCPCS), which is based on CPT-4 (Current Procedural
Terminology, fourth version) codes.
An example was offered of how the existing basic record groups might
be used to conduct analyses related to hip fracture (especially to monitor
trends and examine variations in use of services). First, researchers would
select the ICD-9-CM code for hip fracture and then enter an inpatient
file to extract all records for individuals who had services with that code.
Then, because of the presence of unique beneficiary identifiers, the re-
searchers could enter a file that contains information, for each beneficiary,
on all institutional services and some summary data on outpatient care
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52
APPENDIX
(i.e., MADRS). Third, to obtain more detailed information on physician
and supplier services, researchers could then examine a file that contains
considerably more detailed data on a 5 percent sample of beneficiaries (i.e.,
BMAD).
Acquiring Additional Clinical and Outcomes Data
HCFA can obtain additional clinical information (such as data on
treatments administered and physiologic aspects of the disease itself) from
selected inpatient medical records. One mechanism may be through the
Medicare Peer Review Organizations (PROs) as part of the proposed
Uniform Clinical Data Set.
In 1987, HCFAs Health Standards and Quality Bureau began a com-
plex project to develop a data set for use by the Medicare Peer Review
Organizations (PROs) and the wider research community; it was intended
to contain far more detailed clinical-data than was heretofore available in
the HCFA data files. Known as the Uniform Clinical Data Set (UCDS),
this project is part of a set of steps meant to expand and improve the ability
of the agency to ensure the quality of care delivered to Medicare benefi-
ciaries, using the PROs as the principal mechanism. A second purpose of
the UCDS is to permit the development of more and better information
about what works in the practice of medicine, precisely the aim of effective-
ness research. The availability of extensive clinical information collected in
UCDS formats would support much more thorough and detailed analysis
of patterns of interventions and of outcomes than is possible simply with
billing data. Thus, for patients with particular medical conditions, such as
hip fracture, a large body of information could be made available to the
medical community and for intramural and extramural research.
The basic operating premise of the UCDS is that relevant clinical data
will be abstracted from medical records of all inpatient admissions that are
reviewed by the PROB. (This currently amounts to about 20 to 25 percent
of all Medicare admissions in a year, or about 2.0 to 2.5 million admissions;
of these, about 3 percent are a truly random sample of admissions, and
the remainder are cases mandated for review for various reasons.) PRO
personnel will abstract medical records either on-site or at a central office
using desktop or laptop computers.
The total number of data elements available on the UCDS is about
1,600, although not every datum element is needed or relevant for every
case. The contents of the UCDS fall into 10 major categories:
OCR for page 53
APPENDIX
I. Patient Identifying Information
II. Patient History and Physical Examination and
History and Physical Exam Findings
III. Laboratory Findings
IV. Imaging Findings and Other Diagnostic Test Findings
V. Endoscopic Procedures
VI. Operative Episodes
VII. Treatment Interventions
VIII. Medication Therapy in Hospital
IX. Recovery Phase
X. Patient Discharge Status and Discharge Planning
53
Detailed guidelines that describe precisely the data to be acquired have
been developed; for an example relating to hip fracture, see Able N1.
As of July 1989, the pilot-test phase was complete. Field testing of
the whole approach was under way and was expected to continue through
the summer and fall of 1989. An assessment and recommendation as to
whether to go forward with this approach was expected early in 1990.
HCFA is also working to develop mechanisms to collect quality-of-life and
other patient outcomes data more directly.
Hip Fracture Analyses Illustrating the Use of Medicare Data
Examples of the use of Medicare data in the analysis of hip fracture
were given by a designated representative of HCFA. Preliminary results of
a study designed to provide population-based estimates of the incidence
of hip fractures by age, sex, and race among the elderly population of
the United States and to estimate case-fatality rates for those people were
discussed. The study uses discharge data, obtained from HCFA and the
Department of Veterans Affairs, from all short-stay hospitals from 1984 to
1987.
These estimates are considered unique in that for the first time in this
country they will be based on an enumeration of essentially all hip fractures
occurring among the elderly in all regions of the country. Further, estimates
will include age-specific rates for the very old (age 85 and older). With
these estimates, detailed maps of the incidence of hip fracture will be
developed and combined into an atlas depicting the geographic variation in
incidence across the country. Further, seasonal variation will be assessed
through the detailed examination of dates of admission for 1984 to 1987.
PREWORKSHOP HOMEWORK EXERCISE
In a preworkshop homework exercise, which was conducted as a mod-
ified Delphi process, the committee members first nominated three major
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54
APPENDIX
patient management topics and then recommended research activities for
those specific topics. The committee reached considerable consensus in
the first round of this process. Nearly 75 percent of the responses fell into
the categories of prevention (identification and modification of risk factors,
dissemination of preventive practice information, and timing of preventive
interventions); treatment options (determinations of treatment modality and
need for meaningful outcome measures); and rehabilitation (timing, inten-
sity, and site of service; structure and process of a prototypical program;
and linkage to outcome measures). Other topics mentioned at least once
were related to postoperative management, emotional components of re-
covery, and identification of potential sites of care and their relation to cost
and outcome. A second round of voting was held at the workshop itself.
The committee reaffirmed prevention, treatment options, and rehabilitation
as the three priority patient management issues in those with hip fractures
that it would recommend to HCFN Able A2 provides a summary of these
topics.
Thbles N3 through A9 present the results of the second part of
the exercise, in which committee members specified potential research
strategies for seven main categories of priority patient management topics.
The information in these tables represents the views of skilled clinicians,
some of whom specialize in the care of patients with hip fracture, and
experts in research and other disciplines needed for successful effectiveness
research. The workshop format did not permit a full discussion of all
the issues raised by these committee members, but the breadth of topics
included here provides guidance for a rich research agenda for future years.
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APPENDIX
55
TABLE A.1 Selected Data Elements Related to Hip Fracture Recorded for the Proposed Uniform
Clinical Data Set
OPERATIVE EPISODES
This section refers to operating room procedures. Operative episodes are those that occur in the
operating suites under anesthesia or that would generally be perforTned in the operating suites but
were not because of emergency or patient condition.
One operative episode may involve more than one operative procedure. For example:
Laparotomy and Cholecystectomy and Splenectomy = 1 operative episode = 3 procedures
= 3 procedures codes.
For each operative episode, record the month and day. If the surgery occurred around
midnight, record the date that anesthesia began.
Date:
TREAI~IENT INTERVENTIONS
3. Professional Services
(month)
(day)
3. You are required to enter the procedure codes (lCD-9-CM) that apply to each operative
episode. To access the computer screen lo enter these codes, change F to T and enter
all procedure codes which apply per operative episode.
Surgical Wound Classification (SWC)
You are required to enter the surgical wound classification (SWC) as assigned in the
operating room utilizing the following numbers.
Operating wound, clean
Operating wound, clean contaminated 2
Operating wound, contaminated
Operating wound, dirty
Not documented
4
9
If any of the following professional services were utilized at any point in this hospitalization,
change F to T and record all applicable services.
Physiotherapy
Occupational therapy
Clinical nutrition
Respiratory therapy
Speech therapy
Social work
Clinical pharmacist
Vocational services
Palliative care (of hospice type)
Prosthetics/orthotics
Pastoral care
Psychiatric counseling/care
Patient education
F
F
F
F
F
F
F
F
F
F
F
F
F
SOURCE: Resource Manual for Uniform Clinical Data Set (UCDS)tt prepared by Case Mix
Research, Queens University Department of Community Health and Epidemiology, Kingston,
Ontario, Canada in association with Wisconsin Peer Review Organization (WIPRO), Madison,
Wisconsin, 1988.
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56
APPENDIX
TABLE A.2 Patient Management Topics Nominated by the Hip Fracture Committee in Round
One of the Preworkshop Homework Exercise
A. General (4 percent of responses)
Balancing post operative management, outcome, and cost
Consideration of emotional components in recovery
Consolidation of hip fracture research information
B. Prevention (27 percent of responses)
Identification of and modification strategies for risk factors:
frailty, osteoporosis, falls, and hip fracture
Dissemination of preventive practice information
Timing of preventive interventions
C. Treatment Options (18 percent of responses)
Need for additional information on the most elective type of surgery for specific type
of fracture
Need for improved outcomes research
Nonsurgical option for the very disabled patient
D. Prevention/Managment of Secondary Complication (9 percent of responses)
Prophylaxis of phlebitis and pulmonary embolus
Use of readmission data to assess and improve quality of care
Use of geriatric assessment to prevent secondary complications
Adapting the hospital structure to meet the needs of the frail elderly
E. Rehabilitation (27 percent of responses)
Timing, intensity, and site of rehabilitative services
Classifying patients for appropriate level and type of rehabilitative services
Prototype rehabilitation program: structural and process components
Outcome measures: the need to determine effectiveness of rehabilitation services
F. Site of Care (7 percent of responses)
Identification of potential sites of care and appropriate type of service per site
Relationship of site of care to outcome
G. Outcome Measures (4 percent of responses)
Identification of relevant and meaningful patient and provider outcome measures
TABLE A.3 Summary of Research Issues and Activities Recommended for Hip Fracture
(general category, not classified elsewhere)
I. Emotional Well-Being
A. Determine how and under which circumstances emotional well-being
(especially level of depressive symptoms) can be treated with resultant
improvement in rates and degree of recovery achieved by 2 or 12 months
Research Strategies:
A. Design and conduct observational treatment outcome studies
B. Undertake randomized trials of different mental health programs and
approaches with homogeneous groups of depressed individuals (those with major
depression and those having symptoms of depression but not reaching diagnostic
criteria)
II. Linking Information
A. Determine the best method to provide linkage or integration between hip
fracture-related studies and activities
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APPENDIX
TABLE A.4 Summary of Research Issues and Activities Recommended for Prevention
Activities in Hip Fracture
57
I. Determination of Risk Factors
A. Determine which factors contribute to the incidence of hip fracture
Research Strategies:
A. Conduct randanized, controlled trials designed to:
1. Prevent frailty in elderly people at risk
2. Reduce frailty in those who already are frail
B. Fund large scale studies (possibly, multi-center collaborative studies), combining
behavioral and social interventions with physical interventions
1. Examine pre- and postfracture for possible effects on incidents
2. Determine prevention options that arise from this analysis
II. Cost and Effectiveness of Prevention Interventions
A. Determine the effects of patient's health, life-style and socioeconomic
circumstances pro- and postfracture on cost and effectiveness of treatment
B. Determine effective methods (i.e., system changes, economic incentives, education)
for incorporating efficacious preventive practices (i.e., prescribing estrogen therapy
for women at risk for osteoporosis) into the everyday routine of all community-
. . . .
practlcmg primary care provlc ers
Detennine whether improvements in flexibility, cardiac endurance, and muscle
strength for the frail elderly can be carried over to function in everyday life
thereby reducing the incidence of hip fracture
1. Determine duration of these effects on functional status
2. Determine what personal and environmental factors enhance such
interventions
3. Determine the most effective method of preventing hip fracture (i.e., estrogen
therapy versus calcium replacement versus both versus nothing)
Research Strategies:
A. Conduct demonstration studies designed to change practice styles of community
practicing physicians
1. Population of interest: practicing primary care physicians from all settings
2. Evaluate methods for influencing this change - via prospective trials
3. Design studies to evaluate effectiveness of "efficacious" practices of
prevention
C.
III. Using the Administrative Data Bases to Predict Fracture
A. Determine whether the frequency of trauma predicts fracture (i.e., if you can
prevent trauma can you prevent fracture?)
Hypothesis: loose with frequent trauma are more likely to have a subsequent
fracture
B. Determine whether the frequency of claims predicts fracture (i.e., are fractures a
marker for deterioration?)
Research Strategies:
A. Historical-prospective studies to:
1. Examine link between soft tissue injuries and subsequent fractures
2. Explore the relationship of claims for treatment to hip fracture
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58
TABLE A.4 (Continued)
APPENDIX
IV. Prevention of Falls
A. Determine effective interventions for the prevention of falls in people age 65 and
older
1. Identify persons at greatest risk of fall and fracture
2. Identify failers at greatest risk for fracture
Research Strategies:
A. Develop risk profile for failers who fracture their hips
B.
C.
D.
Test multifactorial interventions to reduce risk of fall in large cooperative studies
Design etiologic studies to elucidate risk factors for falls
Implement focused interventions to demonstrate that individual risk factors can be
modified
Use HCFA data to create population-based injury surveillance systems to identify
fall-related fractures
V. Prevention of Osteoporosis
A. Determine whether estrogen replacement or supplementation reduces the risk of hip
fracture in the elderly Medicare or Medicaid population of women
B. Determine whether thiazide diuretics, which decrease urinary calcium loss, reduce
bone loss and hip fractures in people age 65 or older. Determine how long
preventive therapy/intervention should be applied to maximally reduce the
incidence of fractures
Determine the benefit of starting preventive therapy for osteoporosis before the
menopause
Research Strategies:
A. Design case-control studies of patients on Medicaid who suffer hip fractures
(stratify by age, race, and home status). Compare patients who have had treatment
with estrogen as documented in Medicaid prescription drug records
B. Conduct clinical trial in small sample (200-300 subjects) to determine whether
thiazide diuretics decrease loss of bone mass at the proximal femur in people age
65 and older
C. Conduct larger clinical trials to determine whether thiazide diuretics decrease the
incidence of hip fractures in this population
D. Collect data on estrogen replacement therapy in a large cohort to determine how
long it must be administered to reduce the fracture incidence maximally
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APPENDIX
59
TABLE A.5 Summary of Research Issues and Activities Recommended for Treatment Alternative
Selection in Hip Fracture
... .
I. Develop Guidelines for Selecting Treatment Alternative
A. Determine under what circumstances a patient with a hip fracture should be treated
by a surgical procedure other than nailing
B. Determine whether patient outcomes are clearly better for patients with fracture of
the femoral neck treated with reduction and fixation or endoprosthesis
C. Determine whether there is a subset of patients who sustain hip fractures who are so
disabled that the usual operative intervention offers little functional gain; and
therefore, nonoperative supportive treatment only should be considered
D. Determine the differences in long-tem~ functioning of total hip replacement
compared with that of head replacement compared with that of internal fixation;
determine the mortality implications
E. Determine the best approach for surgical management of the patient with femoral
neck or intertrochanteric fractures
Research Strategies:
A. Patient stratification by specified fractures (subcapital, neck, intertrochanteric) for
surgical procedure selection
1. Open or closed reduction with internal fixation
Prosthetic replacement of femoral head
Primary total hip replacement
Nonoperative supportive treatment
Controlling for:
a. Prefracture health status
b. Prefracture physical and cognitive functioning
c. Access to community care
B. Convene physician consensus panel:
1. To detemmine which patients should be treated by a surgical procedure other
than nailing
2. To determine whether outcomes are clearly better for patients with fracture of
the femoral neck treated with reduction and fixation or endoprosthesis
C. Design observational, prospective studies and randomized clinical trials to follow
patients with fracture of the femoral neck treated with reduction and fixation or
endoprosthesis to assess outcomes
D. Conduct a randomized study of parallel groups of operated and nonoperated patients
(severely disabled) to assess outcomes
E. Conduct randomized clinical trials with mortality, ambulatory status, and functional
status as outcomes to determine the optimal hospital regimen for hip fracture care
Use chart review and follow-up studies after hospital treatment to measure outcomes
of patient subgroup for which nonsurgical treatment was selected and compare them
with a matched sample for which surgical treatment was selected
G. Monitor data bases and determine by type of fracture
1. Time to surgery
2. Type of surgery
3. Postoperative rehabilitation services
4. Use of services
5. Length of stay
6. Postoperative complications
7. Cost of care
8. Prefracture health and functional status
9. Short- and long-term outcomes
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60
TABLE A.S (Continued)
APPENDIX
L.
Analyze Medicare database to assess available outcomes of a very elderly patient
group with severe comorbidities and dementia
I. Monitor trends in the population for individuals receiving different forms of therapy;
establish the relationship of the type of surgery performed to subsequent
hospitalizations, recurrent fractures, length of stay in nursing homes, or time to death
Monitor geographic variation 'end trends in procedures to determine the advantage in
long-term functioning and mortality of total hip replacement over that of head
replacement over that of internal fixation
K. Monitor trends in the population for individuals receiving different forms of therapy
to determine the best approach for surgical management of the patient with femoral
· neck or intertrochanteric fractures
Analyze the relationship of the type of surgery performed to subsequent
hospitalizations, recurrent fractures, length of stay in nursing homes, and time to
death
M. For specified fractures (subcapital, neck, and intertrochanteric) and surgical
treatments (internal fixation, replacement of femoral, head and total hip replacement),
determine the differences in length of stay, readmission change in premorbid home
status, survival, and use of hospital
N. Link MEDPAR/BMAD-relevant tape to the Medicaid files to 'analyze factors related
to:
1. Nursing home placement
Home health utilization
Ambulatory treatment
Medication utilization
Outcomes of interest include:
Mortality-early and late
Morbidity
Second operation
Secondary complications
Readmission
Functional recovery (short and long term)
II. Feedback and Education to Practicing Physicians
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APPENDIX
TABLE A.6 Summary of Research Issues and Activities Recommended for Preventionl
Management of Secondary Complications in Hip Fracture
61
I. Complications of Interest
A. Phlebitis
B. Pulmonary embolus
II. Patient Management Issues
A. Determine whether a geriatric assessment or consultation procedure early in the
course of a hospital stay has an impact on the rate of secondary complication
postfracture
B. Determine whether examination of readmissions data is a valuable method of
judging quality of care; can readmission data identify specific links to correctable
problems in performance?
Determine whether hospitals and institutions that are basically organized for efficient
care of younger adults, can be adapted to support the functional recovery of frail
elderly people
D. Determine the structural and process components of a model geriatric program
Research Strategies:
A. Literature review
B. Randomized controlled trials
1. Implement randomized controlled trials to determine the impact of a geriatric
assessment on secondary complications by matching patients and hospitals and
using hospitals as the unit of study (controlling for geographic variation in
surgical practice)
2. Develop and evaluate model geriatric patient care units randomizing patients to
usual care or experimental setting; such studies should be preceded by modest
pilots of care strategies which attempt to match patient factors (including
cognitive impairment) to care strategies; studies should control for prefecture
function
3. Design randomized controlled trials to assess the efficacies of various prophylaxis
therapies
4. Conduct trials of effectiveness of current prophylaxis therapies in various clinical
settings (especially small and rural hospitals)
Controlling for:
a. Practice setting
b. Prefracture health and functional status
C. Using HCFA data
1. Analyze database to assess or determine
a. Effectiveness and efficacy of prophylaxis therapies
b. Occurrence of phlebitis and embolus
(and the resulting mortality and morbidity)
c. Geographic variations in use of services and outcome
d. Access to services
e. Utilization of services
f. Readmissions
Analyze database for available information regarding occurrence of phlebitis and
embolus, including mortality
3. Analyze database for geographic variations in the occurrence of phlebitis and
embolus, including mortality
4. Monitor trends and geographic variations in readmissions as an indicator of
secondary complications
5. Through examination of medical records, determine whether the coded diagnosis
indicates a problem readmission; compare readmissions to diagnosis mistakes
found in abstracted medical records as a way to pinpoint problems
III. Feedback and Education to Medical Profession
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62
APPENDIX
TABLE A.7 Summary of Research Issues and Activities Recommended for Rehabilitation Services
in Hip Fracture
I. Standards for Rehabilitation in Hip Fracture
A. Determine effectiveness of various structural and process components of rehabilitation
by:
1. Type of service
2. Site of service
a. Acute setting
b. Rehabilitation unit
c. Rehabilitation hospital
d. Skilled nursing facility
e. Intermediate care facility
f. Ambulatory programs
g. Home health services
3. Timing of services
4. Duration and intensity of services
5. Cost of service
Stratified by:
1. Prefracture health and functional status (including cognitive dimensions)
2. Type of fracture
3. Prefracture place of residence (community versus institution)
4. Socioeconomic factors
Outcomes measured over time (i.e., 6 weeks, 6 months, 1 year) including:
1. Health and functional status (including cognitive dimensions)
2. Rehospitalizations
3. Placement in long-term-care facility
4. Retum to community
5. Length of stay in nursing homes
6. Quality-of-life variables
7. Mortality
Research Strategies:
1. Monitoring of time trends of use of services
2. Analysis of geographic (population-based) variations in use of services and in
outcomes of care - Link MEDPAR, BMAD, and tape-to-tape files
Clinical demonstrations and observational studies
a. Define "ideal situation" programs for various levels of expectation
b. Implement "model" programs to test feasibility of defined programs
Study a selected population of individuals with hip fracture to determine
whether their outcomes differ on the basis of rehabilitation program
intensity and comprehensiveness
Study a selected population of individuals with hip fractures, by observing
their return to the horns setting as a function of the intensity of rehabilitation
services and any effect differences in intensity may have on later
quality of life (1 year)
4. Randomized clinical trials, to test those factors identified above.
3.
d.
II. Coordination of Services
A. Examine methods to better coordinate services inpatient to outpatient
1. Determine optimal length of service (i.e., hospital and nursing home stay, or home
care)
Study the effects of programs that involve family, friends, or paid caregivers and
whether they should be included in the rehabilitation process
Stratified by:
1. Prefracture health and functional status
2. Comorbidity
3. Social economic factors
Research Strategy:
A. Medicare waivers to evaluate alternative benefit options (e.g., longer hospital stay or
nursing home or home care)
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APPENDIX
TABLE A.8 Summary of Research Issues and Activities Recommended for Site of Service
Issues in Hip Fracture
63
I. Impact of Site on Rehabilitation
A. Determine whether a rehabilitation unit attached to a community hospital can be
adapted to the special needs of the geriatric hip fracture patients
B. Examine the potential role of a day hospital in the rehabilitation of the hip fracture
patients
C. Determine whether the length of hospitalization for hip fracture should be uniformly
long, with rehabilitation and physical therapy undertaken in the hospital, or whether
hospital stays should be shorter (even than the current diagnosis-related group
allowance), with almost universal discharge to a rehabilitation hospital for a lengthy
stay (if necessary)
D. Determine in cases of uncomplicated hip fracture requiring extended inpatient
rehabilitation, determine whether the type of facility materially affects long-term
outcomes
E. For comparable outcomes, determine whether one form of post-acute-care
rehabilitation costs less to deliver
F. Determine the relative costs and effectiveness of these sites for comparable cases
Research Strategies:
A. Heterogeneous nature of patients with hip fractures must be recognized
Stratify by prefecture:
1. Cognitive function
2. Physical function
3. Emotional well-being
B. Design prospective studies of recovery from hip fracture in different settings to
identify person and environment (social, psychological, and physical) factors that are
associated with good recovery and poor recovery.
1. The physical site must be stratified by:
a. Type of personnel
b. Competence of personnel
c. Management policy
The populations must be stratified by:
a. Age
b. Sex
c. Prefracture variables noted above
Individuals would be randomly assigned lo hospital care or early discharge and
transfer to the rehabilitation unit or hospital for rehabilitation
C. Existing Medicaid data could be linked to Medicare Part A and Part B data to
. . . . .
examine outcomes m nursmg home settings
D. Analyze differential length of hospitalization in terms of:
1. Cost implications
2. Outcome implications
3. Quality of care
Compare utilization of different fomms of post-acute care over rehabilitation time (i.e.,
possibly compare 1984 and 1988 data [sample of Medicare data])
F. Analyze geographic differences in post-acute-care utilization and outcomes in terms
of differences in service utilization (sample of Medicare data)
G. Analyze costs and outcomes through different patterns of post-acute-care
rehabilitation using patient-specific studies
OCR for page 64
64
APPENDIX
TABLE A.9 Summary of Research Issues and Activities Recommended for Outcome Issues in
Hip Fracture Not Included Elsewhere
I. Defining Outcomes
A. Determine measwes that represent relevant and meaningful (to patients as well as
providers) outcomes of the care of hip fractures
Research Strategies:
A. Conduct meta-analysis of existing literature
B. Convene consensus panels of experts in orthopedic surgery, geriatrics, ethics, and
rehabilitation medicine
C. Survey patients before and after fractures
II. Prognostic Stratification
A. Determine the relationship between length of stay (LOS) and outcome in hip
fracture (hypothesis: correcting for severity and comorbidity, length of stay predicts
outcome)
Research Strategy:
A. Using HCFA-Medieare files, identify the population of all individuals with hip
fractures that were treated surgically; for a sample of these individuals, using case-
mix severity adjusters, determine
1. Length of stay
2. Vital status at 30 days, 3 months, 6 months, 1 year, and 2 years
3. Functional status (as measured by interview)
Representative terms from entire chapter:
hip fractures
