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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

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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.

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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:

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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

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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)