Osteoporosis International

, Volume 24, Issue 3, pp 801–810 | Cite as

Magnitude and consequences of misclassification of incident hip fractures in large cohort studies: the Study of Osteoporotic Fractures and Medicare claims data

  • J. T. Schousboe
  • M. L. Paudel
  • B. C. Taylor
  • B. A. Virnig
  • J. A. Cauley
  • J. R. Curtis
  • K. E. Ensrud
Original Article



In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report.


Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported.


We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF.


Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06–1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data.


A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).


Cohort studies False-negative ascertainment of fractures Hip fracture Medicare claims data Misclassification of fractures 


Source of funding

The Study of Osteoporotic Fractures (SOF) is supported by the National Institutes of Health funding. The National Institute on Aging (NIA) provides support under the following grant numbers: R01 AG005407, R01 AR35582, R01 AR35583, R01 AR35584, R01 AG005394, R01 AG027574, and R01 AG027576. Dr. Curtis receives support from the NIH (AR053351) and the Agency for Healthcare Research and Quality (R01HS018517). The purchase of the linked CMS administrative claims data was supported, in part, by a grant to Dr. Curtis from the Arthritis Foundation.


The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Conflicts of interest



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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2012

Authors and Affiliations

  • J. T. Schousboe
    • 1
    • 2
  • M. L. Paudel
    • 3
  • B. C. Taylor
    • 3
    • 4
    • 5
  • B. A. Virnig
    • 2
  • J. A. Cauley
    • 6
  • J. R. Curtis
    • 7
  • K. E. Ensrud
    • 3
    • 4
    • 5
  1. 1.Park Nicollet InstituteMinneapolisUSA
  2. 2.Division of Health Policy and ManagementUniversity of MinnesotaMinneapolisUSA
  3. 3.Division of EpidemiologyUniversity of MinnesotaMinneapolisUSA
  4. 4.Center for Chronic Diseases Outcomes Research, Department of Veterans Affairs Health Care SystemMinneapolisUSA
  5. 5.Department of MedicineUniversity of MinnesotaMinneapolisUSA
  6. 6.Department of EpidemiologyUniversity of PittsburghPittsburghUSA
  7. 7.Division of Clinical Immunology and RheumatologyUniversity of Alabama at BirminghamBirminghamUSA

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