Abstract
This paper aims to identify risk factors for hip fracture in Medicare skilled nursing facility (SNF) residents and to develop a predictive model based on routinely collected administrative data (the Minimum Data Set, MDS) to identify high-risk residents. Prospective cohort study of 28,807 North Carolina Medicare SNF residents aged >65 years with a complete MDS assessment in 1999. Demographic, historical, physical, cognitive, behavioral, activities of daily living, and medication variables were obtained from the MDS. Hip fracture occurring after the first MDS assessment identified by ICD-9 code was the outcome measure. Variables significantly associated with hip fracture by chi-square test in a randomly selected derivation sample were combined in a multivariable logistic model and in models stratified by gender. The models were validated in the remaining subjects. Variables significantly related to subsequent hip fracture in the full cohort include: female sex (odds ratio 1.3, 95% confidence interval 1.0–1.7), white race (2.3, 1.6–3.5), age (1.03 per year, 1.01–1.04), cognitive impairment (1.4, 1.8–1.8), incontinence (0.68, 0.5–0.9), prior fractures (1.6, 1.2–2.1), and prior falls (1.4, 1.2–1.8). In ambulatory non-Hispanic white women, anxiety (1.5, 1.0–2.1), anxiolytic use (1.4, 1.1–1.9), wandering (1.4, 1.0–2.2), and training in community skills (1.4, 1.1–1.8) were new significant variables. For ambulatory non-Hispanic white men, education level (2.0, 1.2–3.2), weight loss (0.5, 0.2–1.0), history of osteoporosis (3.0, 1.3–6.7), pathologic bone fracture (9.7, 2.2–42.6), COPD (2.1, 1.3–3.5), glaucoma (2.6, 1.0–6.2), and standing balance impairment (1.8, 1.0–3.3) were also significant. All models were highly correlated with subsequent hip fracture, but the discriminative ability was limited (c statistic 0.678). Risk factors explained more of hip fracture risk in non-Hispanic white men (c statistic 0.793) than non-Hispanic white women (0.658). Risk factors for hip fracture in Medicare SNF residents have similarities and differences from those previously identified in community-dwelling older adults. Osteoporosis screening and intervention should focus on the healthiest, most independent subset of residents who have the greatest fracture risk.
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Acknowledgements
Dr Colón-Emeric is supported by the Brookdale Foundation Academic Geriatrics Fellowship Program, the Hartford/AFAR Geriatric Fellowship Program, the Institute for Medical Research at the Durham VA Medical Center, and the Claude A. Pepper Older American's Independence Center AG-11268. Dr Lyles is supported by the VA Medical Research Service and AG-11268. The analyses upon which this publication is based were performed under contract no. 500-99-NC03 entitled 'Utilization and Quality Control Peer Review Organization for the State of North Carolina', sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the authors concerning experience in engaging with issues presented are welcomed.
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Colón-Emeric, C.S., Biggs, D.P., Schenck, A.P. et al. Risk factors for hip fracture in skilled nursing facilities: who should be evaluated?. Osteoporos Int 14, 484–489 (2003). https://doi.org/10.1007/s00198-003-1384-5
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DOI: https://doi.org/10.1007/s00198-003-1384-5