Abstract
Summary
Although fractures are associated with short-term reductions in functional status, there is limited information on longer-term burden of fracture. This study documents evidence of an association between fractures and significant declines and functional health and activities that persist but attenuate beyond two years.
Introduction
Although fractures are associated with short-term reductions in functional status and may have other short-term effects on healthcare utilization (hospitalization and follow-up care), there is limited information on long-term burden of fracture beyond 12 to 24 months post-fracture. Analysis of the long-term health burden can inform policymakers, health care practitioners, and payers.
Methods
We acquired a data set containing the 1992–2012 Health and Retirement Survey data linked to the same individuals’ Medicare claims. Fracture cases (n = 745) were matched to non-fracture controls using propensity scores matching. A regression-adjusted difference-in-difference (DD) approach was used to compare the change in functional status measures from baseline to two post-fracture periods for fracture cases relative to the change over the same time periods for matched controls. Self-reported measures of functional status were examined: limitations to activities of daily living (ADLs), limitations to instrumental activities of daily living (IADLs), a mobility index, a gross motor skills index, a fine motor skills index, and self-reported general health status.
Results
Fracture cases reported increases in limitations to ADLs, difficulties with mobility, difficulties with gross motor skills, and difficulties with fine motor skills in each HRS collection period (the survey is administered every 2 years) following the fracture or index date (thus up to two years later) than matched controls (all p values < 0.05). The magnitude of these effects diminished in the second post-fracture wave (two to four years after fracture/index date), but they were still statistically significant.
Conclusions
Results suggest that fractures are associated with significant declines in some measures of functional activities up to two years following the fracture. The effects persist beyond two years but are smaller in magnitude.
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Notes
We include only cases where the Medicare fracture date of service was prior to the HRS interview date.
See http://hrsonline.isr.umich.edu/sitedocs/userg/dr-008.pdf for a detailed list of the questions used from year to year. Generally, the questions are framed as “Because of a health problem, do you have any difficulty…” The specific difficulties for questions used in the mobility index are: (1) “with walking one block,” (2) “with walking several blocks,” (3) “with walking across a room,” (4) “climbing one flight of stairs without resting,” and (5) “climbing several flights of stairs without resting.”
See http://hrsonline.isr.umich.edu/sitedocs/userg/dr-008.pdf for a detailed list of the questions used from year to year. Generally, the questions are framed as “Because of a health problem, do you have any difficulty…” The specific difficulties for questions used in the gross motor skills index are: (1) “with walking one block,” (2) “with walking across a room,” (3) “climbing one flight of stairs without resting,” (4) “getting in or out of bed,” and (5) “bathing or showering.”
See http://hrsonline.isr.umich.edu/sitedocs/userg/dr-008.pdf for a detailed list of the questions used from year to year. Generally, the questions are framed as “Because of a health problem, do you have any difficulty…” The specific difficulties for questions used in the fine motor skills index are: (1) “with picking up a dime from a table,” (2) “with eating, such as cutting up your food,” and (3) “with dressing, including putting on shoes and socks.”
For the 1996 match, we dropped 127 comparison cases that were not within the common support (out of 3737 possible comparison cases). All 91 fracture cases in 1996 were within the common support. For the 1998 match, we dropped 263 comparison cases that were not within the common support (out of 3237 possible comparison cases). We dropped one fracture case in 1998 that was not within the common support (out of 114 fracture cases). For the 2000 match, we dropped 415 comparison cases that were not within the common support (out of 4454 possible comparison cases). All 85 fracture cases in 2000 were within the common support. For the 2002 match, we dropped 305 comparison cases that were not within the common support (out of 4654 possible comparison cases). All 100 fracture cases in 2002 were within the common support. For the 2004 match, we dropped 158 comparison cases that were not within the common support (out of 4568 possible comparison cases). All 82 fracture cases in 2004 were within the common support. For the 2006 match, we dropped 434 comparison cases that were not within the common support (out of 4229 possible comparison cases). All 91 fracture cases in 2006 were within the common support. For the 2008 match, we dropped 363 comparison cases that were not within the common support (out of 4032 possible comparison cases). All 88 fracture cases in 2008 were within the common support. For the 2010 match, we dropped 339 comparison cases that were not within the common support (out of 3910 possible comparison cases). All 97 fracture cases in 2010 were within the common support.
We explored using additional baseline covariates for propensity score matching, including whether individuals smoked (ever smoked), drank alcoholic beverages (measured as counts or whether respondent had 3+ per day), and engaged in 3+ hours of vigorous physical activities per week. These covariates were all statistically insignificant in predicting a fracture and did not affect the matching. Therefore, we chose the more parsimonious model with fewer covariates.
Here is a simplified version of the regression-adjusted DD model:
$$ {Y}_{i t}={\beta}_0+{\beta}_1{{\mathrm{Post}}_t}^{\ast }{\mathrm{Fracture}}_i+{\beta}_2{\mathrm{Post}}_t+{\beta}_3{\mathrm{Fracture}}_i+{\beta}_{4\ }{X}_i+{\varepsilon}_{i t} $$where \( \hat{\beta_1} \) is our estimated difference-in-difference; post = 1 in the period after the fracture and 0 in the pre-period; fracture = 1 for fracture cases and 0 for comparison cases; X is a vector of individual level (time-invariant controls). It does not matter which time-invariant covariates are included in X (or not included), because they are differenced out. To see this, consider what \( \hat{Y_{\mathrm{i}}} \) is for both fracture and comparison cases in the pre- and post-periods; then examine the first differences (last column) where we look at the change in Y for each group.
Pre (post = 0) (column 1)
Post (post = 1) (column 2)
First difference (column 2–column 1)
Fracture (fracture = 1)
β 0 + β 3 + β 4 X i + ε it
β 0 + β 1 + β 2 + β 3 + β 4 X i + ε it
β 1 + β 2
Comparison (fracture = 0)
β 0 + β 4 X i + ε it
β 0 + β 2 + β 4 X i + ε it
β 2
Difference-in-difference
β 1
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Kandice Kapinos, Shira Fischer, Andrew Mulcahy, and Orla Hayden are employees of the RAND Corporation, which received an unrestricted grant from Amgen for this research. Lionel Pinto and Rich Barron are employees of Amgen.
Sponsor’s role
This project was supported by Amgen Inc. under a contract that provided for independent analysis by the authors. The role of the sponsor in each phase of the research was as follows. Design and conduct of the study: the sponsor requested a proposal for analysis from the authors. The authors and the sponsor designed and proposed the study, which the sponsor accepted. The authors conducted the study. Collection, management, analysis, and interpretation of the data: the authors obtained access to the restricted data used in this study and managed, analyzed, and interpreted the data. The sponsor reviewed the output and provided feedback on results and modeling. Preparation, review, or approval of the manuscript: the authors prepared the manuscript. The manuscript was reviewed by the sponsor for comment, which the authors considered in further revisions. By contract, the authors had the authority to independently revise and submit the manuscript.
Appendix
Appendix
Event inclusion
Study wave
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Fischer, S., Kapinos, K.A., Mulcahy, A. et al. Estimating the long-term functional burden of osteoporosis-related fractures. Osteoporos Int 28, 2843–2851 (2017). https://doi.org/10.1007/s00198-017-4110-4
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DOI: https://doi.org/10.1007/s00198-017-4110-4