The broad objective of the proposed research is to provide clinical comparative effectiveness evidence aimed at identifying the most effective approaches to post-fracture care with a focus on secondary fracture prevention. While there has been much interest in improving post-fracture bisphosphonate use, the incidence of second fracture is greatest early after the first fracture?a time period in which pharmacological osteoporosis treatment will have little impact. We currently lack evidence regarding which post-fracture practices will reduce both short- and long-term secondary fracture incidence. We also lack evidence on interventions that might mitigate poor outcomes among the sub-group of elders who may not survive long enough to benefit from osteoporosis treatment. These knowledge gaps will be addressed by evaluating alternative post-fracture care strategies, encompassing the full spectrum of care delivery and medication use, across health systems and regions where differences in post-fracture care exist. By studying the large national population of fracture patients cared for in diverse settings (using Medicare claims data and Centers for Medicare &Medicaid Assessment files for inpatient rehabilitation, skilled nursing facilities, nursing homes and home health, all linked to Part D pharmaceutical data), we will be able to identify correlates of safe, effective post-fracture care. A multidisciplinary team expert in comparative effectiveness research will characterize the impact of variation in care patterns on secondary fracture, mortality, and health care costs.
Aim 1 will address 6-month risk of secondary fracture considering rehabilitation characteristics and use of drugs that increase fall risk.
Aim 2 will extend examination of secondary fracture incidence to 1 -year when access and adherence to osteoporosis treatment will become important.
Aim 3 will study outcomes among those at high-risk for mortality (e.g. nursing homes residents).
Aim 4 will use decision-analytic modeling to quantify the potential clinical and economic value of alternative interventions to improve post-fracture care. By evaluating the impact of alternative post-fracture care strategies in this proposal, the long-term health and economic consequences of specific interventions in post-fracture care can be more fully understood.

Public Health Relevance

Fractures lead to significant morbidity, mortality, and costs among the elderly. As the baby-boomer generation ages, it is critical that fracture prevention and effective treatment be undertaken aggressively, especially among people who have already had at least one fracture. We will identify targets for intervention that have the potential to improve outcomes for the large population of older adults who experience a fracture.

National Institute of Health (NIH)
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Comprehensive Center (P60)
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Dartmouth College
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Akkineni, Roopa; Tapp, Stephanie; Tosteson, Anna N A et al. (2014) Treatment of asymptomatic hyperuricemia and prevention of vascular disease: a decision analytic approach. J Rheumatol 41:739-48
Martin, Brook I; Franklin, Gary M; Deyo, Richard A et al. (2014) How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems. Spine J 14:1237-46
Martin, Brook I; Lurie, Jon D; Tosteson, Anna N A et al. (2014) Indications for spine surgery: validation of an administrative coding algorithm to classify degenerative diagnoses. Spine (Phila Pa 1976) 39:769-79
Weinstein, James N; Tosteson, Anna N A; Tosteson, Tor D et al. (2014) The SPORT value compass: do the extra costs of undergoing spine surgery produce better health benefits? Med Care 52:1055-63
Liu, Stephen K; Munson, Jeffrey C; Bell, John-Erik et al. (2014) Response letter to Herbert L. Muncie, Jr. J Am Geriatr Soc 62:998-9
Lurie, Jon D; Tosteson, Tor D; Tosteson, Anna N A et al. (2014) Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 39:3-16
Resnick, Daniel K; Tosteson, Anna N A; Groman, Rachel F et al. (2014) Setting the equation: establishing value in spine care. Spine (Phila Pa 1976) 39:S43-50
McGuire, Kevin J; Khaleel, Mohammed A; Rihn, Jeffrey A et al. (2014) The effect of high obesity on outcomes of treatment for lumbar spinal conditions: subgroup analysis of the spine patient outcomes research trial. Spine (Phila Pa 1976) 39:1975-80
Liu, Stephen K; Munson, Jeffrey C; Bell, John-Erik et al. (2013) Quality of osteoporosis care of older Medicare recipients with fragility fractures: 2006 to 2010. J Am Geriatr Soc 61:1855-62
Lurie, Jon D; Moses, Rachel A; Tosteson, Anna N A et al. (2013) Magnetic resonance imaging predictors of surgical outcome in patients with lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 38:1216-25

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