Major osteoporotic fractures are common, morbid, and costly among long-stay nursing home residents. Despite the importance of this problem, there are no guidelines to screen nursing home residents for osteoporosis, and it is unclear which osteoporosis medications prevent fractures in long-stay residents. To address these gaps of knowledge we propose the following specific aims: 1) develop and validate a prediction tool using clinical risk factors for falls and fracture that will estimate the 2 year absolute risk of hip fracture and the year absolute risk of major osteoporotic fracture (hip, humerus, and wrist combined) in long-stay nursing home residents;2) determine whether osteoporosis medications (i.e., bisphosphonates, calcitonin, estrogen, raloxifene, and teriparatide) reduce the incidence of hip and major osteoporotic fracture in long-stay nursing home residents;and 3) determine the clinical thresholds of risk at which osteoporosis medications reduce the incidence of hip and major osteoporotic fracture by e 20% in long-stay residents. This project will leverage an existing database that has previously linked claims data from Medicare Parts A and B with pharmacy data (Medicare Part D), clinical characteristics (Minimum Data Set), and facility level characteristics (OSCAR). Using this database we will conduct a prospective analysis on all U.S. nursing home residents enrolled in a Medicare fee-for-service plan and with e 90 day length of stay between the years 2006-2011 (>700,000 residents annually).
For specific aim 1, the prediction tools will be developed entirely from clinical information that is available for all U.S long-stay residents, such as cognitive and functional status, non-osteoporosis medication use, and recent history of falls. The prediction tools will account for the high mortality in nursing home residents.
For specific aim 2 a, we will determine whether osteoporosis medications reduce the incidence of hip and major osteoporotic fracture in long-stay residents by comparing the incidence of fracture among "new users" of an osteoporosis medication with the incidence of fracture in "non-users," matched by propensity scores.
For specific aim 2 b, we will determine a threshold for pharmacologic intervention by examining the efficacy of osteoporosis drugs according to baseline fracture risk, as estimated by the fracture prediction tool. The research team has experience in pharmacoepidemiology, geriatrics, and analysis of Medicare claims data and Minimum Data Set characteristics necessary to complete this project. Our findings will be highly significant as they will provide the first guidance on screening and treatment of osteoporosis in the nursing home setting. We anticipate that our findings will be easy for providers to implement because the fracture prediction tools will be comprised of clinical information that is already available for all U.S. nursing home residents. Knowledge gained from this study could ultimately result in a decreased rate of major osteoporotic fractures in the nursing home setting, with a subsequent reduction in morbidity and health care costs.

Public Health Relevance

Fractures are a major cause of morbidity and expense in the nursing home. The purpose of this project is to develop a screening tool for osteoporosis and to use the screening tool to determine a threshold at which osteoporosis medications prevent fractures. Implementation of this tool is likely to improve quality of care in nursing homes by reducing fractures and simultaneously reducing costs.

National Institute of Health (NIH)
Research Project (R01)
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Health Services Organization and Delivery Study Section (HSOD)
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Joseph, Lyndon
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Hebrew Rehabilitation Center for Aged
United States
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