Every year, one in 10 older people fall and sustain injury requiring medical care. Fall-related injury is the number one cause of accidental death in older Americans. However, fall injury is rarely considered as a outcome in controlled trials, which have traditionally focused on death and cardiovascular events. Until recently, we lacked methods of capturing fall-related injury in large healthcare databases. We will first use the Health and Retirement Study, a national study of older Americans, to develop a method of classifying severe fall injury in found in Medicare claims data across acute, ambulatory, and long-term care (Aim 1). Next, we will study how a national healthcare system, the Veterans Health Administration (VHA), delivers aggressive hypertension care (AHC) and whether AHC results in net benefit or harm due to cardiovascular events and severe fall-related injury. Hypertension is the single most common chronic condition in older adults. Medication treatment prevents important cardiovascular events (strokes, myocardial infarctions and heart failure), however also contributes to risk of falls. We do not fully understand the net benefits and harms among our oldest patients in clinical practice, especially after age 75 - those most prone to severe fall-injury. Thus, we aim to study the net harms and benefits associated with AHC, defined as low blood pressure (BP, <130/65 mmHg) and prescribed =3 BP medications. We have demonstrated that the VHA, a national leader in hypertension care, has used performance measures to improve care but increased rates of AHC - especially among older Veterans. The average BP for those with AHC was 114/58 mmHg - lower than the aggressive treatment arm in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. A study that captures AHC, achieved BP, and falls injury is needed. Such a study is not possible anywhere except in the VHA. In the VHA, we have carefully used sophisticated electronic databases to identify the older patients with AHC. We will study whether certain types of VHA facilities are more likely to deliver AHC to their older patients (Aim 2), then test whether AHC increases short-term risk of injurious falls (Aim 3A). Last, we will compare whether net harm results from AHC when considering both severe fall-related injury and cardiovascular events (Aim 3B). This research will inform which patients and facilities should be targeted for future efforts to reduce AHC. Innovation. This research includes innovative methods of using claims data across acute, ambulatory, and long term care data and cutting-edge statistical methods of modeling multiple outcomes to determine whether the harm of AHC outweighs the benefit of cardiovascular event reduction. Impact. Optimizing risks and benefits of approaches to hypertensive care is patient-centered and has implications for the broader health and care of older adults. At the patient level, health care information about low benefit and potential harm is critical to make informed decisions. At the population level, improved methods of optimizing treatment targets can apply to broader clinical tradeoffs in older patient populations.

Public Health Relevance

Hypertension is the most common condition among older patients, and many older individuals take medications to reduce their risk of cardiovascular disease. However, for older patients with multiple medical conditions, aggressive treatment with multiple cardiac medications is associated with increased falls. The most severe falls result in injuries such as hip fractures that can be as devastating and costly as cardiovascular events such as strokes. This is a study to use electronic health record, interviews, and Medicare data from two large national datasets, the Health and Retirement Study and the Veterans Health Administration. We will study whether older patients with Aggressive Hypertension Care (AHC) have an increase in risk of falls that outweighs their cardiovascular benefits. This research will have future impact on public health efforts, e.g., better determination of which patients should be recommended more modest blood pressure targets due to their increased risk of falls. In addition, the results will help patients and their doctors to make more informed choices and weigh the risks and benefits of aggressive hypertension control.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
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Neurological, Aging and Musculoskeletal Epidemiology (NAME)
Program Officer
Salive, Marcel
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University of Michigan Ann Arbor
Internal Medicine/Medicine
Schools of Medicine
Ann Arbor
United States
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Hoffman, Geoffrey J; Ha, Jinkyung; Alexander, Neil B et al. (2018) Underreporting of Fall Injuries of Older Adults: Implications for Wellness Visit Fall Risk Screening. J Am Geriatr Soc 66:1195-1200