Background: The extent to which life expectancy can be extended through hip fracture prevention remains controversial because those at highest risk for hip fracture are frail and elderly. The Medicare Current Beneficiary Survey (MCBS) provides detailed longitudinal data on health and function that allow this question to be addressed.
Objective: To assess hip fracture as a determinant of early and late mortality in MCBS participants followed for incident hip fracture and death over the period 1997-2001.
Methods: MCBS cost and use files from participants first interviewed between 1996 and 2000 were linked with an incident hip fracture cohort identified through Medicare claims data over the period 1997 to 2001. Cox proportional hazards regression models with time-varying covariates were used to examine associations between mortality among Medicare beneficiaries 65 years and older followed through 2001. In these analyses we explored hip fracture's association with early (within six months) versus late (after six months) mortality. Comorbidities, income, place of residence, self reported health, marital and smoking status, and activities / instrumental activities of daily living (ADL/IADL) were updated at each MCBS interview or until a hip fracture occurred. Interactions between fracture and gender, fracture and race, and fracture and place of residence (facility-dweller vs. others) as a correlate of mortality were also examined.
Results: Among 25,178 MCBS survey participants (mean age 76 years, 58% female, 8.3% African-American, 6.5% facility-dwelling, 4.7% previous hip fracture), 77.4% were alive at the end of 2001 and 739 had a hip fracture following their first interview. Relative risk (RR) of both early 11.6 (95%CI: 8.9, 15.1) and late death 1.4 (95%CI: 1.2, 1.6) were significant when adjusting only for age, sex and race. When adjusting also for insurance status and comorbidities using administrative claims data, relative risks of both early death 7.6 (95%CI: 5.8, 9.9) and late death 1.2 (95%CI:1.0, 1.4) remained elevated. When further adjusting for pre-fracture ADL/IADL, socioeconomic status, facility residence, body mass index, other self-reported comorbidities and overall health status only mortality within six months was significantly increased (RR for early death 6.3 (95%CI: 4.9, 8.3); RR for late death 1.0 (95%CI: 0.9, 1.2)). Interactions with gender, race, facility-dwelling status and fracture were not statistically significant with RRs close to 1.0.
Conclusion: Hip fracture is associated with early excess mortality; however, we found no evidence of longer-term excess risk. Although hip fracture prevention may be of limited benefit in extending life expectancy due to multiple competing mortality risks faced by the elderly, the impact of fracture on quality of life should also be considered.
Disclosure Information:
Faculty Member's Name: Ana Tosteson, ScD
I have no relationships to disclose.
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