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Objectives To determine whether slow gait speed increases the risk of costly long-term nursing home residence when accounting for death as a competing risk remains unknown. Design Longitudinal cohort study using proportional hazards models to predict long-term nursing home residence and subdistribution models with death as a competing risk. Setting Community-based prospective cohort study. Participants Older women (mean age 76.3) participating in the Study of Osteoporotic Fractures who were also enrolled in Medicare fee-for-service plans (N = 3,755). Measurements Gait speed was measured on a straight 6-m course and averaged over two trials. Long-term nursing home residence was defined using a validated algorithm based on Medicare Part B claims for nursing home-related care. Results Participants were followed until long-term nursing home residence, disenrollment from Medicare plan, death, or December 31, 2010. Over the follow-up period (median 11 years), 881 participants (23%) experienced long-term nursing home residence, and 1,013 (27%) died before experiencing this outcome. Slow walkers (55% of participants with gait speed <1 m/s) were significantly more likely than fast walkers to reside in a nursing home long-term (adjusted hazards ratio ( aHR) = 1.79, 95% confidence interval ( CI) = 1.54-2.09). Associations were attenuated in subdistribution models ( aHR = 1.52, 95% CI = 1.30-1.77) but remained statistically significant. Conclusion Older community-dwelling women with slow gait speed are more likely to experience long-term nursing home residence, as well as mortality without long-term residence. Ignoring the competing mortality risk may overestimate long-term care needs and costs. [ABSTRACT FROM AUTHOR]

Summary: A performance algorithm can be successfully used by bone density technologists at the time of a bone density test to identify patients with an indication for vertebral fracture assessment (VFA). Doing so appropriately increases physician prescription of fracture prevention medication. Introduction: Densitometric spine imaging (vertebral fracture assessment, VFA) can identify prevalent vertebral fracture but is underutilized. We developed an algorithm by which DXA technologists identify patients for whom VFA should be performed. Following this algorithm, VFA was performed in patients whose lowest T-score (lumbar spine, total hip, or femoral neck) was between −1.5 and −2.4 inclusive and with one of the following: age, ≥65 years; height loss, ≥1.5 in.; or current systemic glucocorticoid therapy. Our main objectives were to assess change in VFA utilization at two other healthcare organizations after algorithm implementation, and to estimate the association of VFA results with prescription of fracture prevention medication. Methods: The proportions of patients with an indication for VFA who had one performed before and after algorithm implementation were compared. Logistic regression was used to estimate the multivariable-adjusted association of VFA results with subsequent prescription of fracture prevention medication adjusted for healthcare organization (study site). Results: After algorithm introduction, appropriate VFA use rose significantly Patients with a VFA positive for vertebral fracture had an odds ratio of 3.2 (95 % C.I., 2.1-5.1) for being prescribed new fracture prevention medication, adjusted for age, sex, prior clinical fracture, use of glucocorticoid medication, femoral neck bone mineral density T-score, and study site. Conclusions: An algorithm to identify those for whom VFA is indicated can successfully be implemented by DXA technologists. Documentation of vertebral fracture increases prescription of fracture prevention medication for patients who otherwise lack an apparent indication for such therapy. [ABSTRACT FROM AUTHOR]

Summary: In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report. Introduction: Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported. Methods: We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF. Results: Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data. Conclusions: A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures). [ABSTRACT FROM AUTHOR]