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Scientific Articles   |    
Mortality Following the Diagnosis of a Vertebral Compression Fracture in the Medicare Population
Edmund Lau, MS1; Kevin Ong, PhD2; Steven Kurtz, PhD2; Jordana Schmier, MA3; Av Edidin, PhD4
1 Exponent, Inc., 149 Commonwealth Drive, Menlo Park, CA 94025
2 Exponent, Inc., 3401 Market Street, Suite 300, Philadelphia, PA 19104. E-mail address for K. Ong: kong@exponent.com
3 Exponent, Inc., 1800 Diagonal Road, Suite 300, Alexandria, VA 22314
4 Kyphon, Inc., 1221 Crossman Avenue, Sunnyvale, CA 94089
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Kyphon, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at Exponent, Inc., Menlo Park, California

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1479-1486. doi: 10.2106/JBJS.G.00675
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Abstract

Background: Vertebral compression fractures in women are associated with increased mortality, but the generality of this finding, as a function of age, sex, ethnicity, and region, among the entire elderly population in the United States remains unclear. The objective of this study was to assess the survival of the Medicare population with vertebral compression fractures.

Methods: We conducted a retrospective data analysis of Medicare claims generated by a 5% sample of all Medicare enrollees from 1997 through 2004. The patient sample consisted of all 97,142 individuals with a new diagnosis of vertebral compression fracture from 1997 through 2004. Controls were matched for age, sex, race, and Medicare buy-in status, with a five-to-one control-case ratio. The survival of a patient was measured from the earliest date of a new fracture until death or until the end of the study. The patients with a fracture were compared with the controls by calculation of the mortality rates, with use of Kaplan-Meier analysis and the Cox regression method. Demographic subpopulation analysis and analysis by comorbidity levels were performed as well.

Results: Medicare patients with a vertebral fracture had an overall mortality rate that was approximately twice that of the matched controls. The survival rates following a fracture diagnosis, as estimated with the Kaplan-Meier method, were 53.9%, 30.9%, and 10.5% at three, five, and seven years, respectively, which were consistently and significantly lower than the rates for the controls. The mortality risk following a fracture was greater for men than for women. The difference in mortality between the patients with a vertebral compression fracture and the controls was greatest when the patients were younger at the time of the fracture; this difference declined as the age at the time of the fracture increased.

Conclusions: This study establishes the mortality risk associated with vertebral fractures for elderly patients of all ages and ethnicities and both sexes in the Medicare population; however, it does not imply a causal relationship. The difference in mortality between patients with a fracture and controls is higher than previously reported, even after controlling for comorbidities.

Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Alan C. Dang, MD
    Posted on September 21, 2008
    Limitations of Using Large Databases for Clinical Research
    Dept of Orthopaedics, New England Musculoskeletal Institute, University of Connecticut Health Center

    To the Editor:

    Lau et al. described a correlation between vertebral compression fractures and mortality using Medicare data 1 .  To identify vertebral compression fractures, the authors used ICD-9-CM diagnosis codes 733.13, 805.0, 805.2, 805.4, 805.6, or 805.8.  Rao’s invited commentary noted that these codes do not account for the etiology and fail to discern between idiopathic and pathologic fractures 2 .  Patients with metastatic disease would likely have higher mortality rates than the age-matched population.  Unfortunately, these codes are not specific for vertebral compression fractures (see Table 1). 

    ICD-9-CM codes in the 805. x group account for any vertebral body, column, neural arch, pedicle, spinous process, or transverse process fracture 3 .  This imprecision makes definitive conclusions problematic. Increases in mortality may be associated with injuries from high-energy trauma responsible for a Chance fracture without spinal cord injury.  The authors should only claim correlation between closed vertebral fractures of any type without spinal cord injury and mortality.

    This issue highlights a critical limitation of using a billing database with inadequate clinical information for clinical research.  As we evolve toward a fully electronic medical record (EMR), an unprecedented opportunity to revolutionize clinical research exists.  Rather than using an incomplete billing database or relying on sheer effort to review individual charts, we should develop EMRs that also optimize clinical research .  With a sophisticated EMR, compression fractures can be identified through key phrases in a discharge summary or an X-ray report.  The amount of vertebral collapse can be determined while addressing differences between a dictation of "approximately 50% collapsed" and measurements entered into the EMR as part of a research study.  

    Current EMRs store data in incompatible formats and will be bottlenecked for future clinical research.  Our advance in medical charting has been modest.  Current EMRs “merely” simplify and organize the creation of chart records, improve legibility, standardize care, and prevent medication interactions.  These improvements fix the problems of yesterday’s handwritten charts. We must be proactive and invest today to improve the quality of care in a completely novel way.

    This is not a call for a standardized EMR, but a call to standardize the language that describes those electronic records to maximize future research potential.  Current initiatives for electronic health record interoperability provide a framework upon which we can build the language needed for storing clinical information in a machine- interpretable form that can be semantically analyzed for future research.

    To call these changes a monumental undertaking is an understatement. They require much more than a simple request to software developers; rather, they require a collaboration among surgeons, clinical researchers, and software developers to critically consider the most effective methods we can use to record and use clinical information in the next decade.  Orthopaedic surgery is a field of innovation, a leader in minimally invasive surgery, materials science, regenerative medicine, and even computational science. Taking charge of our future starts today by being innovative in information science.


    Table 1: ICD-9-CM codes and description

    ICD-9-CM Code

    Description

    733.13

    Pathologic facture of vertebrae / Collapse of vertebra NOS

    805.0

    Closed fracture of cervical vertebra without mention of spinal cord injury 

    805.2

    Closed fracture of dorsal (thoracic) vertebra without spinal cord injury

    805.4

    Closed fracture of lumbar vertebra without spinal cord injury

    805.6

    Closed fracture of sacrum and coccyx without spinal cord injury

    805.8

    Closed fracture of unspecified part of vertebral column without spinal cord injury

     

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Lau E, Ong K, Kurtz S, Schmier J, Edidin A. Mortality following the diagnosis of a vertebral compression fracture in the Medicare population. J Bone Joint Surg Am. Jul 2008;90(7):1479-1486.

    2. Rao RD. Commentary and Perspective on "Mortality Following the Diagnosis of a Vertebral Compression Fracture in the Medicare Population" by Edmund Lau, MS, et al. J Bone Joint Surg Am. Vol 90; 2008.

    3. ICD-9-CM Professional for Physicians. Vol 1-2. Salt Lake City, Utah: Ingenix; 2008.

     

     

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