Indicator Definitions - Older Adults

Hospitalization for hip fracture among Medicare-eligible persons aged ≥ 65 years Category: Older Adults
Demographic Group:	Medicare-eligible resident persons aged ≥65 years
Numerator:	Hospitalizations with an International Classification of Diseases (ICD)-9-CM code 820 (search all diagnostic fields) among Medicare-eligible persons aged ≥ 65 years among residents during a calendar year.
Denominator:	Residents aged ≥65 years who were eligible for Medicare Part A benefits on July 1 of the calendar year, excluding members of health maintenance organizations.
Measures of Frequency:	Annual number of hospitalizations. Annual hospitalization rate — crude and age-adjusted (standardized by the direct method to the year 2000 standard U.S. population, distribution 111) with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Calendar year.
Background:	Based on National Hospital Discharge Survey data from 2010 there were 258,000 hospital admissions for hip fractures among people aged 65 and older.2 The majority (95%) of hip fractures are caused by falling.3 Notably, the majority of hip fractures were related to falling sideways onto the hip.4
Significance:	The most common cause of death after a fall was complications from a hip fracture.5 One in three adults who lived independently before their hip fracture subsequently resided in a nursing home for at least a year after their injury.6
Limitations of Indicator:	Hip fracture is a proxy measure for osteoporosis. Because osteoporosis is a chronic disease, years might pass before changes in patient behavior or clinical practice affect hospitalization for hip fracture. Indicator excludes younger persons who are at risk for osteoporosis (e.g., as a result of steroid treatment or early menopause).
Data Resources:	Centers for Medicare and Medicaid Services (CMS) Part A claims data (numerator) and CMS estimates of the population of persons eligible for Medicare (denominator).
Limitations of Data Resources:	Diagnoses listed on hospital discharge data might be inaccurate. Practice patterns and payment mechanisms might affect decisions by health-care providers to hospitalize patients. Indicator is limited to Medicare-eligible population. Multiple admissions for an individual patient can falsely elevate the number of persons with hip fracture.  The Medicare claims dataset cannot provide incident (new) hospitalizations for hip fracture.  Because not all persons aged ≥ 65 years participate in Medicare Part A, this measure may not be directly comparable to data estimates for this same population from other data sources, such as the National Hospital Discharge Survey.
Related Indicators or Recommendations:	Healthy People 2020 Objective AOCBC-11.1: Reduce hip fractures among females aged ≥65 years. Healthy People 2020 Objective AOCBC-11.2: Reduce hip fractures among males aged ≥65 years.
Related CDI Topic Area:	Nutrition, Physical Activity, and Weight Status

1. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January 2001. http://www.cdc.gov/nchs/data/statnt/statnt20.pdf
2. National Hospital Discharge Survey (NHDS), National Center for Health Statistics. Available at: http://205.207.175.93/hdi/ReportFolders/ReportFolders.aspx?IF_ActivePath=P,18 and www.cdc.gov/HomeandRecreationalSafety/Falls/adulthipfx.html.
3. Samelson EJ, Zhang Y, Kiel DP, Hannan MT, Felson DT. Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham Study. American Journal of Public Health 2002;92(5):858–62.
4. Parkkari J, Kannus P, Palvanen M, Natri A, Vainio J, Aho H, Vuori I, Järvinen M. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int, 1999;65:183–7.
5. Deprey SM, Descriptive analysis of fatal falls of older adults in a Midwestern counting in the year 2005. Journal of Geriatric Physical Therapy 2009;32(2):23–28.
6. Leibson CL, Toteson ANA, Gabriel SE, Ransom JE, Melton JL III. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. Journal of the American Geriatrics Society 2002;50:1644–50.

 

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Percentage of women Medicare beneficiaries aged ≥65 years who reported not ever being screened for osteoporosis with a bone mass or bone density measurement Category: Older Adults
Demographic Group:	Medicare-eligible resident women aged ≥65 years
Numerator:	The subset of the denominator who reported ever being screened for osteoporosis with a bone mass or bone density measurement.
Denominator:	Full-year data for women aged ≥65 years who ever talked to a doctor about osteoporosis who resided in the community.
Measures of Frequency:	Annual prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Calendar year.
Background:	Osteoporosis screening with hip DEXA scans and follow-up management in older adults has been shown in a large population-based cohort study to be associated with 36 percent fewer incident hip fractures over six years compared with usual medical care.1 While screening alone would not have an effect on fractures, it may lead physicians to implement management strategies that may decrease fractures.2
Significance:	Over a course of an individual’s lifetime it is estimated that 30 to 50 percent of women and 15 to 30 percent of men will experience an osteoporotic fracture.3 Medicare spent more than $8 billion in 1999 to treat injuries to older adults, with fractures accounting for two-thirds of the spending.4
Limitations of Indicator:	Data are from only the Medicare Current Beneficiary Survey (MCBS), Access to Care file, which contains information on beneficiaries’ reports. The measure involves self-reports regarding being screened for osteoporosis with a bone mass or bone density measurement.
Data Resources:	Medicare Current Beneficiary Survey (MCBS), Access to Care.
Limitations of Data Resources:	Data may not be available at the state level.
Related Indicators or Recommendations:	Healthy People 2020 Objective AOCBC-11:  Reduce hip fractures among older adults.
Related CDI Topic Area:

1. Kern LM, Powe NR, Levine MA, Fitzpatrick AL, Harris TB, et al. Association between screening for osteoporosis and the incidence of hip fracture. Annals of Internal Medicine 2005;142(3):17.3-181.
2. Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. Enhancing Use of Clinical Preventive Services Among Older Adults. Washington, DC: AARP, 2011.  Available at www.cdc.gov/aging and www.aarp.org/healthpros.
3. U.S. Department of Health and Human Services. Bone health and osteoporosis: A report of the Surgeon General (2004). Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.
4. Bishop CE, Gilden D, Blom J, Kubisiak J, Hakim R, et al. Medicare spending for injured elders: Are there opportunities for savings? Health Affairs 2002;21(6):215-223.

 

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Prevalence of 2 or more chronic conditions among Medicare-enrolled persons aged ≥65 years Category: Older Adults
Demographic Group:	Medicare-enrolled resident persons aged ≥65 years
Numerator:	Medicare beneficiaries enrolled in the fee for service program, who had a Medicare administrative claim indicating receipt of service or treatment for at least two of the following conditions: Alzheimer’s disease and related dementia, arthritis (Osteoarthritis and Rheumatoid), asthma, atrial fibrillation, autism spectrum disorders, cancer (breast, colorectal, lung, prostate), chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hyperlipidemia, hypertension, ischemic heart disease, osteoporosis, Schizophrenia and Other Psychotic Disorders, and stroke.
Denominator:	Medicare beneficiaries enrolled in fee-for-service coverage of both Parts A and B for the entire year. Beneficiaries who were enrolled at any point during the year in a Medicare Advantage  plan were excluded as were beneficiaries who first became eligible for Medicare after January of the calendar year. Beneficiaries who died during the year were included up to their date of death if they meet the other inclusion criteria.
Measures of Frequency:	Prevalence of 2 or more chronic conditions during the calendar year.
Time Period of Case Definition:	Calendar year.
Background:	Twenty-six percent of U.S. adults had multiple chronic conditions (MCC) in 2010, and increase from 21.8% in 2001.1  The prevalence of MCC significantly increases with age.  In 2010, 68.4% of Medicare beneficiaries had 2 or more chronic conditions.2 The prevalence of Medicare beneficiaries with 4 or more chronic conditions was 36.4%.2
Significance:	Public health approaches to prevention and treatment of chronic diseases traditionally focused on single conditions and risk factors.  However, recent trends in population growth and age distribution, coupled with increases in chronic disease, will have implications in the prevalence of MCC.  To address MCC, coordinated health care approaches, which consider the broader context of multiply occurring risk factors and functional limitations, may be needed from public health, clinicians, and social programs.3
Limitations of Indicator:	The indicator does not provide information on specific dyads or triads of multiple chronic conditions.  Although the HHS Framework includes 20 proposed chronic conditions, these data do not include 3 of the proposed conditions (substance abuse, HIV, and hepatitis).
Data Resources:	Centers for Medicare and Medicaid Services (CMS) administrative enrollment and claims data for Medicare beneficiaries enrolled in the fee-for-service parts A and B, available at the CMS Chronic condition Data Warehouse (CCW):  http://www.ccwdata.org/index.htm Detailed information on the identification of chronic conditions in the CCW is available at http://www.ccwdata.org/chronic-conditions/index.htm
Limitations of Data Resources:	Discrepancies in physician coding are possible and could have introduced error.  Lack of treatment for a condition is possible and thus would not be reflected in these prevalence estimates.  These estimates are for the Medicare fee-for-service population only; therefore estimates of multiple chronic conditions among beneficiaries enrolled in Medicare Advantage plans are not available.  The actual prevalence of MCC among the Medicare-eligible population is likely underestimated.
Related Indicators or Recommendations:	U.S. Department of Health and Human Services Inventory of Programs, Activities, and Initiatives Focused on Improving the Health of Individuals with Multiple Chronic Conditions.  http://www.hhs.gov/ash/initiatives/mcc/mcc-inventory-20111018.pdf
Related CDI Topic Area:	Arthritis; Asthma; Cancer; Cardiovascular Disease; Chronic Kidney Disease; Chronic Obstructive Pulmonary Disease; Diabetes.

1. Ward BW, Schiller JS.  Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010.  Prev Chronic Dis 2013;10:120203.  DOI: http://dx.doi.org/10.5888/pcd10.120203.
2. Lochner KA, Cox CS. Prevalence of multiple chronic conditions among Medicare beneficiaries, United States, 2010. Prev Chronic Dis 2013;10:120137.  DOI: http://dx.doi.org/10.5888/pcd10.120137.
3. Goodman RA, Posner SF, Huang ES, Parekh AK, Koh HK.  Defining and measuring chronic conditions: imperatives for research, policy, program, and practice.  Prev Chronic Dis 2013;10:120239. DOI: http://dx.doi.org/10.5888/pcd10.120239.

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Proportion of older adults aged ≥65 years who are up to date on a core set of clinical preventive services by age and sex Category: Older Adults
Demographic Group:	All resident persons aged ≥65 years.
Numerator:	Women: Number of women aged ≥ 65 years reporting having received all of the following: a flu shot in past year; a pneumococcal vaccination (PPV) ever; a fecal occult blood test (FOBT) within the previous year, or a sigmoidoscopy within the previous 5 years and a FOBT within the previous 3 years, or a colonoscopy within the previous 10 years; and a mammogram in past 2 years. Men: Number of men aged ≥ 65 years reporting having received all of the following: a flu shot in past year; a PPV ever; and a fecal occult blood test (FOBT) within the previous year, or a sigmoidoscopy within the previous 5 years and a FOBT within the previous 3 years, or a colonoscopy within the previous 10 years.
Denominator:	Women: Number of women aged ≥65 years. Men: Number of men aged ≥65 years.
Measures of Frequency:	Annual prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Calendar year.
Background:	Older adults are among the fastest growing age groups; and the first “baby boomers” (adults born between 1946 and 1964) turned 65 in 2011.1 In 2010, 68% of adults aged 65 or older had multiple chronic conditions,2 which defined as having two or more chronic conditions.3 For those aged 85 or older, 83% had multiple chronic conditions.2 Older adults are at high risk for developing chronic illnesses and related disabilities. National experts agree on a set of recommended clinical preventive services for adults aged ≥65 that can help detect many of these diseases, delay  their onset, or identify them early in more treatable stages, which include influenza vaccination, pneumococcal vaccination, colorectal cancer screening, and mammography screening for women.4  Colorectal cancer screening has been shown to significantly reduce mortality from the disease.5
Significance:	The up-to-date measure improves program transparency, accountability and decision making by driving the coordination of prevention activities across disease-based “silos” in both the clinical and public health setting. Since it is an all-or-none measure, it cannot increase unless multiple component activities (screenings and vaccinations) are delivered to the same individual. It thereby potentially raises the bar on performance.
Limitations of Indicator:	Is limited to a select set of clinical preventive services by age and sex for which data are available in the Behavioral Risk Factor Surveillance System (BRFSS). Data on all services in the core set are not available every year given the rotating core questions on BRFSS.  Indicator should not be interpreted as covering all recommended clinical preventives services for this age group.
Data Resources:	Behavioral Risk Factor Surveillance System (BRFSS).
Limitations of Data Resources:	As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).  In an effort to address some of these potential concerns, BRFSS began including cell phone only users in the 2011 data collection.  Due to changes in sampling and weighting methodology, 2011 is a new baseline for BRFSS, and comparisons with prior year data are inappropriate.
Related Indicators or Recommendations:	Healthy People 2020 Objective OA-2:  Increase the proportion of older adults who are up to date on a core set of clinical preventive services.
Related CDI Topic Area:	Cancer; Immunizations

1. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at [Specific URL]. Accessed September 30, 2013.
2. Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012.
3. U.S. Department of Health and Human Services. Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC. December 2010.
4. U.S. Preventive Services Task Force. USPSTF A and B Recommendations: 2011. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
5. Whitlock EP, Lin JS, Liles E, Bell TL, et al. Screening for colorectal cancer: a targeted systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:638-58.

 

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Proportion of older adults aged 50-64 years who are up to date on a core set of clinical preventive services Category: Older Adults
Demographic Group:	All resident persons aged 50-64 years.
Numerator:	Women: Number of women aged 50-64 years reporting having received all of the following: a flu shot in past year; a pneumococcal vaccination (PPV) ever; a fecal occult blood test (FOBT) within the previous year, or a sigmoidoscopy within the previous 5 years and a FOBT within the previous 3 years, or a colonoscopy within the previous 10 years; a Pap test within the past 3 years; and a mammogram in past 2 years. Men: Number of men aged 50-64 years reporting having received all of the following: a flu shot in past year; a PPV ever; and a fecal occult blood test (FOBT) within the previous year, or a sigmoidoscopy within the previous 5 years and a FOBT within the previous 3 years, or a colonoscopy within the previous 10 years.
Denominator:	Women: Number of women aged 50-64 years. Men: Number of men aged 50-64 years.
Measures of Frequency:	Annual prevalence with 95% confidence interval; and by demographic characteristics when feasible.
Time Period of Case Definition:	Calendar year.
Background:	Older adults are among the fastest growing age groups; and the first “baby boomers” (adults born between 1946 and 1964) turned 65 in 2011.1 In 2010, 68% of adults aged 65 or older had multiple chronic conditions,2 which defined as having two or more chronic conditions.3 For those aged 85 or older, 83% had multiple chronic conditions.2 Older adults are at high risk for developing chronic illnesses and related disabilities. National experts agree on a set of recommended clinical preventive services for adults aged >65 that can help detect many of these diseases, delay  their onset, or identify them early in more treatable stages, which include influenza vaccination, pneumococcal vaccination, colorectal cancer screening, and mammography screening for women.4 Colorectal cancer screening has been shown to significantly reduce mortality from the disease.5
Significance:	The up-to-date measure improves program transparency, accountability and decision making by driving the coordination of prevention activities across disease-based “silos” in both the clinical and public health setting. Since it is an all-or-none measure, it cannot increase unless multiple component activities (screenings and vaccinations) are delivered to the same individual. It thereby potentially raises the bar on performance.
Limitations of Indicator:	Is limited to a select set of clinical preventive services by age and sex for data that are available in the Behavioral Risk Factor Surveillance System (BRFSS). Data on all services in the core set are not available every year given the rotating core questions on BRFSS.  Indicator should not be interpreted as covering all recommended clinical preventives services for this age group.
Data Resources:	Behavioral Risk Factor Surveillance System (BRFSS).
Limitations of Data Resources:	As with all self-reported sample surveys, BRFSS data might be subject to systematic error resulting from noncoverage (e.g., on college campuses or in the military), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement (e.g., social desirability or recall bias).  In an effort to address some of these potential concerns, BRFSS began including cell phone only users in the 2011 data collection.  Due to changes in sampling and weighting methodology, 2011 is a new baseline for BRFSS, and comparisons with prior year data are inappropriate.
Related Indicators or Recommendations:	None.
Related CDI Topic Area:	Cancer; Immunizations

1. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at [Specific URL]. Accessed September 30, 2013.
2. Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012.
3. U.S. Department of Health and Human Services. Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC. December 2010.
4. U.S. Preventive Services Task Force. USPSTF A and B Recommendations: 2011. Available at: www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
5. Whitlock EP, Lin JS, Liles E, Bell TL, et al. Screening for colorectal cancer: a targeted systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:638-58.

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