Publications by authors named "Sarah D Berry"

66 Publications

Reduced BNT162b2 mRNA vaccine response in SARS-CoV-2-naive nursing home residents.

medRxiv 2021 Mar 22. Epub 2021 Mar 22.

The SARS-CoV-2 pandemic impact on nursing home (NH) residents prompted their prioritization for early vaccination. To fill the data gap for vaccine immunogenicity in NH residents, we examined antibody levels after BNT162b2 mRNA vaccine to spike, receptor binding domain (RBD) and for virus neutralization in 149 NH residents and 111 health care worker controls. SARS-CoV-2-naive NH residents mount antibody responses with nearly 4-fold lower median neutralization titers and half the anti-spike level compared to SARS-CoV-2-naive healthcare workers. By contrast, SARS-CoV-2-recovered vaccinated NH residents had neutralization, anti-spike and anti-RBD titers similar to SARS-CoV-2-recovered vaccinated healthcare workers. NH residents' blunted antibody responses have important implications regarding the quality and durability of protection afforded by neoantigen vaccines. We urgently need better longitudinal evidence on vaccine effectiveness specific to NH resident populations to inform best practices for NH infection control measures, outbreak prevention and potential indication for a vaccine boost.
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http://dx.doi.org/10.1101/2021.03.19.21253920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010759PMC
March 2021

Lessons learned from frontline skilled nursing facility staff regarding COVID-19 vaccine hesitancy.

J Am Geriatr Soc 2021 Mar 25. Epub 2021 Mar 25.

Center for Health Policy and Evaluation in LTC, American Health Care Association, Washington, District of Columbia, USA.

Background: Presently a median of 37.5% of the U.S. skilled nursing facility (SNF) workforce has been vaccinated for COVID-19. It is essential to understand vaccine hesitancy among SNF workers to inform vaccine campaigns going forward.

Objective: To describe the concerns raised among healthcare workers and staff from SNFs during town hall meetings.

Design: Sixty-three SNFs from four corporations were invited to send Opinion Leaders, outspoken staff from nursing, nurse aid, dietary, housekeeping or recreational therapy, to attend a 1-h virtual town hall meeting. Meetings used a similar format where the moderator solicited concerns that the attendees themselves had or had heard from others in the facility about the COVID-19 vaccine. Physicians and moderators used personal stories to address concerns and reaffirmed positive emotions.

Setting: Twenty-six video town hall meetings with SNF staff.

Participants: Healthcare workers and staff, with physicians serving as content experts.

Measurement: Questions and comments about the COVID-19 vaccines noted by physicians.

Results: One hundred and ninety three staff from 50 facilities participated in 26 meetings between December 30, 2020 and January 15, 2021. Most staff reported getting information about the vaccine from friends or social media. Concerns about how rapidly the vaccines were developed and side effects, including infertility or pregnancy related concerns, were frequently raised. There were no differences in concerns raised by discipline. Questions about returning to prior activities after being vaccinated were common and offered the opportunity to build on positive emotions to reduce vaccine hesitancy.

Conclusions: Misinformation about the COVID-19 vaccine was widespread among SNF staff. Sharing positive emotions and stories may be more effective than sharing data when attempting to reduce vaccine hesitancy in SNF staff.
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http://dx.doi.org/10.1111/jgs.17136DOI Listing
March 2021

A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic.

Contemp Clin Trials 2021 Mar 11:106356. Epub 2021 Mar 11.

Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, MO, United States of America.

Background: Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown.

Methods: The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density.

Results: Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology.

Conclusions: Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.
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http://dx.doi.org/10.1016/j.cct.2021.106356DOI Listing
March 2021

Validation of the Minimum Data Set Items on Falls and Injury in Two Long-Stay Facilities.

J Am Geriatr Soc 2020 Dec 7. Epub 2020 Dec 7.

Beth Israel Deaconess Medical Center, Department of Medicine, Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1111/jgs.16974DOI Listing
December 2020

An advance care planning long-term care initiative in response to COVID-19.

J Am Geriatr Soc 2021 Feb 12. Epub 2021 Feb 12.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Objective: Describe a systematic approach to address advance care planning (ACP) during a COVID-19 outbreak and its impact on the incidence of new do-not-hospitalize (DNH) directives among long-term care (LTC) residents.

Design: Prospective quality improvement initiative.

Setting: Two long-term chronic care campuses within a large academic healthcare organization.

Participants: LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020.

Intervention: Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID-19 focused ACP discussions. Residents without DNH directives with COVID-19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly.

Measurements: Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020.

Results: At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID-19 from April 2, 2020 to May 21, 2020. During follow-up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID-19, and 29/124 (23%) died.

Conclusions: There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID-19 pandemic through a systematic ACP initiative which utilized real-time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.
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http://dx.doi.org/10.1111/jgs.17051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013602PMC
February 2021

Association of Beta Blocker Use With Bone Mineral Density in the Framingham Osteoporosis Study: A Cross-Sectional Study.

JBMR Plus 2020 Sep 30;4(9):e10388. Epub 2020 Jul 30.

Department of Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA USA.

Some, but not all, prior observational studies have shown that beta blocker (BB) use is associated with lower fracture risk and higher bone mineral density (BMD). Rodent studies show the mechanism to involve the reduction in the effects of beta-adrenergic signaling on bone remodeling. Because previous studies did not have detailed information on dose, duration, and beta-1 selectivity, we examined these in a cross-sectional analysis of the association between BB use and hip and spine BMD using DXA with the Offspring Cohort of the Framingham Heart Study. The sample size was = 1520, and 397 individuals used BBs. We used propensity score modeling to balance a comprehensive set of covariates using inverse probability of treatment weighting (IPTW) to minimize bias due to treatment indication. We found significant differences in BMD between BB users and non-users for three of four BMD measurements (femoral neck: 3.1%, 95% CI, 1.1% to 5.0%; total femur: 2.9%, 95% CI, 0.9% to 4.9%; femoral trochanter: 2.4%, 95% CI, -0.1% to 5.0%; and lumbar spine: 2.7%, 95% CI, 0.2% to 5.0%). Results were found to be similar between sexes although the magnitude of association was larger for women. Similar differences were estimated for beta-1 selective and nonselective BBs compared with no BB use. We modeled dose in categories (no BB use, low-dose, high-dose) and as a continuous variable and found an increasing dose response that levels off at higher doses. Finally, associations were similar for short-term versus long-term (≤4 years versus >4 years) use. In summary, this large comprehensive study shows that BB use is associated with higher BMD in a dose-related manner regardless of beta-1 specificity and duration of use, which supports the conduct of a randomized clinical trial of BBs for achieving improvements in BMD for individuals at risk of bone loss with aging. © 2020 The Authors. published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbm4.10388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507481PMC
September 2020

Risk Factors, Presentation, and Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility.

J Am Med Dir Assoc 2020 Oct 25;21(10):1378-1383.e1. Epub 2020 Aug 25.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA; Hebrew SeniorLife, Department of Medicine, Boston, MA. Electronic address:

Objective: To describe clinical characteristics and risk factors associated with coronavirus disease 2019 (COVID-19) in long-stay nursing home residents.

Design And Participants: Retrospective cohort study (March 16, 2020 to May 8, 2020).

Setting: Academic long-term chronic care facility (Boston, MA).

Participants: Long-term care residents.

Methods: Patient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risks of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk (RR) and 95% confidence intervals (CI) of patient characteristics and staff community of residence.

Results: Overall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course, the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up, 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; P < .001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0%‒90.5%). In adjusted models, male sex (RR 1.80, 95% CI 1.07, 3.05), bowel incontinence (RR 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI 1.04, 1.08).

Conclusions And Implications: Among long-term care residents diagnosed with COVID-19, nearly one-half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence, and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigate outbreaks.
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http://dx.doi.org/10.1016/j.jamda.2020.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447263PMC
October 2020

Secular Trends in the Incidence of Hip Fracture Among Nursing Home Residents.

J Bone Miner Res 2020 09 8;35(9):1668-1675. Epub 2020 May 8.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

A recent study suggested a decline in the incidence of hip fracture among US women between 2002 and 2012, followed by a leveling in the incidence rate from 2013 to 2015. Newly admitted nursing home residents are particularly vulnerable to hip fracture, and it is unclear whether that trend is observed in this high risk group. The purpose of our study was to describe trends in hip fracture rates and postfracture mortality among 2.6 million newly admitted US nursing home residents from 2007 to 2015, and to examine whether these trends could be explained by differences in resident characteristics. Medicare claims data were linked with the Minimum Data Set (MDS), a clinical assessment performed quarterly on all nursing home residents. In each year (2007-2015), we identified newly admitted long-stay (ie, 100 days in the same facility) nursing home residents. Hip fracture was defined using Medicare Part A diagnostic codes. Follow-up time was calculated from the index date until the first event of hospitalized hip fracture, Medicare disenrollment, death, or until 1 year. Poisson regression was used to adjust rates of hip fracture for age and sex. The number of newly admitted nursing home residents ranged from 324,508 in 2007 to 257,350 in 2015. Although mean age remained similar (83 years), residents were more functionally dependent over time. There was a small absolute decrease in the incidence rate of hip fracture between 2007 (3.32/100 person-years) and 2013 (2.82/100 person-years), with an increase again in 2015 (3.03/100 person-years). Adjusting for patient characteristics somewhat attenuated these trends. One-year mortality was high following fracture in all years (42.6% in 2007, 42.1% in 2014). In summary, we observed a recent slight rise in the incidence rates of hip fracture among nursing home residents that was at least partially explained by differences in resident characteristics over time. © 2020 American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbmr.4032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486242PMC
September 2020

Comment on: Can Hearing Aids Delay Time to Diagnosis of Dementia, Depression, or Falls in Older Adults?

J Am Geriatr Soc 2020 03 20;68(3):670-671. Epub 2020 Feb 20.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1111/jgs.16367DOI Listing
March 2020

Potentially burdensome end-of-life transitions among nursing home residents with poor-prognosis cancer.

Cancer 2020 03 20;126(6):1322-1329. Epub 2019 Dec 20.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston, Massachusetts.

Background: This study examined factors associated with potentially burdensome end-of-life (EOL) transitions between care settings among older adults with advanced cancer in nursing homes (NHs).

Methods: A retrospective analysis of deceased older NH residents with poor-prognosis solid tumors was conducted with Medicare claims and the Minimum Data Set. A potentially burdensome transition was defined as 2 or more hospitalizations or an intensive care unit admission in the last 90 days of life.

Results: Among 34,670 subjects, many had moderate to severe cognitive impairment (53.8%), full dependence in activities of daily living (ADLs; 66.5%), and comorbidities such as congestive heart failure (CHF; 29.3%) and chronic obstructive pulmonary disease (34.1%). Only 56.3% of the patients used hospice at any time in the 90 days before death; 36.0% of the patients experienced a potentially burdensome EOL transition, and this was higher among patients who did not receive hospice (45.4% vs 28.7%; P < .01). In multivariable analyses, full dependence in ADLs (odds ratio [OR], 1.70; P < .01), CHF (OR, 1.48; P < .01), and chronic obstructive pulmonary disease (OR, 1.28; P < .01) were associated with a higher risk of burdensome EOL transitions. Those with do-not-resuscitate directives (OR, 0.60; P < .01) and impaired cognition (OR, 0.89; P < .01) had lower odds of burdensome EOL transitions.

Conclusions: NH residents with advanced cancer have substantial comorbidities and functional impairment, yet more than a third experience potentially burdensome EOL transitions. These findings help to identify a population at risk for poor EOL outcomes in order to target interventions, and they point to the importance of advanced care planning in this population.
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http://dx.doi.org/10.1002/cncr.32658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306135PMC
March 2020

AGS and NIA Bench-to Bedside Conference Summary: Osteoporosis and Soft Tissue (Muscle and Fat) Disorders.

J Am Geriatr Soc 2020 01 2;68(1):31-38. Epub 2019 Dec 2.

University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.

This report summarizes the presentations and recommendations of the eleventh annual American Geriatrics Society and National Institute on Aging research conference, "Osteoporosis and Soft Tissue (Muscle/Fat) Disorders," on March 11-12, 2019, in Bethesda, Maryland. Falls, fractures, and sarcopenia have a major impact on health in older adults, and they are interconnected by known risk factors. The link between osteoporosis, which is common in older adults, and the risk of falls is well known. Sarcopenia, the age-related decline in skeletal muscle mass and function, is also associated with an increased risk of falls and fractures because it reduces strength and leads to functional limitations. In addition to increasing the risk of falls, sarcopenia and osteoporosis can lead to frailty, reduced quality of life, morbidity, and mortality. The conference highlighted the impact of bone and soft tissue disorders on quality of life, morbidity, and mortality in older adults. Presenters described factors that contribute to these disorders; health disparities experienced by various subpopulations; and promising biological, pharmacologic, and behavioral interventions to prevent or treat these disorders. The workshop identified many research gaps and questions along with research recommendations that have the potential to enhance the prospect of healthy aging and improved quality of life for older adults. J Am Geriatr Soc 68:31-38, 2019.
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http://dx.doi.org/10.1111/jgs.16248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316395PMC
January 2020

Antihypertensive Medication Use in Older Adults at Risk for Hip Fracture-Reply.

JAMA 2019 10;322(16):1609

Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jama.2019.13954DOI Listing
October 2019

Predictors of Hip Fracture Despite Treatment with Bisphosphonates among Frail Older Adults.

J Am Geriatr Soc 2020 02 3;68(2):256-260. Epub 2019 Oct 3.

Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.

Objectives: Bisphosphonates are effective at preventing hip fractures among older adults, yet many patients still fracture while on treatment and may benefit from additional preventive interventions. Little data are specifically available to target such efforts among bisphosphonate users. We aimed to identify predictors of hip fracture unique to frail older adults initiating pharmacologic treatment for osteoporosis.

Design: Retrospective cohort using 2008-2013 linked national Minimum Data Set assessments, Medicare claims, and nursing home (NH) facility data.

Setting: NHs in the United States.

Participants: Long-stay NH residents 65 years or older who initiated treatment with a bisphosphonate (N = 17 753). Estimates for bisphosphonate initiators were contrasted with those for calcitonin initiators (control group; N = 5348).

Measurements: Hospitalized hip fracture outcomes were measured using Part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for 36 a priori selected potential predictors.

Results: The mean (SD) age of the study population was 84 (8) years, 85% were women, and 51% had moderate to severe cognitive impairment. Predictors associated with a higher risk of hip fracture despite bisphosphonate use included age 75 years or older to 85 years (vs ≥65 to <75 y; HR = 1.25; 95% CI = 1.02-1.55), female sex (HR = 1.33; 95% CI = 1.06-1.67), white race (vs black race (HR = 1.87; 95% CI = 1.36-2.58), and body mass index = 18.5-24.9 (vs ≥30; HR = 1.93; 95% CI = 1.53-2.42). Independent ability to transfer (vs total dependence; HR = 3.11; 95% CI = 1.83-5.30) and occasional urinary incontinence (vs frequent; HR = 1.45; 95% CI = 1.18-1.78) were also important predictors. Dementia, diabetes, psychoactive drug use, and other characteristics were not associated with post-prescribing hip fracture. Predictors did not differ between bisphosphonate and calcitonin users.

Conclusion: Predictors of hip fracture among frail older adults did not differ between those who were new users of bisphosphonates vs calcitonin. Given the absence of risk factors unique to bisphosphonate users, targeting of fracture prevention efforts should extend beyond pharmacologic therapy to include existing nonpharmacologic therapies, particularly fall prevention strategies. J Am Geriatr Soc 68:256-260, 2020.
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http://dx.doi.org/10.1111/jgs.16176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002229PMC
February 2020

Validation of the FRAiL model to predict non-vertebral and hip fractures in nursing home residents.

Bone 2019 11 28;128:115050. Epub 2019 Aug 28.

Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, United States of America; Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, United States of America.

Objective: Tools were unavailable to assess fracture risk in nursing homes (NH); therefore, we developed the Fracture Risk Assessment in Long term care (FRAiL) model. The objective of this validation study was to assess the performance of the FRAiL model to predict 2-year risk of non-vertebral and hip fractures in a separate large cohort of NH residents.

Methods: This retrospective cohort study included most long-stay NH residents in the United States (N = 896,840). Hip and non-vertebral fractures were identified using Medicare claims. The Minimum Data Set (MDS) was used to identify characteristics from the original FRAiL model. Multivariable competing risk regression was used to model risk of fracture.

Results: Mean age was 83.8 years (±8.2 years) and 70.7% were women. Over a mean follow-up of 1.52 years (SD 0.65), 41,531 residents (4.6%) were hospitalized with non-vertebral fracture (n = 30,356 hip fractures). In the fully adjusted model, 14/15 model characteristics remained significant predictors of non-vertebral fracture. Female sex (HR = 1.55, 95% CI 1.52, 1.59), wandering (HR = 1.30, 95% CI 1.26, 1.34), and falls (HR = 1.28, 95% CI 1.26, 1.31) were strongly associated with non-vertebral fracture rate. Total dependence in ADLs (versus independence) was associated with a decrease in non-vertebral fracture rate (HR = 0.57, 95% CI 0.52, 0.64). Discrimination was moderate in men (C-index = 0.68 for hip, 0.66 for non-vertebral) and women (C-index = 0.68 for hip, 0.65 for non-vertebral), and calibration was excellent.

Conclusions: Our model comprised entirely from routinely collected data was able to identify NH residents at greatest risk for non-vertebral fracture.
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http://dx.doi.org/10.1016/j.bone.2019.115050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823926PMC
November 2019

Corrigendum to "Incidence of hip fracture in native American residents of U.S. nursing homes" [Bone 123 (2019) 204-210].

Bone 2019 Oct 17;127:676. Epub 2019 Jul 17.

Department of Health Services, Policy and Practice, School of Public Health, Brown University, 121 South Main Street, Providence, RI 02912, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bone.2019.07.005DOI Listing
October 2019

Considering the Risks and Benefits of Osteoporosis Treatment in Older Adults.

JAMA Intern Med 2019 Jun 17. Epub 2019 Jun 17.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2019.0688DOI Listing
June 2019

Post-Hip Fracture Mortality in Nursing Home Residents by Obesity Status.

J Am Geriatr Soc 2019 09 12;67(9):1983-1985. Epub 2019 Jun 12.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1111/jgs.16028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732026PMC
September 2019

Hip Fractures in Older Adults in 2019.

JAMA 2019 06;321(22):2231-2232

Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jama.2019.5453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800121PMC
June 2019

Incidence of hip fracture in Native American residents of U.S. nursing homes.

Bone 2019 06 3;123:204-210. Epub 2019 Apr 3.

Department of Health Services, Policy and Practice, School of Public Health, Brown University, 121 South Main Street, Providence, RI 02912, USA. Electronic address:

Objectives: To compare the standardized incidence rates (IRs) of hip fracture for Native Americans versus other racial groups in U.S. nursing homes (NHs).

Methods: We studied Medicare fee-for-service NH residents aged ≥65 years who became long-stay (index date) between 1/1/2008 and 12/31/2009 (n = 1,136,544). Residents were followed from the index date until occurrence of hip fracture, death, Medicare disenrollment, or study end (12/31/2013). We calculated hip fracture IRs by race and used inverse probability weighting to standardize the rates for baseline demographic and clinical characteristics collected from the Minimum Data Set and Medicare claims data. We compared characteristics of NHs used by residents of different races using Online Survey, Certification and Reporting (OSCAR) data.

Results: Among long-stay U.S. NH residents, the standardized IR of hip fracture per 100 person-years was highest in Native Americans [2.16; 95% confidence interval (CI) 1.91-2.44] and white residents (2.05; 2.03-2.06), and lowest in black residents (0.82; 0.79-0.85). NHs caring for Native American residents were more likely to be rurally located as compared to other racial group.

Conclusions: In U.S. NHs, Native Americans and whites have the highest standardized IR of hip fracture and should receive particular attention in fracture prevention efforts.
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http://dx.doi.org/10.1016/j.bone.2019.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527125PMC
June 2019

Risk factors for hip fracture in New Zealand older adults seeking home care services: a national population cross-sectional study.

BMC Geriatr 2019 03 25;19(1):93. Epub 2019 Mar 25.

Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.

Background: Hip fractures are a common injury in older people. Many studies worldwide have identified various risk factors for hip fracture. However, risk factors for hip fracture have not been studied extensively in New Zealand. The interRAI home care assessment consists of 236 health questions and some of these may be related to hip fracture risk.

Methods: The cohort consisted of 45,046 home care clients aged 65 years and older, in New Zealand. Assessments ranged from September 2012 to October 2015. Hip fracture diagnosis was identified by linking ICD (International Classification of Diseases) codes from hospital admissions data (September 2012 to December 2015) to the interRAI home care data. Unadjusted and adjusted competing risk regressions, using the Fine and Gray method were used to identify risk factors for hip fracture. Mortality was the competing event.

Results: The cohort consisted of 61% female with a mean age of 82.7 years. A total of 3010 (6.7%) of the cohort sustained a hip fracture after assessment. After adjusting for sociodemographic and potentially confounding variables falls (SHR (Subhazard Ratio) = 1.17, 95% CI (Confidence interval): 1.05-1.31), previous hip fracture (SHR = 4.16, 95% CI: 2.93-5.89), female gender (SHR = 1.38, 95% CI: 1.22-1.55), underweight (SHR = 1.67, 95% CI = 1.39-2.02), tobacco use (SHR = 1.56, 95% CI = 1.25-1.96), Parkinson's disease (SHR = 1.45, 95% CI: 1.14-1.84), and Wandering (SHR = 1.36, 95% CI: 1.07-1.72) were identified as risk factors for hip fracture. Shortness of breath (SHR = 0.80, 95% CI: 0.71-0.90), was identified as being protective against hip fracture risk. Males and females had different significant risk factors.

Conclusions: Risk factors for hip fracture similar to international work on risk factors for hip fracture, can be identified using the New Zealand version of the interRAI home care assessment.
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http://dx.doi.org/10.1186/s12877-019-1107-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434861PMC
March 2019

Incidence of Lower-Extremity Fractures in US Nursing Homes.

J Am Geriatr Soc 2019 06 27;67(6):1253-1257. Epub 2019 Feb 27.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.

Background/objectives: Limited studies suggest lower-extremity (LE) fractures are morbid events for nursing home (NH) residents. Our objective was to conduct a nationwide study comparing the incidence and resident characteristics associated with hip (proximal femur) vs nonhip LE (femoral shaft and tibia-fibula) fractures in the NH.

Design: Retrospective cohort study.

Setting: US NHs.

Participants: We included all long-stay residents, aged 65 years or older, enrolled in Medicare from January 1, 2008, to December 31, 2009 (N = 1 257 279). Residents were followed from long-stay qualification until the first event of LE fracture, death, or end of follow-up (2 years).

Measurements: Fractures were classified using Medicare diagnostic and procedural codes. Function, cognition, and medical status were obtained from the Minimum Data Set prior to long-stay qualification. Incidence rates (IRs) were calculated as the total number of fractures divided by person-years.

Results: During 42 800 person-years of follow-up, 52 177 residents had an LE fracture (43 695 hip, 6001 femoral shaft, 2481 tibia-fibula). The unadjusted IRs of LE fractures were 1.32/1000 person-years (95% confidence interval [CI] = 1.27-1.38) for tibia-fibula, 3.20/1000 person-years (95% CI = 3.12-3.29) for femoral shaft, and 23.32/1000 person-years (95% CI = 23.11-23.54) for hip. As compared with hip fracture residents, non-hip LE fracture residents were more likely to be immobile (58.1% vs 18.4%), to be dependent in all activities of daily living (31.6% vs 10.8%), to be transferred mechanically (20.5% vs 4.4%), to be overweight (mean body mass index = 26.6 vs 24.0 kg/m ), and to have diabetes (34.8% vs 25.7%).

Conclusions: Our findings that non-hip LE fractures often occur in severely functionally impaired residents suggest these fractures may have a different mechanism of injury than hip fractures. The resident differences in our study highlight the need for distinct prevention strategies for hip and non-hip LE fractures.
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http://dx.doi.org/10.1111/jgs.15825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561809PMC
June 2019

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults.

J Am Geriatr Soc 2019 04 21;67(4):768-776. Epub 2018 Dec 21.

Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.

Background: Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety.

Objective: We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults.

Design: Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims.

Setting: US nursing homes (NHs).

Participants: Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator).

Measurements: Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics.

Results: The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk.

Conclusions: Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.
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http://dx.doi.org/10.1111/jgs.15725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705123PMC
April 2019

Patient-Important Adverse Events of β-blockers in Frail Older Adults after Acute Myocardial Infarction.

J Gerontol A Biol Sci Med Sci 2019 07;74(8):1277-1281

Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center.

Background: We evaluated the burden of adverse events caused by β-blocker use after acute myocardial infarction (AMI) in frail, older nursing home (NH) residents.

Methods: This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population was individuals aged ≥65 years who resided in a U.S. NH for ≥30 days, had a hospitalized AMI between May 2007 and March 2010, and returned to the NH. Exposure was new use of β-blockers versus nonuse post-AMI. Orthostasis, general hypotension, falls, dizziness, syncope, and breathlessness outcomes were measured over 90 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using multinomial logistic regression models after 1:1 propensity score-matching of β-blocker users to nonusers.

Results: Among the 10,992 NH propensity score-matched residents with an AMI, the mean age was 84 years and 70.9% were female. β-blocker users were more likely than nonusers to be hospitalized for hypotension (OR = 1.20, 95% CI 1.03-1.39) or experience breathlessness (OR = 1.10, 95% CI 1.01-1.20) after AMI. With the exception of falls, other outcome estimates, though imprecise, were compatible with a potential elevated risk of orthostasis (OR = 1.14, 95% CI 0.96-1.35), syncope, (OR = 1.24, 95% CI 0.55-2.77), and dizziness (OR = 1.28, 95% CI 0.82-1.99) among β-blocker users.

Conclusions: Considered alongside prior evidence that β-blockers may worsen functional outcomes in NH residents with poor baseline functional and cognitive status, our results suggest that providers should exercise caution when prescribing for these vulnerable groups, balancing the mortality benefit against the potential for causing adverse events.
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http://dx.doi.org/10.1093/gerona/gly191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625583PMC
July 2019

Drug Burden Index and Its Association With Hip Fracture Among Older Adults: A National Population-Based Study.

J Gerontol A Biol Sci Med Sci 2019 06;74(7):1127-1133

School of Health Sciences, College of Education, Health and Human Development University of Canterbury, Christchurch, New Zealand.

Background: The Drug Burden Index (DBI) calculates the total sedative and anticholinergic load of prescribed medications and is associated with functional decline and hip fractures in older adults. However, it is unknown if confounding factors influence the relationship between the DBI and hip fractures. The objective of this study was to evaluate the association between the DBI and hip fractures, after correcting for mortality and multiple potential confounding factors.

Methods: A competing-risks regression analysis conducted on a prospectively recruited New Zealand community-dwelling older population who had a standardized (International Resident Assessment Instrument) assessment between September 1, 2012, and October 31, 2015, the study's end date. Outcome measures were survival status and hip fracture, with time-varying DBI exposure derived from 90-day time intervals. The multivariable competing-risks regression model was adjusted for a large number of medical comorbidities and activities of daily living.

Results: Among 70,553 adults assessed, 2,249 (3.2%) experienced at least one hip fracture, 20,194 (28.6%) died without experiencing a fracture, and 48,110 (68.2%) survived without a fracture. The mean follow-up time was 14.9 months (range: 1 day, 37.9 months). The overall DBI distribution was highly skewed, with median time-varying DBI exposure ranging from 0.93 (Q1 = 0.0, Q3 = 1.84) to 0.96 (Q1 = 0.0, Q3 = 1.90). DBI was significantly related to fracture incidence in unadjusted (p < .001) and adjusted (p < .001) analyses. The estimated subhazard ratio was 1.52 (95% confidence interval: 1.28-1.81) for those with DBI > 3 compared with those with DBI = 0 in the adjusted analysis.

Conclusions: In this study, increasing DBI was associated with a higher likelihood of fractures after accounting for the competing risk of mortality and adjusting for confounders. The results of this unique study are important in validating the DBI as a guide for medication management and it could help reduce the risk of hip fractures in older adults.
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http://dx.doi.org/10.1093/gerona/gly176DOI Listing
June 2019

Caring for Patients With Neurological Impairment: Conversations Between a Pediatrician and Geriatrician.

JAMA Pediatr 2018 09;172(9):795-796

Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamapediatrics.2018.1079DOI Listing
September 2018

Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia.

JAMA Intern Med 2018 06;178(6):774-780

Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.

Importance: The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging.

Objective: To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical hip fracture repair.

Design, Setting, And Participants: We conducted a retrospective cohort study of 3083 NH residents with advanced dementia and hip fracture, but not enrolled in hospice care, using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from January 1, 2008, through December 31, 2013.

Methods: Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture and to determine whether the fracture was managed surgically. Survival between surgical and nonsurgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). All analyses took place between November 2015 and January 2018. Among 6-month survivors, documented pain, antipsychotic drug use, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and nonsurgical groups.

Results: Among 3083 residents with advanced dementia and hip fracture (mean age, 84.2 years; 79.2% female [n = 2441], 28.5% ambulatory [n = 879]), 2615 (84.8%) underwent surgical repair. By 6-month follow-up, 31.5% (n = 824) and 53.8% (n = 252) of surgically and nonsurgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die than residents without surgery (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.98). Among 2007 residents who survived 6 months, residents with surgical vs nonsurgical management had less docmented pain (29.0% [n = 465] vs 30.9% [n = 59]) and fewer pressure ulcers (11.2% [n = 200] vs 19.0% [n = 41]). In IPTW models, surgically managed residents reported less pain (aHR, 0.78; 95% CI, 0.61-0.99) and pressure ulcers (aHR, 0.64; 95% CI, 0.47-0.86). There was no difference between antipsychotic drug use and physical restraint use between the groups. Few survivors remained ambulatory (10.7% [n = 55] of surgically managed vs 4.8% [n = 1] without surgery).

Conclusions And Relevance: Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents' goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.
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http://dx.doi.org/10.1001/jamainternmed.2018.0743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997966PMC
June 2018

Identification of an immune modulation locus utilising a bovine mammary gland infection challenge model.

J Dairy Res 2018 May;85(2):185-192

DairyNZ,Hamilton,New Zealand.

Inflammation of the mammary gland following bacterial infection, commonly known as mastitis, affects all mammalian species. Although the aetiology and epidemiology of mastitis in the dairy cow are well described, the genetic factors mediating resistance to mammary gland infection are not well known, due in part to the difficulty in obtaining robust phenotypic information from sufficiently large numbers of individuals. To address this problem, an experimental mammary gland infection experiment was undertaken, using a Friesian-Jersey cross breed F2 herd. A total of 604 animals received an intramammary infusion of Streptococcus uberis in one gland, and the clinical response over 13 milkings was used for linkage mapping and genome-wide association analysis. A quantitative trait locus (QTL) was detected on bovine chromosome 11 for clinical mastitis status using micro-satellite and Affymetrix 10 K SNP markers, and then exome and genome sequence data used from the six F1 sires of the experimental animals to examine this region in more detail. A total of 485 sequence variants were typed in the QTL interval, and association mapping using these and an additional 37 986 genome-wide markers from the Illumina SNP50 bovine SNP panel revealed association with markers encompassing the interleukin-1 gene cluster locus. This study highlights a region on bovine chromosome 11, consistent with earlier studies, as conferring resistance to experimentally induced mammary gland infection, and newly prioritises the IL1 gene cluster for further analysis in genetic resistance to mastitis.
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http://dx.doi.org/10.1017/S0022029918000158DOI Listing
May 2018

Epidemiology of hip fracture in nursing home residents with multiple sclerosis.

Disabil Health J 2018 10 21;11(4):591-597. Epub 2018 Mar 21.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States; Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts, United States. Electronic address:

Background: Hip fracture risk is high in young people with multiple sclerosis (MS), but has not been examined in an institutionalized aging population with MS.

Objective: We aimed to compare the hip fracture risk in nursing home (NH) residents with and without MS; and (2) examine risk factors for hip fracture in those with MS.

Methods: We conducted a retrospective cohort study using national NH clinical assessment and Medicare claims data. Participants included age-, sex- and race-matched NH residents with/without MS (2007-2008). Multivariable competing risk regression was used to compare 2-year hip fracture risk, and to examine risk factors.

Results: A total of 5692 NH residents with MS were matched to 28,460 without MS. Approximately 80% of residents with MS vs. 50% of those without MS required extensive assistance in walking at NH admission. The adjusted incidence rate of hip fracture was 7.1 and 18.6 per 1000 person-years in those with or without MS, respectively. Wandering and anxiolytic exposure were the main hip fracture risk factors in transfer independent residents with MS; while pneumonia and antidepressant use were the main factors in dependent residents with MS.

Conclusions: In contrast to prior comparisons from non-NH populations, the incidence of hip fracture was lower in NH residents with MS as compared with matched controls. Residents with MS were much more functionally dependent, which likely explains these findings. Fracture prevention strategies should focus on fall prevention in independent residents; and possibly improvement of health status and facility quality of care in dependent residents.
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http://dx.doi.org/10.1016/j.dhjo.2018.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150858PMC
October 2018

Re: "Widespread prevalence of a CREBRF variant amongst Māori and Pacific children is associated with weight and height in early childhood".

Int J Obes (Lond) 2018 07 9;42(7):1392-1393. Epub 2018 Feb 9.

Centre for Longitudinal Research - He Ara ki Mua and Growing Up in New Zealand, University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1038/s41366-018-0026-0DOI Listing
July 2018

Facility and State Variation in Hip Fracture in U.S. Nursing Home Residents.

J Am Geriatr Soc 2018 03 16;66(3):539-545. Epub 2018 Jan 16.

Department of Medicine, Hebrew SeniorLife, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.

Objectives: To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility- and state-level characteristics.

Design: Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

Setting: U.S. NHs with 100 or more beds.

Participants: Long-stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892).

Measurements: Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years.

Results: The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01-3.26) per 100 person-years (range 1.20, 95% CI = 1.15-1.26 to 6.40, 95% CI = 6.07-6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%.

Conclusion: Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs.
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http://dx.doi.org/10.1111/jgs.15264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849498PMC
March 2018