Comparison of hip fracture and osteoporosis medication prescription rates across Canadian provinces

Effects of Teriparatide on Bone Mineral Density and Prevention of Fragility Fractures in Saudi Arabian Subjects with Osteoporosis: A Two-Year Clinical Study from a Single Center

DESIGN

A prospective study was conducted. Setting. This study took place at King Fahd Hospital of the University, Imam AbdulRahman Bin Faisal University, Dammam, Saudi Arabia. Primary and Secondary Outcomes. The study aimed to evaluate changes in BMD and prevention of fragility fractures.

MATERIALS AND METHODS

We followed up 439 patients who were prescribed teriparatide at the King Fahd Hospital of the University, AlKhobar, and 415 (94.5%) patients completed a 24-month teriparatide course. The data gathered before starting medication were age, sex, previous therapy, history of fractures, and other diseases like diabetes mellitus, hypertension, and cardiac disease. At the time of the final assessment after 24 months, a history of fractures if any during the treatment was collected and a DXA scan was done.

RESULTS

A total of 415 patients were followed up for 2 years. Three hundred and sixty-five patients (87.9%) were females, and the rest were males. The average age was 68.21 ± 17.6 years. Two hundred and forty-eight patients (59.8%) were treatment naïve, and 167 (40.2%) were on treatment for osteoporosis. Twenty patients (4.8%) sustained fracture on treatment. The pretreatment DXA showed that the mean hip T-score was -3.1 ± 0.79, and after completion of the treatment, it was -1.5 ± 0.62 (P < 0.001), while the T-score of the lumbar spine was 4.4 ± 0.86 versus -3.2 ± 0.87 (P < 0.001). Seventeen (4.09%) had fractures while on teriparatide treatment. The mean significant gain (MSG) for BMD for the hip was 0.095 g/cm², and for the lumbar spine, it was was 0.109 g/cm² with P < 0.001 at 95% CI.

CONCLUSIONS

Our study shows that 94.5% completed the treatment duration, and there was an increase in the BMD. The decrease in T-scores of the lumbar spine and hip was significant so was the reduction in the number of fractures.

Haemoglobin and transfusions in elderly patients with hip fractures: the effect of a dedicated orthogeriatrician

Background

Hip fractures are common in elderly patients, in whom it is important to monitor blood loss; however, unnecessary transfusions should be avoided. The primary objective of this study was to assess whether the employment of a dedicated orthogeriatrician in an Orthopaedic Department allows to optimise the clinical conditions of patients, influencing blood loss and consequently the number of transfusions. The secondary objective was to determine whether the influence of the orthogeriatrician differs according to the type of surgical treatment.

Methods

A total of 620 elderly patients treated for hip fracture were included in the study. These patients were divided into two groups according to the presence or not of the orthogeriatrician. For each patient, age, sex, comorbidities, type of fracture, surgical treatment, length of hospital stay, time from hospitalisation and surgery, time from surgery to discharge, haemoglobin (Hb) values (admission, 24h post-surgery, lowest Hb reached, discharge) and the number of transfusions were recorded.

Results

Regardless of the surgical procedure performed, in patients managed by the orthogeriatrician, the Hb at discharge was significantly higher (p = 0.003). In addition to the highest Hb at discharge, in patients who underwent hemiarthroplasty, the number of transfusions per patient is significantly reduced (p = 0.03).

Conclusion

The introduction of the orthogeriatrician in an orthopaedic ward for the management of elderly patients treated for hip fracture allows to discharge the patients with higher Hb values, reducing the risk of anemisation and the costs related to possible re-admission.

Meta-analysis for the efficacy of bisphosphonates on hip fracture prevention

The aim of this study was to investigate the effect of bisphosphonates on preventing osteoporotic hip fracture in patients with or without prior major osteoporotic fracture. Randomized controlled trials (RCTs) and observational studies (OSs) based on electronic health records were used to assess bisphosphonate efficacy and were searched using PubMed, Scopus, and the Cochrane Library databases. Eight RCT studies and 14 OSs were extracted from the studies and quantitatively combined by random-effects meta-analysis. The odds ratio (OR) for all hip fractures in RCTs of 0.66, with a 95% confidence interval (CI) of 0.55-0.79, was lower than that in the OSs (OR 0.83; CI 0.74-0.94). The OR in patients with prior fracture was significantly reduced by bisphosphonates in both RCTs and OSs. Conversely, significant fracture reduction was not apparent in patients without prior fracture. A moderate relationship between prior major fracture rates and OR in hip fractures was defined. In patients with an average age of over 80 years, similar results were confirmed. In this meta-analysis, the efficacy of bisphosphonates was significant in patients with prior major fracture, recommending to prescribe for such patients. Their effect in patients without prior fracture, in contrast, remains unclear.

Incidence of and trends in hip fracture among adults in urban China: A nationwide retrospective cohort study

BACKGROUND

Hip fracture is a public health concern because of its considerable morbidity, excess mortality, great risk of disability, and high societal healthcare costs. China has the largest population of older people in the world and is experiencing rapid population aging and facing great challenges from an increasing number of hip fractures. However, few studies reported the epidemiology, especially at a national level. We aimed to evaluate trends in hip fracture incidence and associated costs for hospitalization in China.

METHODS AND FINDINGS

We conducted a population-based study using data between 2012 and 2016 from the national databases of Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance in China, covering about 480 million residents. Data from around 102.56 million participants aged 55 years and older during the study period were analyzed. A total of 190,560 incident hip fracture patients (mean age 77.05 years, standard deviation 8.94; 63.99% female) were identified. Primary outcomes included the age- and sex-specific incidences of hip fracture. Associated annual costs for hospitalization were also calculated. Incidence was described as per 100,000 person-years at risk, and 95% confidence intervals were computed assuming a Poisson distribution. Hip fracture incidence overall in China did not increase during the study period despite rapid population aging. Incidence per 100,000 was 180.72 (95% CI 137.16, 224.28; P < 0.001) in 2012 and 177.13 (95% CI 139.93, 214.33; P < 0.001) in 2016 for females, and 121.86 (95% CI 97.30, 146.42; P < 0.001) in 2012 and 99.15 (95% CI 81.31, 116.99; P < 0.001) in 2016 for males. For both sexes, declines in hip fracture incidence were observed in patients aged 65 years and older, although incidence was relatively stable in younger patients. However, the total absolute number of hip fractures in those 55 years and older increased about 4-fold. The total costs for hospitalization showed a steep rise from US$60 million to US$380 million over the study period. Costs for hospitalization per patient increased about 1.59-fold, from US$4,300 in 2012 to US$6,840 in 2016. The main limitation of the study was the unavailability of data on imaging information to adjudicate cases of hip fracture.

CONCLUSIONS

Our results show that hip fracture incidence among patients aged 55 and over in China reached a plateau between 2012 and 2016. However, the absolute number of hip fractures and associated medical costs for hospitalization increased rapidly because of population aging.

The Cost of Osteoporosis, Osteopenia, and Associated Fractures in Australia in 2017

Osteoporosis and osteopenia are increasingly prevalent conditions among older adults. Not only do the fractures associated with poor bone health have significant health consequences for the individual, but also their economic impact is placing increasing financial burden on governments and society. This study aimed to determine the direct economic cost of osteoporosis, osteopenia, and fractures among Australians aged 50 years and older in 2017. This study uses previous Australian data on the incidence and prevalence of osteoporosis and osteopenia together with recent Australian data on health service utilization after fracture to provide an estimate of the economic burden of osteoporosis. A bottom-up costing approach was used to determine the average direct health care and non-health care total costs of a fracture, as well as the average community health service costs of managing individuals with osteoporosis or osteopenia. The total direct cost of osteoporosis in Australia in 2017 was estimated to be $3.44 billion (AUD 2017, USD 2.77 billion). Treatment of fractures accounted for 68% of total direct costs, and non-fracture management of osteoporosis accounted for 32%. Hip fractures accounted for the highest proportion (43%) of the total direct cost of fractures, although fractures at "other" sites accounted for 38.5%. Fractures among individuals aged 70 years and older accounted for 74% of the direct costs (55% and 19% in women and men, respectively). Fracture costs in those with osteopenia accounted for 50% of direct fracture treatment costs. This up-to-date cost analysis estimated that costs in 2017 were three times higher than in 2007. These estimates will aid clinicians, policy makers, researchers, and health care organizations to acknowledge the economic importance of reducing osteoporosis-related fractures and associated costs. This provides a strong public health case to promote bone health that will assist in reducing future fracture-related costs. © 2018 American Society for Bone and Mineral Research.

Does Simultaneous Computed Tomography and Quantitative Computed Tomography Show Better Prescription Rate than Dual-energy X-ray Absorptiometry for Osteoporotic Hip Fracture?

Purpose

This study aimed to evaluate the efficacy of simultaneous computed tomography (CT) and quantitative CT (QCT) in patients with osteoporotic hip fracture (OHF) by analyzing the osteoporosis detection rate and physician prescription rate in comparison with those of conventional dual-energy X-ray absorptiometry (DXA).

Materials and Methods

This study included consecutive patients older than 65 years who underwent internal fixation or hip arthroplasty for OHF between February and May 2015. The patients were assigned to either the QCT (47 patients) or DXA group (51 patients). The patients in the QCT group underwent QCT with hip CT, whereas those in the DXA group underwent DXA after surgery, before discharge, or in the outpatient clinic. In both groups, the patients received osteoporosis medication according to their QCT or DXA results. The osteoporosis evaluation rate and prescription rate were determined at discharge, postoperative (PO) day 2, PO day 6, and PO week 12 during an outpatient clinic visit.

Results

The osteoporosis evaluation rate at PO week 12 was 70.6% (36 of 51 patients) in the DXA group and 100% in the QCT group (P<0.01). The prescription rates of osteoporosis medication at discharge were 70.2% and 29.4% (P<0.001) and the cumulative prescription rates at PO week 12 were 87.2% and 60.8% (P=0.003) in the QCT and DXA groups, respectively.

Conclusion

Simultaneous CT and QCT significantly increased the evaluation and prescription rates in patients with OHF and may enable appropriate and consistent prescription of osteoporosis medication, which may eventually lead to patients' medication compliance.

Variation in Antiosteoporotic Drug Prescribing and Spending Across Spain. A Population-Based Ecological Cross-Sectional Study

Introduction: Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Nevertheless, very few studies have addressed the variability in osteoporotic drug consumption. We aimed to describe variations in pharmaceutical utilization and spending on osteoporotic drugs between Health Areas (HA) in Spain.

Methods: Population-based cross-sectional ecological study of expenditure and utilization of the five therapeutic groups marketed for osteoporosis treatment in Spain in 2009. Small area variation analysis (SAVA) methods were used. The units of analysis were the 168 HA of 13 Spanish regions, including 7.2 million women aged 50 years and older. The main outcomes were the defined daily dose (DDD) per 1000 inhabitants and day (DDD/1000/Day) dispensed according to the pharmaceutical claims reimbursed, and the expenditure on antiosteoporotics at retail price per woman ≥50 years old and per year.

Results: The average osteoporosis drug consumption was 116.8 DDD/1000W/Day, ranging from 78.5 to 158.7 DDD/1000W/Day between the HAs in the 5th and 95th percentiles. Seventy-five percent of the antiosteoporotics consumed was bisphosphonates, followed by raloxifene, strontium ranelate, calcitonins, and parathyroid hormones including teriparatide. Regarding variability by therapeutic groups, biphosphonates showed the lowest variation, while calcitonins and parathyroid hormones showed the highest variation. The annual expenditure on antiosteoporotics was €426.5 million, translating into an expenditure of €59.2 for each woman ≥50 years old and varying between €38.1 and €83.3 between HAs in the 5th and 95th percentiles. Biphosphonates, despite accounting for 79% of utilization, only represented 63% of total expenditure, while parathyroid hormones with only 1.6% of utilization accounted for 15% of the pharmaceutical spending.

Conclusion: This study highlights a marked geographical variation in the prescription of antiosteoporotics, being more pronounced in the case of costly drugs such as parathyroid hormones. The differences in rates of prescribing explained almost all of the variance in drug spending, suggesting that the difference in prescription volume between territories, and not the price of the drugs, is the main source of variation in this setting. Data on geographical variation of prescription can help guide policy proposals for targeting areas with inadequate antiosteoporotic drug use.

Epidemiology of fragility fractures and fall prevention in the elderly: a systematic review of the literature

Fragility fractures in the elderly is an ongoing concern for orthopaedic surgeons. A 50-year-old woman has a 40% chance of having a vertebral compression fracture in her lifetime. The incidence of vertebral fractures, reported to be more than 10 times higher than that of femoral fractures, is estimated as 1–1.5 million per year in Japan. Vertebral fractures often occur without a fall, whereas the majority of nonvertebral fractures are the consequence of falls; the site of the nonvertebral fracture appears to be dictated by the type of fall. Distal radial fractures commonly occur as a consequence of hand protection during the fall. In older patients, falling load tends to directly affect shoulder and hip joints and lead to proximal humeral and femoral fractures. The incidence of vertebral fractures is increased in women over 50 yr of age, following the same trend as osteoporosis prevalence. Conversely, the mean age for proximal femoral fractures is around 80 yr, and more than 75% of femoral fractures occur in individuals over the age of 75. The prognostic risk of aging is 11-fold greater than that of reduced bone mineral density, and age is another risk factor for femoral fractures. Prophylactic therapy for osteoporosis and femoral fractures was shown to more effective in women in their 70s than in those over the age of 80. Although several approaches, including exercise therapy, vitamin D administration, and environmental adjustment at home, have been reported to be effective in fall prevention, effective fracture prevention approaches in frail elderly individuals have not yet been well established.

Nuclear magnetic resonance therapy (MBST) in the treatment of osteoporosis. Case report study

Despite various pharmacological treatments, the problem of osteoporosis is not yet solved nor decreased. Drug's adverse event and fractures after long termed pharmacotherapy indicate a need for new treatment modalities. Nuclear magnetic resonance therapy could be a supplement to exercise and an alternative or supplement to pharmacotherapy. Number of clinical studies showed increase of BMD after nuclear magnetic resonance therapy and here presented case reports of eleven well-documented cases in which patients experienced severe trauma, having a huge hematoma around the hip but did not suffer any fracture, encourage this expectation. This case report study additionally presents case reports based on the follow-up of the incidence of fractures in a group of 450 patients (males n = 55, females n = 395) with a mean age of 68.4 years. All patients had been treated with MBST - therapeutic nuclear magnetic resonance, standard cycles of 10 days subsequently and followed during a five-year period. The data indicates that NMRT might reduce a risk of fractures in osteoporotic patients.

Anti-Osteoporosis Medication Prescriptions and Incidence of Subsequent Fracture Among Primary Hip Fracture Patients in England and Wales: An Interrupted Time-Series Analysis

In January 2005, the National Institute for Health and Care Excellence (NICE) in England and Wales provided new guidance on the use of antiosteoporosis therapies for the secondary prevention of osteoporotic fractures. This was shortly followed in the same year by market authorization of a generic form of alendronic acid within the UK. We here set out to estimate the actual practice impact of these events among hip fracture patients in terms of antiosteoporosis medication prescribing and subsequent fracture incidence using primary care data (Clinical Practice Research Datalink) from 1999 to 2013. Changes in level and trend of prescribing and subsequent fracture following publication of NICE guidance and availability of generic alendronic acid were estimated using an interrupted time series analysis. Both events were considered in combination within a 1-year "intervention period." We identified 10,873 primary hip fracture patients between April 1999 and Sept 2012. Taking into account prior trend, the intervention period was associated with an immediate absolute increase of 14.9% (95% CI, 10.9 to 18.9) for incident antiosteoporosis prescriptions and a significant and clinically important reduction in subsequent major and subsequent hip fracture: -0.19% (95% CI, -0.28 to -0.09) and -0.17% (95% CI, -0.26 to -0.09) per 6 months, respectively. This equated to an approximate 14% (major) and 22% (hip) reduction at 3 years postintervention relative to expected values based solely on preintervention level and trend. We conclude that among hip fracture patients, publication of NICE guidance and availability of generic alendronic acid was temporally associated with increased prescribing and a significant decline in subsequent fractures. © 2016 American Society for Bone and Mineral Research.

Hip Fracture Types in Canadian Men and Women Change Differently with Age: A Population-Level Analysis

BACKGROUND

We have previously reported a gender difference in the occurrence of hip fracture type with age in our local population. In the current report, we have explored this phenomenon in a Canadian population using five years of data from a national administrative database. We have compared community-dwelling and institutionalized individuals to determine if frailty is important and has a differential effect on the type of hip fracture experienced.

METHODS

Hospitalization records from 2005 to 2009, in which the most responsible diagnosis, that is the diagnosis causing the admission to hospital, was a hip fracture, were obtained from the Discharge Abstract Database of the Canadian Institute for Health Information. Hip fracture type was identified using the Canadian Classification of Health Interventions and the International Classification of Diseases 10th Revision, Canada (ICD-10-CA). Hip fracture proportions were calculated for the study period and stratified by age group and sex.

RESULTS

The relative proportion of intertrochanteric fractures in women rose from 35% in the youngest group (55-59 years) to 51% in the oldest group (84+ years; P < 0.0001). In men, the proportions remain relatively stable (47% and 44%, respectively). Community and institutionalized patients showed the same pattern.

CONCLUSIONS

The change in the proportion of the two hip fracture types that occur in women but not men may point to differences in the etiology and consequently the approaches to prevention for the two fracture types. Level of frailty did not seem to be important.

Changes in number and incidence of hip fractures over 12 years in France

The incidence of hip fractures decreased in France in both genders, especially in the elderly, from 2002 to 2008, in parallel with availability of bone densitometry and effective anti-osteoporotic treatments. However prescriptions of these treatments are decreasing, since 2008, and recent studies show declining of osteoporosis management after fragility fractures. The aim of this study was to assess the incidence of hip fractures in men and women aged 60 years and over, from 2002 to 2013 in France. Data were drawn from the French Hospital National Database which includes all hospitalizations of the country. Hospital data for hip fractures between 2002 and 2013 were numbered and the incidence rates per 1,000,000 adjusted on age (60-74; 74-84, and ≥ 85 years), and gender was calculated using the data of the French population. The number of hip fractures increased in women (+5%; from 49,287 in 2002 to 50,215) and in men (+22%, from 12,716 to 15,482) aged over 60 years. Between 2002 and 2013, the French population increased by 21 and 29% in women and men of this age group; thus, incidence of hip fractures decreased by 14% in women (6929 and 5987 per million in 2002 and 2013, respectively) and a slight decrease of -1% was observed in men (2344 and 2316). The decrease in incidence is also confirmed in the very elderly (≥ 85 years), with a decrease of -29% and -24% in women and men respectively. Over the last 12 years, the incidence of hip fractures decreased in France in women and men aged over 60 years. This decrease is also observed in the subjects (≥ 85 years and older in both genders). Further studies are needed to assess potential changes in risk factors of hip fractures during the last decade.

Osteoporosis: the emperor has no clothes

Current prevention strategies for low-trauma fractures amongst older persons depend on the notions that fractures are mainly caused by osteoporosis (pathophysiology), that patients at high risk can be identified (screening) and that the risk is amenable to bone-targeted pharmacotherapy (treatment). However, all these three notions can be disputed.

PATHOPHYSIOLOGY

Most fracture patients have fallen, but actually do not have osteoporosis. A high likelihood of falling, in turn, is attributable to an ageing-related decline in physical functioning and general frailty.

SCREENING

Currently available fracture risk prediction strategies including bone densitometry and multifactorial prediction tools are unable to identify a large proportion of patients who will sustain a fracture, whereas many of those with a high fracture risk score will not sustain a fracture.

TREATMENT

The evidence for the viability of bone-targeted pharmacotherapy in preventing hip fracture and other clinical fragility fractures is mainly limited to women aged 65-80 years with osteoporosis, whereas the proof of hip fracture-preventing efficacy in women over 80 years of age and in men at all ages is meagre or absent. Further, the antihip fracture efficacy shown in clinical trials is absent in real-life studies. Many drugs for the treatment of osteoporosis have also been associated with increased risks of serious adverse events. There are also considerable uncertainties related to the efficacy of drug therapy in preventing clinical vertebral fractures, whereas the efficacy for preventing other fractures (relative risk reductions of 20-25%) remains moderate, particularly in terms of the low absolute risk reduction in fractures with this treatment.