Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013: a UK study

Hip fracture projections up to the year 2060: an analysis based on data from the National Hip Fracture Database (NHFD) for England, Wales, and Northern Ireland

INTRODUCTION

Hip fractures are common and cause a huge socioeconomic burden to patients, their carers, and healthcare services worldwide. Our aim was to examine how much hip fracture numbers would be expected to rise over coming decades, simply as a consequence of the ageing of the population.

METHODS

We used data from the National Hip Fracture Database on the volume of hip fractures occurring in England, Wales and Northern Ireland in the year 2019 (n = 67,210). We projected future numbers of hip fractures by applying this number, assuming stable rates, to population growth forecast data provided by the Office for National Statistics up to the year 2060.

RESULTS

By 2060, the number of hip fractures occurring in England, Wales and Northern Ireland are projected to increase by 107 % (n = 139,105). In males, there was an estimated increase of 130 % compared with 97 % in females. There was an estimated increase across all age ranges, however the oldest age groups demonstrated the largest relative increases. The estimated increase for those aged 90 years or over was as high as 348 % and 198 % for males and females, respectively.

CONCLUSION

As a consequence of future ageing of the population, the demand on the health service posed by people with hip fracture is projected to more than double by the year 2060. Policymakers should be striving to mitigate against the huge public health impact of these projections by maximising fracture prevention strategies as far as possible and by improving the quality of hip fracture care.

Regional disparities in the risk of secondary fractures in patients with hip fractures

PURPOSE

We aimed to examine the regional disparities in secondary fracture incidence among patients with hip fractures in South Korea.

METHODS

This observational, retrospective, cohort study was conducted using data of 6,213 South Korean nationals from the National Health Insurance Service-National Sample Cohort (2004-2019). Secondary fractures included hip, wrist, humerus, spine, ankle, and pelvis fractures that occurred 6 months after hip fracture. The position value for relative composite index was used to identify medically vulnerable regions. Cox proportional hazards models were used for statistical analysis.

RESULTS

Among the 6,213 (1,949 male, 4,264 female) patients with hip fracture, 981 lived in medically vulnerable areas and 5,232 in non-vulnerable areas. Patients residing in vulnerable areas had a higher risk of secondary fractures than did those residing in non-vulnerable areas (hazard ratio [HR]: 1.24, 95 % confidence interval [CI]: 1.05-1.47); the factors that increased their risk included female sex (HR: 1.30, 95 % CI: 1.08-1.57), age ≥71 years (HR: 1.23, 95 % CI: 1.01-1.44), and not receiving osteoporosis medication (HR: 1.47, 95 % CI: 1.14-1.89). Ten years after hip fracture surgery, the risk of secondary fracture more than tripled in the vulnerable areas than that in the non-vulnerable areas.

CONCLUSION

Patients living in vulnerable regions had a higher risk of secondary fractures than that of those in non-vulnerable regions. Prevention and medication policies should thus be implemented to reduce regional healthcare disparities.

Following hip fracture, hospital organizational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: a record-linkage study

Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organizational factors predict prescription of post-hip fracture AOM and refracture risk. A cohort of 178 757 patients aged ≥60 yr who sustained a hip fracture in England and Wales (2016-2019) was examined and followed for 1 yr. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organizational reports. Multilevel models determined organizational factors, independent of patient case-mix, associated with (1) AOM prescription and (2) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) yr old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission, while 50 354 (28%) died during 1-yr follow-up, 12 240 (7%) refractured. Twelve organizational factors were associated with AOM prescription, for example, orthogeriatrician-led care compared to traditional care models (odds ratio [OR] 4.65 [95% CI, 2.25-9.59]); AOM was 9% (95% CI, 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126 d (IQR 59-234). Eight organizational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72 h of admission had an 18% (95% CI, 2%-31%) lower refracture risk, weekend physiotherapy provision had an 8% (95% CI, 3%-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95% CI, 2%-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95% CI, 3%-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist, and occupational therapist involvement in secondary fracture prevention post hip fracture; notably, fracture risk reductions were seen within 12 mo of hip fracture.

Geographic Variation in Osteoporosis Treatment in Postmenopausal Women: A 15-Year Longitudinal Analysis

Context

Osteoporosis affects more than half of older women, but many are not treated. Whether treatment differs between rural and urban areas is unknown.

Objective

To examine differences in osteoporosis treatment among postmenopausal women living in urban and rural areas of Australia.

Methods

Women participating in the Australian Longitudinal Study on Women's Health, a prospective longitudinal cohort study, born between 1946-1951, and with osteoporosis or fractures, were included. Surveys from 2004 to 2019 were linked to the Pharmaceutical Benefits Scheme (government-subsidized medications) to assess osteoporosis treatment and adherence, comparing geographical areas.

Results

Of the 4259 women included (mean age, 55.6 years), 1703 lived in major cities, 1629 inner regional, 794 outer regional, and 133 remote areas. Over the 15-year follow-up, 1401 (32.9%) women received treatment, including 47.4% of women with osteoporosis and 29.9% with fractures. Women in outer regional and remote areas were less likely to use antiosteoporosis treatment than those in major cities on univariable analysis (outer regional odds ratio, 0.83; 95% CI, 0.72-0.95; remote, 0.65; 0.49-0.86), but this did not remain significant on multivariable analysis. Median duration of use was 10 to 36 months, adherence varied by treatment type (34%-100%) but was not related to incident fractures, and of the women who stopped denosumab, 85% did not receive another consolidating treatment.

Conclusions

One-third of women with osteoporosis/fractures received treatment, and adherence was low. There was no difference in treatment use between urban and rural areas after adjusting for risk factors, although the specific treatment used, and adherence, differed.

Exploring the osteoporosis treatment gap after fragility hip fracture at a Tertiary University Medical Center in Thailand

BACKGROUND

(1) To evaluate the prescription rate of anti-osteoporosis medication, and (2) to identify factors associated with patients not receiving anti-osteoporosis medication or, when prescribed, not persisting with medication 1 year after hip fracture treatment.

METHODS

We retrospectively reviewed the medical records of all fragility hip fracture patients admitted to the orthopedic unit of the Faculty of Medicine Siriraj Hospital, Mahidol University, between July 1, 2016, and December 31, 2019. We identified patients who did not receive anti-osteoporosis medication both 6 months and 1 year after fracture treatment. Patients who did not receive the medication 1 year after their treatment were enrolled and interviewed using a no-treatment questionnaire.

RESULTS

In total, 530 patients with fragility hip fractures were eligible (mean age, 79.0 years), and most (74.5%) were women. Only 148 patients (31.6%) received anti-osteoporosis medication 1 year after hip fracture. Logistic regression analysis identified predictors for not receiving the medication: male sex (OR 1.8; 95% CI 1.1-3.0), Charlson comorbidity index score ≥ 5 (OR 1.5; 95% CI 1.0-2.3), and secondary school education or below (OR 2.0; 95% CI 1.2-3.3). The main reason for not receiving the medication was that healthcare providers neither discussed nor initiated pharmacological treatment for osteoporosis (48.2%). When the medication was prescribed, non-persistence primarily stemmed from transportation difficulties that resulted in patients missing follow-ups (50.0%).

CONCLUSIONS

Improved physician attitudes toward anti-osteoporosis medications might enhance the treatment rate. Developing a follow-up team and facilitating access to medications (eg, courier delivery to patients) would promote therapy compliance.

TRIAL REGISTRATIONS

The protocol for the first phase and second phase was approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021) and for the second phase, patients-informed consent forms used in the cross-sectional component were approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021). The research was registered with the Thai Clinical Trials Registry (TCTR number: 20210824002). The study was conducted in accordance with the Declaration of Helsinki. Each patient (or a relative/caregiver) provided informed consent in writing or by telephone to participate in this second study phase.

The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

BACKGROUND

Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.

METHODS

We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.

RESULTS

Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92-0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02-1.10) and return to original residence (OR=1.04, CI=1.00-1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.

CONCLUSIONS

Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

Osteoporosis in 2022: Care gaps to screening and personalised medicine

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.

Predictors of returning home after hip fracture: a prospective cohort study using the UK National Hip Fracture Database (NHFD)

INTRODUCTION

our objective was to describe trends in returning home after hospitalisation for hip fracture and identify predictive factors of this important patient-focussed outcome.

METHODS

a cohort of hip fracture patients from England and Wales (2018-2019) resident in their own home pre-admission were analysed to identify patient and service factors associated with returning home after hospital discharge, and with living in their own home at 120 days. Geographical variation was also analysed.

RESULTS

analysis of returning home at discharge included 87,797 patients; 57,104 (65%) were discharged home. Patient factors associated with lower likelihood of discharge home included cognitive impairment (odds ratio (OR) 0.60 [95% CI: 0.57, 0.62]), malnutrition (OR 0.81 [0.76, 0.86]), being at risk of malnutrition (OR 0.81 [0.78, 0.85]) and experiencing delay to surgery due to reversal of anti-coagulant medication (OR 0.84 [0.77, 0.92]). Corresponding service factors included surgery delay due to hospital logistical reasons (OR 0.91 [0.87, 0.95]) and early morning admission between 4:00 and 7:59 am (OR 0.83 [0.78, 0.89]). Nerve block prior to arrival at the operating theatre was associated with higher likelihood of discharge home (OR 1.07 [1.03, 1.11]). Most of these associations were stronger when analysing the outcome 'living in their own home at 120 days', in which two out of 11 geographic regions were found to have significantly more patients returning home.

CONCLUSION

we identify numerous modifiable factors associated with short-term and medium-term return to own home after hip fracture, in addition to significant geographical variation. These findings should support improvements to care and inform future research.

Osteoporosis Care Gap After Hip Fracture - Worse With Low Healthcare Access and Quality

Despite the burden of osteoporosis-related fractures and availability of effective treatment, a substantial osteoporosis care gap persists. We evaluated this gap following fragility hip fracture, testing the hypothesis that patients who live in areas with low health care access or quality are less likely to undergo evaluation or treatment following hip fragility fracture. This retrospective analysis quantified osteoporosis evaluation and treatment just prior and for 12 mo following fragility hip fracture at an academic medical center in the upper Midwest. Initiation of pharmacologic therapy, Vitamin D screening and dual energy X-ray absorptiometry (DXA) scanning were measured. Each patient was assigned a value for 3 metrics of regional healthcare access and quality: (1) population per PCP ratio, (2) percent un-insured <65 yrs old, and (3) preventable hospitalization >65 yrs old. Generalized estimating equations, with county as a random effect, were used to assess the association of patient characteristics and/or heath care metrics with osteoporosis treatment at the time of admission and/or osteoporosis evaluation and treatment during hospitalization and post-discharge. A total of 585 patients were 80.7 ± 8.4 yrs of age at the time of hip fragility fracture; 68% were women. In 12 mo post-fracture, 17% underwent vitamin D screening, 12% received a DXA scan and 17% began a new bone anti-resorptive medication. Only in-hospital Vitamin D screening was more common in patients from counties with low healthcare access; all other pre- and post-fracture care was more common for patients with greater healthcare access and quality. Overall rates of initiating pharmacologic treatment and/or obtaining a Vitamin D screen or DXA scan following hip fragility fracture were very low and were worse in patients from counties with low access and quality of healthcare. These results remind the practitioner to diagnose and treat osteoporosis following hip fracture and suggests a role for targeting high-risk groups.

Long-term persistence of treatment after hip fracture in a fracture liaison service

Long-term adherence to antiosteoporosis medication (AOM) in the setting of a fracture liaison service (FLS) are not well known. Patients ≥ 50 with hip fracture seen in an FLS and recommended for treatment to prevent new fractures were analyzed. Baseline data included demographics, identification mode, previous treatment and FRAX items. Patient records were reviewed 3-8 years later, and these data were collected: (1) survival; (2) major refracture; (3) initiation of treatment, proportion of days covered (PDC) and persistence with AOM. 372 patients (mean age, 79 years; 76% women) were included. Mean follow-up was 47 months, 52 patients (14%) had a refracture (22 hip) and 129 (34.5%) died. AOM was started in 283 patients (76.0%). Factors associated with initiation of AOM were previous use of bisphosphonate (OR 9.94; 95% CI 1.29-76.32) and a lower T-score lumbar (OR 0.80; 95% CI 0.65-0.99). Persistence decreased to 72.6%, 60% and 47% at 12, 36 and 60 months. A PDC > 80% was confirmed in 208 patients (55.7%) and associated with previous use of bisphosphonate (OR 3.38; 95% CI 1.34-8.53), treatment with denosumab (OR 2.69; 95% CI:1.37-5.27), and inpatient identification (OR 2.26; 95% CI 1.18-4.34). Long-term persistence with AOM was optimal in patients with hip fracture seen at an FLS. A PDC > 80% was associated with inpatient identification and prescription of denosumab.

Overview of fracture liaison services in the UK and Europe: standards, model of care, funding, and challenges

Fragility fractures represent a growing global problem, including in the United Kingdom and European countries. Reports demonstrate the benefits of national guidance and organized fragility fracture programs through fracture liaison services to deliver care to patients who sustain these injuries. The challenge of assembling multidisciplinary teams, providing routine screening of appropriate patients, and monitoring therapies where there is a known compliance problem, remains an obstacle to the success of fragility fracture treatment programs to all. Efforts should continue to introduce and maintain fracture liaison services through coordinated national approaches and advanced systems.

Geographical variation in surgical care and mortality following hip fracture in England: a cohort study using the National Hip Fracture Database (NHFD)

We describe variation across geographical regions of England in operations undertaken following presentation of hip fracture and in 30-day mortality. Some significant geographic variation in 30-day mortality was observed particularly for patients with trochanteric hip fractures and warrants further investigation of other aspects of post-hip fracture care INTRODUCTION: Mortality after hip fracture has improved considerably in the UK over recent decades. Our aim here was to describe geographical variation in type of operation performed and 30-day mortality amongst patients in England with hip fracture.

METHODS

The National Hip Fracture Database was used to carry out a prospective cohort study of nearly all over-60 year olds with hip fracture in England. These data were linked to Hospital Episode Statistics (HES), allowing us to explore regional variation in the operations performed for three fracture types (intracapsular, trochanteric and subtrochanteric), and use logistic regression models adjusted for demographic and clinical factors to describe associated 30-day mortality.

RESULTS

NHFD recorded data for 64,211 patients who underwent surgery in England during 2017. Most had an intracapsular (59%) or trochanteric fracture (35%), and we found significant geographical variation across regions of England in use of total hip replacement (THR) (ranging from 10.1 to 17.4%) for intracapsular fracture and in intermedullary nailing (ranging from 14.9 to 27.0%) of trochanteric fracture. Some geographical variation in mortality amongst intracapsular fracture patients was found, with slightly higher mortality in the East of England (adjusted odds ratio [aOR]: 1.22, 95% CI: 1.02-1.46). Trochanteric fractures showed slightly more variation, with higher 30-day mortality (aOR: 1.40, 95%CI: 1.05-1.88) in the East of England and significantly lower mortality in the North East (aOR: 0.65, 95%CI: 0.46-0.93).

CONCLUSIONS

We have identified regional differences in operation type and 30-day mortality amongst hip fracture patients in England. The relationship between surgical approach and mortality has been explored, but the extent to which differential mortality reflects variation in approach to medical assessment, anaesthesia and other aspects of care warrants further investigation.

Management of osteoporosis in older men

As many as one out of three fragility fractures occur in older men and the outcome of major osteoporotic fractures, in particular hip fractures, is worse in men than in women. Osteoporosis in older men is thus an important threat to the quality of life of individual patients and a considerable burden for society. However, only a small minority of older men with high or very high fracture risk are receiving therapy. This does not need to be so as tools for fracture risk assessment are available and several drugs have been approved for treatment. Nevertheless, the evidence base for the management of osteoporosis in older men remains limited. This narrative review summarises the evidence for older men on the burden of osteoporosis, the pathophysiology of fragility fractures, the clinical presentation, diagnosis and risk assessment, the patient evaluation, and the non-pharmacological and pharmacological management.

Adherence to Anti-Osteoporotic Treatment and Clinical Implications after Hip Fracture: A Systematic Review

The role of anti-osteoporotic treatment as part of the secondary prevention after hip fracture in terms of mortality and re-fracture risk has been studied, and the results are promising. Decreased treatment adherence and compliance is a problem that needs to be addressed by healthcare professionals. A systematic review of the literature was performed using the PubMed database with terms that included hip fracture, mortality, second fracture, and specific anti-osteoporotic treatment. We included 28 articles, 21 regarding mortality and 20 re-fracture rates in hip fracture patients. All studies showed lower mortality after hip fracture associated with anti-osteoporotic treatment, mostly bisphosphonate agents. The re-fracture risk is still debatable, since conflicting data were found. Although most of the studies showed notable effects on mortality and re-fracture rates associated with anti-osteoporotic treatment, we still need more data to validate the actual results.

Trends and Geographical Variability in Osteoporosis Treatment After Hip Fracture: A Multilevel Analysis of 30,965 Patients in the Region of Valencia, Spain

Despite improvements in the therapeutic arsenal and the recommendations of guidelines, low rates of prescribing osteoporosis medications are being reported worldwide for patients surviving a hip fracture, and important geographical variation remain. We aimed to describe trends in the proportion of patients that receive osteoporosis medication after hip fracture and to analyze the geographical variation in the prescription of drug therapy and its associated factors in the region of Valencia, Spain. We studied a population-based retrospective cohort of 30,965 patients aged 65 years and older, discharged from hospital after a hip fracture from January 2008 to December 2015, who were followed up for 3 months after discharge to identify the presence of any prescription of osteoporosis medication. We conducted a multilevel multiple logistic regression analysis with two levels (individuals and health departments [HD]) to determine which individual covariates were associated with receiving a prescription of osteoporosis medication in the 3 months after discharge, as well as the importance of the HD of hospitalization. The percentage of patients treated in the region decreased from a maximum of 28.9% in 2009 to 16.4% in 2015. By sex, the proportion of women treated reached a maximum of 33.4% in 2009 and declined to 19% in 2015, while the proportion of men reached a maximum of 14% in 2011 and reduced to 8.1% in 2015. By health department, there was a noticeable variability in the rate of patients treated, ranging from 40.9% to 11.1% in the whole period (intraclass correlation coefficient [ICC] = 7.54%; median odds ratio [MOR] = 1.64). Proportion of treated patients decreased in 20 of the 24 HDs. Variability could be also observed with regard to choice of medication by HD. This situation pressingly demands action (both at the organizational and professional levels) focused on populations at a higher risk (such as hip fracture patients) that particularly address underutilization and unwarranted variation.

Anti-osteoporosis medication treatment pattern after osteoporotic fracture during 2010-2016 in Fujian, China

This study demonstrates a low anti-osteoporosis drug treatment rate (22.1% in women, 9.5% in men) after osteoporotic fracture in the real-world setting of Fujian, China. The primary medication was calcitonin. The suboptimal treatment was particularly critical among men, low-level hospitals, wrist/vertebral fracture, and the younger elderly patients.

INTRODUCTION

The objective of this study was to investigate the prescription patterns and related influencing factors of anti-osteoporosis drug prescribing after osteoporotic fracture in Fujian, China, between 2010 and 2016.

METHODS

This is a retrospective cohort study based on an existing electronic health record database (National Healthcare Big Data in Fuzhou, China, 37 hospitals included). Patients over 50 years old with newly diagnosed osteoporotic fractures between 2010 and 2016 were included. Postfracture osteoporosis therapies were summarized by overall and fracture site. Multivariate logistic regression was performed to identify influencing factors of anti-osteoporosis medication (AOM) prescription.

RESULTS

Overall, 22.1% of women and 9.5% of men over 50 years old received AOM treatment after osteoporotic fracture within 1 year during 2010-2016, with particular low use of bisphosphonates, 5.3% in women and 1.5% in men. The highest rate of AOM treatment was found in patients with hip fracture (24.5%), followed by vertebral fracture (14.2%) and wrist fracture (2.3%). Of the AOM-treated patients, 90.5% received calcitonin therapy. The treatment rate of AOM showed a slight decline during 2010-2016, but steady rise trends were observed in Ca/vitamin D (VD) prescription. Hospital level, age, sex, previous osteoporosis, previous AOM prescription, and previous oral glucocorticoid prescription were strong predicting factors of AOM prescription.

CONCLUSION

In a real-world setting, AOM treatment was suboptimal and the treatment rate even decreased over time among osteoporosis fracture patients in Fujian, China. The suboptimal treatment was particularly critical among men, low-level hospitals, wrist/vertebral fracture, and the younger elderly patients.

Usefulness of a national hip fracture registry to evaluate the profile of patients in whom antiosteoporotic treatment is prescribed following hospital discharge

This study was carried out to describe the profile of prescription of antiosteoporotic treatment at discharge after a hip fracture in the Spanish National Hip Fracture Registry. Prescription rates among hospitals ranged from 0 to 94% of patients discharged. The prescription rate was higher among patients with better cognitive and functional baseline status.

PURPOSE

National hip fracture registries are useful for assessing current care processes. The goals of this study were as follows: first, to know the rate of antiosteoporotic prescription at discharge among hip fracture patients in hospitals participating in the Spanish National Hip Fracture Registry (RNFC); second, to compare the differences between treated and non-treated patients; third, to analyze patients' characteristics associated with antiosteoporotic prescription at discharge; and fourth, to evaluate whether there were differences in the profile of patients discharged from hospitals with high and low prescription rates.

METHOD

Patients discharged after a fragility hip fracture in 2017 and participating in the RNFC were included. Demographic variables, cognitive and functional status, prefracture osteoporosis treatment, fracture type, anesthetic risk, hospital volume, and antiosteoporotic prescription at discharge were analyzed. Given that patients were clustered within hospitals, intraclass correlation was calculated and generalized estimating equations were fitted.

RESULTS

A total of 6701 patients from 54 hospitals were included. Antiosteoporotic prescription at discharge was prescribed to 36.5% (CI95% 35.8-37.2%), with a wide inter-hospital variability (range 0-94%). The intraclass correlation due of clustering of patients within hospitals was 47.9%. Antiosteoporotic prescription was more likely in patients who were younger, lived at home, previously treated for osteoporosis, had better baseline functional and cognitive status, lower anesthetic risk, and were discharged from high-volume hospitals, all with p < 0.001. The general profile of patients discharged from hospitals with high and low rate of prescription was similar.

CONCLUSIONS

There is a wide variability between hospitals regarding antiosteoporotic prescription after hip fracture. This is more likely to be initiated in patients with better clinical, functional, and mental status and in those discharged from hospitals with larger volumes of patients. These results offer insights regarding the selection of patients receiving secondary prevention and raises questions on who and how many should be treated.

Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk

We reviewed the experimental and clinical evidence that hip bone strength estimated by BMD and/or finite element analysis (FEA) reflects the actual strength of the proximal femur and is associated with hip fracture risk and its changes upon treatment.

INTRODUCTION

The risk of hip fractures increases exponentially with age due to a progressive loss of bone mass, deterioration of bone structure, and increased incidence of falls. Areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), is the most used surrogate marker of bone strength. However, age-related declines in bone strength exceed those of aBMD, and the majority of fractures occur in those who are not identified as osteoporotic by BMD testing. With hip fracture incidence increasing worldwide, the development of accurate methods to estimate bone strength in vivo would be very useful to predict the risk of hip fracture and to monitor the effects of osteoporosis therapies.

METHODS

We reviewed experimental and clinical evidence regarding the association between aBMD and/orCT-finite element analysis (FEA) estimated femoral strength and hip fracture risk as well as their changes with treatment.

RESULTS

Femoral aBMD and bone strength estimates by CT-FEA explain a large proportion of femoral strength ex vivo and predict hip fracture risk in vivo. Changes in femoral aBMD are strongly associated with anti-fracture efficacy of osteoporosis treatments, though comparable data for FEA are currently not available.

CONCLUSIONS

Hip aBMD and estimated femoral strength are good predictors of fracture risk and could potentially be used as surrogate endpoints for fracture in clinical trials. Further improvements of FEA may be achieved by incorporating trabecular orientations, enhanced cortical modeling, effects of aging on bone tissue ductility, and multiple sideway fall loading conditions.

General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal

PURPOSE OF REVIEW

The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied.

RECENT FINDINGS

A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.

Geographic Variations in Intertrochanteric Femoral Fractures in China

Background

Hip fracture is one of the major risk factors of global mortality and disability. The aim of this study was to map the pattern of intertrochanteric femoral fractures in China, providing a pilot national dataset and basis for medical policy proposals.

Methods

A multistage probability sampling strategy was applied in the national baseline survey. Thirty provinces in mainland China were included in this survey. A standardized questionnaire survey was conducted to collect information about basic characteristics such as age, working seniority, hospital level, and residence, with two other parts including perioperative and postoperative treatment parameters. Odds ratios and 95% confidence interval were used to determine essential statistical differences. The proportion of the options in each region was compared using the chi-square (χ ²) test. The histogram and choropleth map of the monthly number of admissions were created using Excel 2016 to show the distribution characteristics.

Results

In total, 1065 valid responses were included, representing a 96.7% survey capture rate. Perioperative treatment and postoperative care distinctly varied across regions and hospital levels. The monthly number of admissions was relatively lower in the Northern region, with higher proportion of hospitalizations to secondary hospitals compared with the Eastern region. The patients in the Eastern region or tertiary hospitals had shorter preoperative waiting time and hospitalization period.

Conclusions

We found apparent geographic variations in intertrochanteric femoral fractures in this study, and the data can be used for drafting national healthcare plans and medical policies.

Integrated Practice Units: What Are They and How Can They Be Applied to Orthopaedic Trauma?

Musculoskeletal professionals are looking for opportunities to provide integrated patient-centered models of care. Integrated practice units (IPUs) are structurally and functionally organized around the patient's medical condition over a full cycle of care with a comprehensive range of services delivered by dedicated multidisciplinary teams. Although IPUs have been developed for chronic orthopaedic conditions, such as hip and knee osteoarthritis, relatively little has been explored in relation to orthopaedic trauma. Development of novel IPUs for managing musculoskeletal injuries may help surgeons to better contend with the substantial burden associated with these conditions on the quality of life of individual patients and society at large. This review explores the challenges and unmet needs unique to orthopaedic trauma that could be bridged by high-value, integrated patient-centered models of care. It also provides a framework for the design and implementation of IPUs and the rationale of this framework in 3 major populations: ambulatory trauma, fragility fractures, and complex polytrauma. To conclude, in this review, we consider the mechanism and impact of alternative payment models in this setting.

Use of anti-osteoporosis medication dispensing by patients with hip fracture: could we do better?

Although Scandinavian countries have the highest incidence of hip fracture in the world, trends in anti-osteoporosis medication use have not been studied. We found less than one-third of Danish hip fracture patients had dispensing of anti-osteoporosis medication over a 10-year period using routinely collected data from population-based registries.

INTRODUCTION

To examine trend in dispensing of anti-osteoporosis medication before and after hip fracture surgery in Denmark over a 10-year period using routinely collected data from population-based registries.

METHODS

From the Danish Multidisciplinary Hip Fracture Registry, we included 65,011 patients aged 65 years or older with an incident hip fracture in 2005-2015. We calculated, for each calendar year of hip fracture diagnosis, the prevalence of use of anti-osteoporosis medication (at least one dispensing of bisphosphonates, strontium ranelate, denosumab, selective estrogen receptor modulators, or teriparatide) in the year before and in the year following hip fracture diagnosis. Among those without a dispensing in the year before hip fracture, we computed 1-year cumulative incidence of use following hip fracture. We treated death as a competing risk and stratified the analysis on sex, age, and comorbidity.

RESULTS

The prevalence of use before hip fracture varied between 7 and 12%, increasing slightly from 2005 to 2015. The cumulative incidence of use following hip fracture decreased from 16% in 2005 to 13% in 2010, whereupon it increased to 20%. A similar pattern was seen with each stratum of sex, age groups, and comorbidity. The overall prevalence of use after hip fracture was below 22% in all calendar years.

CONCLUSIONS

Less than one-third of hip fracture patients had dispensing of anti-osteoporosis medication up to 1 year after hip fracture. We observed only a slight increase in dispensing after hip fracture over the study period, irrespective of patient sex, age, and comorbidity at the time of hip fracture.

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.

Preventing future fractures: effectiveness of an orthogeriatric fracture liaison service compared to an outpatient fracture liaison service and the standard management in patients with hip fracture

An observational study was carried out in two hospitals in patients > 65 years admitted for hip fracture. At 6 months, 15% of patients in the hospital with orthogeriatric standard care and 75% in the hospital with fracture liaison service were receiving bisphosphonates.

PURPOSE

Many patients with fractures are discharged without preventive therapy against further fractures. We sought to compare the effectiveness of an orthogeriatric fracture liaison service (FLS), outpatient FLS, and the standard care after hip fractures in prevention of future fractures.

METHODS

An observational study was carried out in two hospitals in patients > 65 years of age, admitted between March and July 2016 for fractures. The Candelaria hospital (HUNSC) has no specific protocol for secondary prevention, while at the Negrin Hospital (HUGCDN), an FLS nurse visits the inpatients, gathers metabolic history, instructs regarding the diet, exercises, and fall prevention, and completes a discharge report regarding osteoporosis treatment. The prescription rate of osteoporosis treatment was analyzed at admission, discharge, and 6 months after discharge. We also analyzed the data of patients with hip fractures who attended the outpatient FLS before March 2016.

RESULTS

We included a total of 185 inpatients with a mean age of 82 years and 73% were women. At admission, 8% of the patients in HUNSC and 10% in HUGCDN were receiving bisphosphonates. At discharge, the percentages were 8 and 96%, while at 6 months they were 15 and 75%, respectively (p < 0.001). The outpatient FLS recorded 206 hip fractures (27% of discharges for fractures), with 77% adherence to treatment at 6 months.

CONCLUSIONS

Compared with the conventional management, the FLS model for inpatients with hip fractures achieved a fivefold increase in the adherence to treatment at 6 months, similar to the rates of outpatient FLS.