Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

Total hip arthroplasty for fractured neck of femur does not restore preoperative hip-specific function, health-related quality of life, or level of fitness

PURPOSE

The primary aim was to assess whether a total hip arthroplasty (THA) was able to restore health-related quality of life (HRQoL) following an intracapsular hip fracture. The secondary aims were to assess changes in hip-specific function, fitness/frailty, mortality risk, complications and revision risk, and factors independently associated with these.

METHODS

This retrospective cohort study included all patients aged ≥ 50 years admitted with a hip fracture from the emergency department at a single centre during a 42-month period. Patient demographics, perioperative variables, complications, revision, and mortality were collected. Patient-reported outcome measures (PROMs) were assessed at final follow-up.

RESULTS

Among 250 identified patients, 189 (75.6%) were women with a mean age of 70.3 (range 50-94 years). Mean follow-up was 2.3 (SD 1.1) years. The implant and patient survival rates at 2 years were both 95.5% (95% confidence intervals (CI) +/- 2.7). Older age (hazard ratio [HR] 1.22, 95% CI 1.12-1.33, p < 0.001) and male sex (HR 3.33, 95% CI 1.15-10.0, p = 0.026) were independently associated with mortality. There were 19 (7.6%) postoperative complications that included 6 (2.4%) periprosthetic fractures, 5 (2.0%) deep infections, and 8 (3.2%) dislocations, of which 13 underwent revision. Increasing time to theatre (HR 1.02, 95% CI 1.01-1.03, p = 0.017) was independently associated with a postoperative complication. Postoperative PROMs were available for 166 (66.4%) patients. There were significant (p < 0.001) deteriorations in EuroQol-5D (Mean difference [MD] 0.192, 95% CI 0.133-0.252), Oxford hip score (MD 2.5, 95% CI 1.5-3.6), and fitness (Rockwood score MD 0.7, 95% CI 0.5-0.8) relative to preoperative levels of function.

CONCLUSION

THA may be the treatment of choice in a physically active patient with the aim of restoring their HRQoL, hip function, and fitness, but this was not observed. Furthermore, there was a high complication rate which was associated with increasing time to theatre.

LEVEL OF EVIDENCE

III, retrospective cohort study.

The incidence of subsequent contralateral hip fracture and factors associated with increased risk: the IMPACT Contralateral Fracture Study

Patients who sustain a contralateral hip fracture experience significantly inferior outcomes; however, the incidence and predictors of contralateral hip fracture remain poorly understood. In the present study, 2.5% of patients sustained a contralateral hip fracture within 12 months, and socioeconomic deprivation was associated with reduced risk of contralateral hip fracture.

INTRODUCTION

Hip fractures are associated with high morbidity and mortality, and patients that sustain a subsequent contralateral fracture experience inferior outcomes. The risk of contralateral fracture is highest within the first year; however, the incidence and associated factors remain poorly understood. The aims were to investigate (i) the incidence of a subsequent contralateral hip fracture within the first year, (ii) identify factors associated with an increased risk of contralateral fracture and (iii) compare early mortality risk after index versus contralateral hip fracture.

METHODS

This study included all patients aged over 50 years admitted to NHS hospitals in Scotland between 1st March 2020 and 31st December 2020 (n = 5566) as routine activity of the Scottish Hip Fracture Audit (SHFA). Multivariate logistic regression was used to examine factors associated with 30-day mortality, and cox regression was used to identify factors associated with a contralateral fracture.

RESULTS

During the study period 2.5% (138/5566) of patients sustained a contralateral hip fracture within 12 months of the index hip fracture. Socioeconomic deprivation was inversely associated with increased risk of contralateral fracture (odds ratio 2.64, p < 0.001), whilst advancing age (p = 0.427) and sex (p = 0.265) were not. After adjusting for significant cofounders, there was no significant difference in 30-day mortality following contralateral fracture compared to index fracture (OR 1.22, p = 0.433).

CONCLUSION

One in 40 (2.5%) hip fracture patients sustained a contralateral fracture within 12 months of their index fracture, and deprivation was associated with a reduced risk of contralateral fracture. No difference in 30-day mortality was found.

Using normalisation process theory for intervention development, implementation and refinement in musculoskeletal and orthopaedic interventions: a qualitative systematic review

BACKGROUND

Normalisation process theory (NPT) provides researchers with a set of tools to support the understanding of the implementation, normalisation and sustainment of an intervention in practice. Previous reviews of published research have explored NPT's use in the implementation processes of healthcare interventions. However, its utility in intervention research, specifically in orthopaedic and musculoskeletal interventions, remains unclear. The aim of this review is to explore how NPT (including extended NPT, ENPT) has been used in orthopaedic/musculoskeletal intervention research.

METHODS

A qualitative systematic review was conducted. Two bibliographic databases (Scopus and Web of Science) and a search engine (Google Scholar) were searched for peer-reviewed journal articles citing key papers outlining the development of NPT, related methods, tools or the web-based toolkit. We included studies of any method, including protocols, and did not exclude based on published language. A data extraction tool was developed, and data were analysed using a framework approach.

RESULTS

Citation searches, of the 12 key studies, revealed 10,420 citations. Following duplicate removal, title, abstract and full-text screening, 14 papers from 12 studies were included. There were 8 key findings assessed against GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research). Five were of high confidence supporting NPT/ENPT's use in the implementation process for interventions targeting a range of MSK/orthopaedic conditions. NPT/ENPT offers a useful analytical lens to focus attention and consider implementation factors robustly. There is limited evidence for the selection of NPT/ENPT and for the use of the Normalisation Measure Development instrument. Three findings of moderate confidence suggest that coherence is seen as a fundamental initial step in implementation, there is limited evidence that study population limits NPT's utility and the application of ENPT may pose a challenge to researchers.

CONCLUSION

This review demonstrates NPT's utility in supporting intervention implementation for orthopaedic and musculoskeletal conditions. We have theorised the benefits ENPT offers to intervention development and refinement and recommend future researchers consider its use. We also encourage future researchers to offer clear justification for NPT's use in their methodology.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (CRD42022358558).

Socioeconomically-deprived patients suffer hip fractures at a younger age and require more hospital admissions, but early mortality risk is unchanged: The IMPACT Deprivation Study

INTRODUCTION

Socioeconomic deprivation is associated with multi-morbidity and frailty, but influence on hip fracture outcomes is poorly understood. The primary aim was to investigate the association between deprivation and mortality, and secondary aims were to assess the effects on: (i) age at presentation; (ii) inpatient outcomes, and (iii) post-discharge outcomes.

METHOD

This cohort study included all patients aged >50 years admitted with a hip fracture to a high-volume centre between 01 March 2020 and 20 November 2021. Data were collected contemporaneously by specialist auditors and underwent validation using live health records after 180 days follow-up. Variables were demographics including Scottish Index of Multiple Deprivation, injury and management factors, and outcome measures including length of stay, discharge destination, readmission, and mortality status at 180 days.

RESULTS

There were 1822 patients of which 1306/1822 (72%) were female. Deprivation was independently associated with younger age at hip fracture, demonstrating a linear correlation with each deprivation level. The overall mean age was 80.7 years (range 50-102), with the mean age in the most deprived group being 77.2 years (95% CI; 75.7-78.7) versus 82.8 years (95% CI; 82.0-83.5) in the least deprived. Multivariate logistic regression showed no association between deprivation and 30- or 180-day mortality risk. Kaplan-Meier survival analysis demonstrated no difference between the most deprived versus least deprived (log-rank, p = 0.854). Deprivation had no influence on length of stay, discharge destination, or COVID-19 status, but deprived patients had an increased risk of readmission (OR 1.63, 95% CI [1.18-2.24]; p = 0.003).

CONCLUSION

Deprivation showed no linear correlation with early mortality risk (within 180 days of injury), but it was associated with an earlier age at presentation (the most deprived sustained a hip fracture 5.6 years earlier than the least deprived) which may impact overall life expectancy. More deprived patients were more likely to require further acute hospital admissions.

Association of Polypharmacy and Anticholinergic Burden with Length of Stay in Hospital Amongst Older Adults Admitted with Hip Fractures: A Retrospective Observational Study

BACKGROUND

Age-associated multimorbidity and polypharmacy, predispose individuals to falls and consequent hip fractures. We examined the impact of polypharmacy (≥ 4 drugs daily), including anticholinergic agents, on hospital length of stay (LOS), mobility within 1-day of hip surgery and pressure ulcers in adults ≥ 60 years admitted with hip fractures.

METHODS

In this retrospective observational study, information on medications at admission was obtained to calculate the total number of drugs taken, including those imposing an anticholinergic burden (ACB). Associations between variables were examined by logistic regression; adjusted for age, sex, co-morbidities, pre-fracture functional limitations and alcohol consumption.

RESULTS

There were 787 women and 318 men of similar mean age (± SD): 83.1 years (± 8.6) and 82.5 years (± 9.0), respectively. Compared to patients with an ACB score = 0 and taking < 4 drugs daily, those with an ACB score ≥ 1 and taking ≥ 4 drugs daily had greater risk of prolonged LOS (≥ 2 weeks), OR 1.8 (1.2-2.7); failure to mobilise within 1-day of surgery, OR 1.9 (1.1-3.3); and pressure ulcers, OR 3.0 (95% CI 1.2-7.9). LOS was further prolonged by failure to mobilise within 1-day of surgery and/or pressure ulcers. Those with either an ACB score ≥ 1 or the use of ≥ 4 drugs daily had intermediate risks.

CONCLUSIONS

Anticholinergic agents and polypharmacy in patients with hip fractures are associated with longer LOS in hospital, further accentuated by failure to mobilise within 1-day after surgery and pressure ulcers. This study provides further evidence of the impact of polypharmacy, including those with an ACB, on adverse health outcomes and lends support to reduce potentially inappropriate prescribing.

Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

BACKGROUND

Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care.

METHODS

Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway.

RESULTS

Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team.

CONCLUSION

Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Cost of hospitalisation for hip fracture-findings from the Irish hip fracture database

The authors utilised the Irish Hip Fracture Database (IHFD) to quantify the impact of hip fracture on the health service in terms of incidence, bed days and financial costs. The absolute number of hip fracture cases recorded by the IHFD has increased, as has the associated costs of hospitalisation.

INTRODUCTION

Hip fracture places a considerable clinical and financial burden on the healthcare system, with acute hospitalisation accounting for a substantial proportion of the costs incurred. This paper aimed to quantify the cost of hospitalisation for hip fracture in Ireland in terms of bed days and direct hospital costs.

METHODS

The authors analysed 23,494 cases in the Irish Hip Fracture Database (IHFD) from 2014 to 2020. Case numbers and length of stay were analysed annually. Hospital costs for hip fracture were described using the 2020 Activity-Based Funding Price List, which outlines the fees paid to public hospitals for inpatient activity.

RESULTS

For the time period 2014-2020, the total cost of hospitalisation for hip fracture was approximately €296 million, equating to approximately €11,700 per episode of care. The annual cost of hospitalisation increased from approximately €34 million in 2014 to €44 million in 2020. In 2020, the mean length of stay for hip fracture was 17 days accounting for > 62,600 acute hospital bed days.

CONCLUSION

The absolute number of hip fracture cases recorded by the IHFD has increased, as has the cost of hospitalisation. Given the current capacity issues and economic constraints, there is a growing need to prioritise time spent in the most expensive acute hospital setting to the immediate perioperative period and maximise the use of community services and early supportive discharge for the rehabilitation phase.

Machine learning outperforms clinical experts in classification of hip fractures

Hip fractures are a major cause of morbidity and mortality in the elderly, and incur high health and social care costs. Given projected population ageing, the number of incident hip fractures is predicted to increase globally. As fracture classification strongly determines the chosen surgical treatment, differences in fracture classification influence patient outcomes and treatment costs. We aimed to create a machine learning method for identifying and classifying hip fractures, and to compare its performance to experienced human observers. We used 3659 hip radiographs, classified by at least two expert clinicians. The machine learning method was able to classify hip fractures with 19% greater accuracy than humans, achieving overall accuracy of 92%.

Unicompartmental compared with total knee replacement for patients with multimorbidities: a cohort study using propensity score stratification and inverse probability weighting

BACKGROUND

Although routine NHS data potentially include all patients, confounding limits their use for causal inference. Methods to minimise confounding in observational studies of implantable devices are required to enable the evaluation of patients with severe systemic morbidity who are excluded from many randomised controlled trials.

OBJECTIVES

Stage 1 - replicate the Total or Partial Knee Arthroplasty Trial (TOPKAT), a surgical randomised controlled trial comparing unicompartmental knee replacement with total knee replacement using propensity score and instrumental variable methods. Stage 2 - compare the risk benefits and cost-effectiveness of unicompartmental knee replacement with total knee replacement surgery in patients with severe systemic morbidity who would have been ineligible for TOPKAT using the validated methods from stage 1.

DESIGN

This was a cohort study.

SETTING

Data were obtained from the National Joint Registry database and linked to hospital inpatient (Hospital Episode Statistics) and patient-reported outcome data.

PARTICIPANTS

Stage 1 - people undergoing unicompartmental knee replacement surgery or total knee replacement surgery who met the TOPKAT eligibility criteria. Stage 2 - participants with an American Society of Anesthesiologists grade of ≥ 3.

INTERVENTION

The patients were exposed to either unicompartmental knee replacement surgery or total knee replacement surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was the postoperative Oxford Knee Score. The secondary outcome measures were 90-day postoperative complications (venous thromboembolism, myocardial infarction and prosthetic joint infection) and 5-year revision risk and mortality. The main outcome measures for the health economic analysis were health-related quality of life (EuroQol-5 Dimensions) and NHS hospital costs.

RESULTS

In stage 1, propensity score stratification and inverse probability weighting replicated the results of TOPKAT. Propensity score adjustment, propensity score matching and instrumental variables did not. Stage 2 included 2256 unicompartmental knee replacement patients and 57,682 total knee replacement patients who had severe comorbidities, of whom 145 and 23,344 had linked Oxford Knee Scores, respectively. A statistically significant but clinically irrelevant difference favouring unicompartmental knee replacement was observed, with a mean postoperative Oxford Knee Score difference of < 2 points using propensity score stratification; no significant difference was observed using inverse probability weighting. Unicompartmental knee replacement more than halved the risk of venous thromboembolism [relative risk 0.33 (95% confidence interval 0.15 to 0.74) using propensity score stratification; relative risk 0.39 (95% confidence interval 0.16 to 0.96) using inverse probability weighting]. Unicompartmental knee replacement was not associated with myocardial infarction or prosthetic joint infection using either method. In the long term, unicompartmental knee replacement had double the revision risk of total knee replacement [hazard ratio 2.70 (95% confidence interval 2.15 to 3.38) using propensity score stratification; hazard ratio 2.60 (95% confidence interval 1.94 to 3.47) using inverse probability weighting], but half of the mortality [hazard ratio 0.52 (95% confidence interval 0.36 to 0.74) using propensity score stratification; insignificant effect using inverse probability weighting]. Unicompartmental knee replacement had lower costs and higher quality-adjusted life-year gains than total knee replacement for stage 2 participants.

LIMITATIONS

Although some propensity score methods successfully replicated TOPKAT, unresolved confounding may have affected stage 2. Missing Oxford Knee Scores may have led to information bias.

CONCLUSIONS

Propensity score stratification and inverse probability weighting successfully replicated TOPKAT, implying that some (but not all) propensity score methods can be used to evaluate surgical innovations and implantable medical devices using routine NHS data. Unicompartmental knee replacement was safer and more cost-effective than total knee replacement for patients with severe comorbidity and should be considered the first option for suitable patients.

FUTURE WORK

Further research is required to understand the performance of propensity score methods for evaluating surgical innovations and implantable devices.

TRIAL REGISTRATION

This trial is registered as EUPAS17435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 66. See the NIHR Journals Library website for further project information.

Bridging the gaps in secondary fracture prevention at a single center in Pakistan-compliance with the IOF best practice framework

PURPOSE

The International Osteoporosis Foundation (IOF) formulated a set of best practice framework as an international benchmark for secondary fracture prevention (SFP) and fracture liaison services (FLS), delineating essential elements of service delivery. The aim of this audit was to assess compliance with the IOF standards for patients ≥ 50 years presenting with fragility hip fractures at a tertiary care center in Pakistan.

METHODS

A retrospective sample of hip fracture cases from Jan 2019 to Dec 2019, treated at the section of Orthopedic Surgery, Aga Khan University, Karachi, was conducted. After excluding high energy trauma cases and patients younger than 50 years of age, medical records were audited, using a pre-structured Performa based on IOF standards. Compliance level of 0, 1, 2, and 3 was recorded as defined by IOF. Microsoft excel was used for data analysis.

RESULTS

A compliance level of 3 was recorded for patient identification and fall prevention services, whereas level 1 was attained for database maintenance for 25 (100%) cases. For medication initiation, level 0 was recorded for all the cases; however, 8 (32%) cases were prescribed calcium and vitamin D supplements. For the standards, including post-fracture assessment timing, evaluation of secondary causes of osteoporosis, multifaceted assessment, medication review, communication strategy, and long-term management, a level 0 was noted for 25 (100%) cases. Moreover, no recommended assessment guidelines were followed uniformly.

CONCLUSION

The care gaps identified require substantial efforts to ensure adequate implementation of the overall best practice standards for SFP, necessitating the need for FLS initiation and establishment of fracture care pathway.

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England

We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia.

INTRODUCTION

Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England.

METHODS

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission.

RESULTS

We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001).

CONCLUSION

Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

Bisphosphonates to reduce bone fractures in stage 3B+ chronic kidney disease: a propensity score-matched cohort study

BACKGROUND

Bisphosphonates are contraindicated in patients with stage 4+ chronic kidney disease. However, they are widely used to prevent fragility fractures in stage 3 chronic kidney disease, despite a lack of good-quality data on their effects.

OBJECTIVES

The aims of each work package were as follows. Work package 1: to study the relationship between bisphosphonate use and chronic kidney disease progression. Work package 2: to study the association between using bisphosphonates and fracture risk. Work package 3: to determine the risks of hypocalcaemia, hypophosphataemia, acute kidney injury and upper gastrointestinal events associated with using bisphosphonates. Work package 4: to investigate the association between using bisphosphonates and changes in bone mineral density over time.

DESIGN

This was a new-user cohort study design with propensity score matching.

SETTING AND DATA SOURCES

Data were obtained from UK NHS primary care (Clinical Practice Research Datalink GOLD database) and linked hospital inpatient records (Hospital Episode Statistics) for work packages 1-3 and from the Danish Odense University Hospital Databases for work package 4.

PARTICIPANTS

Patients registered in the data sources who had at least one measurement of estimated glomerular filtration rate of < 45 ml/minute/1.73 m2 were eligible. A second estimated glomerular filtration rate value of < 45 ml/minute/1.73 m2 within 1 year after the first was requested for work packages 1 and 3. Patients with no Hospital Episode Statistics linkage were excluded from work packages 1-3. Patients with < 1 year of run-in data before index estimated glomerular filtration rate and previous users of anti-osteoporosis medications were excluded from work packages 1-4.

INTERVENTIONS/EXPOSURE

Bisphosphonate use, identified from primary care prescriptions (for work packages 1-3) or pharmacy dispensations (for work package 4), was the main exposure.

MAIN OUTCOME MEASURES

Work package 1: chronic kidney disease progression, defined as stage worsening or starting renal replacement. Work package 2: hip fracture. Work package 3: acute kidney injury, hypocalcaemia and hypophosphataemia identified from Hospital Episode Statistics, and gastrointestinal events identified from Clinical Practice Research Datalink or Hospital Episode Statistics. Work package 4: annualised femoral neck bone mineral density percentage change.

RESULTS

Bisphosphonate use was associated with an excess risk of chronic kidney disease progression (subdistribution hazard ratio 1.12, 95% confidence interval 1.02 to 1.24) in work package 1, but did not increase the probability of other safety outcomes in work package 3. The results from work package 2 suggested that bisphosphonate use increased fracture risk (hazard ratio 1.25, 95% confidence interval 1.13 to 1.39) for hip fractures, but sensitivity analyses suggested that this was related to unresolved confounding. Conversely, work package 4 suggested that bisphosphonates improved bone mineral density, with an average 2.65% (95% confidence interval 1.32% to 3.99%) greater gain in femoral neck bone mineral density per year in bisphosphonate users than in matched non-users.

LIMITATIONS

Confounding by indication was a concern for the clinical effectiveness (i.e. work package 2) data. Bias analyses suggested that these findings were due to inappropriate adjustment for pre-treatment risk. work packages 3 and 4 were based on small numbers of events and participants, respectively.

CONCLUSIONS

Bisphosphonates were associated with a 12% excess risk of chronic kidney disease progression in participants with stage 3B+ chronic kidney disease. No other safety concerns were identified. Bisphosphonate therapy increased bone mineral density, but the research team failed to demonstrate antifracture effectiveness.

FUTURE WORK

Randomised controlled trial data are needed to demonstrate antifracture efficacy in patients with stage 3B+ chronic kidney disease. More safety analyses are needed to characterise the renal toxicity of bisphosphonates in stage 3A chronic kidney disease, possibly using observational data.

STUDY REGISTRATION

This study is registered as EUPAS10029.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 17. See the NIHR Journals Library website for further project information. The project was also supported by the National Institute for Health Research Biomedical Research Centre, Oxford.

The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study

This study in 8 countries across Europe found that about 75% of elderly women seen in primary care who were at high risk of osteoporosis-related fractures were not receiving appropriate medication. Lack of osteoporosis diagnosis appeared to be an important contributing factor.

INTRODUCTION

Treatment rates in osteoporosis are documented to be low. We wished to assess the osteoporosis treatment gap in women ≥ 70 years in routine primary care across Europe.

METHODS

This cross-sectional observational study in 8 European countries collected data from women 70 years or older visiting their general practitioner. The primary outcome was treatment gap: the proportion who were not receiving any osteoporosis medication among those at increased risk of fragility fracture (using history of fracture, 10-year probability of fracture above country-specific Fracture Risk Assessment Tool [FRAX] thresholds, T-score ≤ - 2.5).

RESULTS

Median 10-year probability of fracture (without bone mineral density [BMD]) for the 3798 enrolled patients was 7.2% (hip) and 16.6% (major osteoporotic). Overall, 2077 women (55%) met one or more definitions for increased risk of fragility fracture: 1200 had a prior fracture, 1814 exceeded the FRAX threshold, and 318 had a T-score ≤ - 2.5 (only 944 received a dual-energy x-ray absorptiometry [DXA] scan). In those at increased fracture risk, the median 10-year probability of hip and major osteoporotic fracture was 11.2% and 22.8%, vs 4.1% and 11.5% in those deemed not at risk. An osteoporosis diagnosis was recorded in 804 patients (21.2%); most (79.7%) of these were at increased fracture risk. The treatment gap was 74.6%, varying from 53% in Ireland to 91% in Germany. Patients with an osteoporosis diagnosis were found to have a lower treatment gap than those without a diagnosis, with an absolute reduction of 63%.

CONCLUSIONS

There is a large treatment gap in women aged ≥ 70 years at increased risk of fragility fracture in routine primary care across Europe. The gap appears to be related to a low rate of osteoporosis diagnosis.

Closing the Osteoporosis Care Gap

PURPOSE OF REVIEW

This review outlines the scope of the problem in osteoporosis care and secondary fracture prevention and describes fracture prevention strategies, with a focus on the frail elderly.

RECENT FINDINGS

Despite heightened awareness among patients and clinicians alike and the availability of efficacious anti-osteoporosis medications, osteoporosis is still underdiagnosed and undertreated. However, the introduction of systematic risk assessment and secondary fracture prevention programmes has gained momentum, and evidence of success is accumulating. We possess today the knowledge required to close the osteoporosis care gap. The basic components in a secondary prevention model are similar in all health care settings, number one being a dedicated fracture coordinator, with anti-osteoporosis medications and multifaceted falls prevention as cornerstones, particularly in the frailest, both in the near and long-term. Initiation of structured care pathways including the key elements - identification, investigation, intervention and follow-up of adherence - demonstrably reduces re-fracture rates and is cost-effective.

A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture.

PURPOSE/INTRODUCTION

To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice.

METHODS

The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses.

RESULTS

One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%).

CONCLUSION

A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

Socioeconomic and clinical risk factors of hip fracture among the elderly: a case-control study

Background/Aims

The aim of the study was to investigate the socioeconomic and clinical risk factors for hip fracture among a community-dwelling elderly population in Greece. It also aimed to identify characteristics associated with reducing mobility.

Methods

A case-control study was conducted on 202 patients who had a hip fracture and on 202 other members of the elderly population who did not have a hip fracture as the control group.

Results

In the multivariate analysis, the variables related to an increased risk of hip fracture were: gender (odds ration [OR]=10.88; 95%confidence Interval [CI]=2.28–51.98), income (OR=32.50; 95%CI=2.96–356.43), income adequacy (OR=129,34; 95%CI=7,09–2360,88), inability to pay expenses/medication (OR=0.02; 95%CI=0.003–0.09), depression (OR=0.03; 95%CI=0.002–0.35), multimorbidity (OR=0.01; 95%CI=0.001–0.97), number of medication (OR=0.02; 95%CI=0.001–0.28) and history of falls (OR=0.08; 95%CI=0.01–0.40). Factors related to deterioration of mobility were: age (OR=28.43; 95%CI:5.45–148.32), dementia (OR=15.60; 95%CI:1.80–135.27), walking ability (OR=0.20; 95%CI:0.07–0.56), balance (OR=9.10; 95%CI:1.89–43.75), use of walking aid (OR=7.42; 95%CI:2.70–20.39), and length of hospitalisation (OR=3.01; 95%CI:1.27–7.14).

Conclusions

Socioeconomic and clinical factors that lead to an increased risk of hip fracture were identified, as well as factors affecting post-operative functional ability that could guide prevention programmes.

Fracture liaison programs

In view of the high imminent risk of having subsequent fractures after a fracture, early evaluation and treatment decisions to prevent subsequent fractures are advocated. After a hip fracture, the fracture liaison service (FLS) and orthogeriatric care are considered the most appropriate organisational approaches for secondary fracture prevention following a recent fracture. Their introduction and implementation have been shown to increase evaluation and treatment of patients at high risk for subsequent fracture. Of real-world cohort studies, most, but not all studies, indicate a lower incidence of fracture and longer survival after treatment with nitrogen-containing bisphosphonates.

Conceptual Framework for an Episode of Rehabilitative Care After Surgical Repair of Hip Fracture

Researchers face a challenge when evaluating the effectiveness of rehabilitation after a surgical procedure for hip fracture. Reported outcomes of rehabilitation will vary depending on the end point of the episode of care. Evaluation at an inappropriate end point might suggest a lack of effectiveness leading to the underuse of rehabilitation that could improve outcomes. The purpose of this article is to describe a conceptual framework for a continuum-care episode of rehabilitation after a surgical procedure for hip fracture. Definitions are proposed for the index event, end point, and service scope of the episode. Challenges in defining the episode of care and operationalizing the episode, and next steps for researchers are discussed. The episode described is intended to apply to all patients eligible for entry to rehabilitation after hip fracture and includes most functional recovery end points. This framework will provide a guide for rehabilitation researchers when designing and interpreting evaluations of the effectiveness of rehabilitation after hip fracture. Evaluation of all potential care episodes facilitates transparency in reporting of outcomes, enabling researchers to determine the true effectiveness of rehabilitation after a surgical procedure for hip fracture.

Efficacy, cost, and aspects to take into account in the treatment of osteoporosis in the elderly

Age is one of the principal risk factors for development of frailty fractures. Age pyramids show a population that is becoming increasingly more elderly, with an increasing incidence of fractures, and the forecasts for the future are truly alarming. Adequate handling of these patients who are especially at risk, at both the preventive and care levels, with a well-defined orthogeriatric model is necessary to respond to this clinical challenge. The objective of this review is to analyze the efficacy of the different strategies for the handling of geriatric patients with fracture risk.

Improvement in the primary and secondary prevention of osteoporosis by a Fracture Liaison Service: feedback from a single French center care pathway

Osteoporosis is responsible for fragility fractures, thus causing significant morbidity and mortality. This study shows that care pathways, such as Le Mans General Hospital Fracture Liaison Service, are useful and efficient in improving the prevention of osteoporosis and of its consequences.

INTRODUCTION

Osteoporosis is a major public health concern, causing significant morbidity and mortality. Care pathways, called Fracture Liaison Services, have demonstrated their utility in preventing osteoporosis-associated morbidity and mortality. The aim of this study was to analyze the activity of one such care pathway.

METHODS

This was a retrospective, observational, cohort study, in which 272 patients who had fragility fractures between January 2012 and December 2016 were included. Screening of the medical records and data analyses were performed to characterize the population and the medical care received related to osteoporosis, and to compare these data with those of another study carried out from January 2010 to January 2011 on 54 patients in the same Fracture Liaison Service.

RESULTS

There was no statistically significant difference between the two cohorts concerning their demographic characteristics, with 92.3% women and a mean age of 68.7 in our cohort. Secondary prevention was improved, as shown by a reduction in the number of vertebral fractures detected by systematic assessment and fewer low-energy fractures. This study also demonstrated a decline in the percentage of patients with a first-degree parental history of hip fracture and a trend towards a decline in the rate of those having vitamin D insufficiency.

CONCLUSIONS

Communication with patients and healthcare professionals through the Fracture Liaison Service was beneficial for patients in terms of fracture prevention. This study supports the development of similar care pathways in other healthcare institutions.