Mild prolonged chronic hyponatremia and risk of hip fracture in the elderly

BACKGROUND

Hip fractures are among the most serious bone fractures in the elderly, producing significant morbidity and mortality. Several observational studies have found that mild hyponatremia can adversely affect bone, with fractures occurring as a potential complication. We examined if there is an independent association between prolonged chronic hyponatremia (>90 days duration) and risk of hip fracture in the elderly.

METHODS

We performed a retrospective cohort study in adults >60 years of age from a prepaid health maintenance organization who had two or more measurements of plasma sodium between 2005 and 2012. The incidence of hip fractures was assessed in a very restrictive population: subjects with prolonged chronic hyponatremia, defined as plasma sodium values <135 mmol/L, lasting >90 days. Multivariable Cox regression was performed to determine the hazard ratio (HR) for hip fracture risk associated with prolonged chronic hyponatremia after adjustment for the propensity to have hyponatremia, fracture risk factors and relevant baseline characteristics.

RESULTS

Among 31 527 eligible patients, only 228 (0.9%) had prolonged chronic hyponatremia. Mean plasma sodium was 132 ± 5 mmol/L in hyponatremic patients and 139 ± 3 mmol/L in normonatremic patients (P < 0.001). The absolute risk for hip fracture was 7/282 in patients with prolonged chronic hyponatremia and 411/313 299 in normonatremic patients. Hyponatremic patients had a substantially elevated rate of hip fracture [adjusted HR 4.52 (95% CI 2.14-9.6)], which was even higher in those with moderate hyponatremia (<130 mmol/L) [adjusted HR 7.61 (95% CI 2.8-20.5)].

CONCLUSION

Mild prolonged chronic hyponatremia is independently associated with hip fracture risk in the elderly population, although the absolute risk is low. However, proof that correcting hyponatremia will result in a reduction of hip fractures is lacking.

Physicians perceptions of an educational support system integrated into an electronic health record

The purpose of this study is to determine the perceptions by physicians of an educational system integrated into an electronic health record (EHR). Traditional approaches to continuous medical education (CME) have not shown improvement in patient health care outcomes. Hospital Italiano de Buenos Aires (HIBA) has implemented a system that embeds information pearls into the EHR, providing learning opportunities that are integrated into the patient care process. This study explores the acceptability and general perceptions of the system by physicians when they are in the consulting room. We interviewed 12 physicians after one or two weeks of using this CME system and we performed a thematic analysis of these interviews. The themes that emerged were use and ease of use of the system; value physicians gave to the system; educational impact on physicians; respect for the individual learning styles; content available in the system; and barriers that were present or absent for using the CME system. We found that the integrated CME system developed at HIBA was well accepted and perceived as useful and easy to use. Future work will involve modifications to the system interface, expansion of the content offered and further evaluation.

Narrowing the Gap in Hypertension: Effectiveness of a Complex Antihypertensive Program in the Elderly

Hypertension control is a difficult goal to achieve in common practice even when its benefits have been widely proved. We assessed the effectiveness of a Complex Antihypertensive Intervention Program in the Elderly (CAPE). A program trial of 500 elderly hypertensive patients was conducted. 250 were followed by primary care physicians and intervened by the CAPE and 250 received usual care. The program included an organizational change with the addition of an office where patients had their blood pressure measured, were appointed to join educational sessions and received verbal and printed advice before medical attendance. Data was systematically recorded in the electronic medical record which functioned as a physician reminder during the visit. Differences in systolic blood pressure level and in percentage of well-controlled (<140/90 mm Hg) patients between groups were measured after 12 months of follow-up. The difference of mean change in systolic blood pressure between groups was 7.1 mm Hg (95% confidence interval, 4-10 mm Hg). Sixty-seven percent of patients in the intervention group were well-controlled, as were 51% of patients in the control group (p < 0.001). Patients who attended educational sessions showed the lowest odd ratio (0.25; 95% confidence interval, 0.11-0.54) for blood pressure above 140/90 mm Hg in multivariate analysis after adjusting for age, sex, initial systolic blood pressure level, and changes in antihypertensive treatment. These results support the effectiveness of our complex intervention program. Routine clinical care of hypertension can be improved with simple strategies that go beyond pharmacotherapy, tending to overcome clinical inertia.