Incidence, Quality of Care, and Mortality in Hip Fracture Patients in the Course of the COVID Pandemic: A Population-Based Cohort Study

BACKGROUND

We assessed the incidence, quality of in-hospital care, and mortality for hip fracture (HF) patients in Denmark before and during the coronavirus disease (COVID) pandemic.

METHODS

We obtained data from the Danish registries in the COVID period (March 11, 2020 to January 27, 2021, overall and in 5 periods) and compared it to a pre-COVID period (March 13, 2019 to March 10, 2020). We calculated the proportion of patients (%) that have fulfilled all the relevant quality indicators (a composite score of 100%) and adjusted hazard ratios (HR) with a 95% confidence interval (CI) for 30-day mortality.

RESULTS

The incidence of HF was 5.7 per 1 000 person-years both in pre-COVID and COVID periods. About 35% of patients had a composite score of 100% in the COVID period compared to 28% in the pre-COVID period (proportion ratio 1.23 [95% CI: 1.17-1.30]). Fulfillment of all individual quality indicators was similar or higher in the COVID period. 30-day mortality was 9.5% in pre-COVID period, compared to 10.8% in the COVID period (HR 1.15 [95% CI: 1.02-1.30]). HRs varied from 1.07 (95% CI: 0.89-1.29) to 1.31 (95% CI: 1.06-1.62) in 5 COVID periods. In-hospital mortality was 4% in pre-COVID versus 4.4% in COVID period.

CONCLUSIONS

The incidence of HF in Denmark remained unchanged. The quality of in-hospital care was higher in the COVID compared to pre-COVID period. Unfortunately, 30-day mortality was also higher, highlighting the importance of recognizing diversity of social networks, home support, and digital health intervention after discharge for outcome of HF patients.

Mortality in patients with incident rheumatoid arthritis and depression: a Danish cohort study of 11 071 patients and 55 355 comparators

OBJECTIVES

In patients with RA, the association between mortality and depression has been investigated only in patients with prevalent RA. In this study, we estimated the mortality risk associated with depression, defined as the first filling of a prescription for antidepressants, in patients with incident RA and background population comparators.

METHODS

From 2008 to 2018, we identified patients with incident RA in the nationwide Danish rheumatologic database, DANBIO. For each patient, we randomly selected five comparators. Participants were not treated with antidepressants or diagnosed with depression 3 years prior to the index date. From other registers we collected data on socioeconomic status, mortality and cause of death using unique personal identifiers. Using Cox models, we calculated hazard rate ratios (HRR) with 95% CI.

RESULTS

In depressed patients with RA vs patients without depression, adjusted HRR for all-cause mortality was 5.34 (95% CI 3.02, 9.45) during 0-2 years and 3.15 (95% CI 2.62, 3.79) during the total follow-up period, and highest in patients <55 years with HRR 8.13 (95% CI 3.89, 17.02). In comparators with depression vs comparators without depression, the association with mortality was similar to that in patients with RA. There were no unnatural causes of death among depressed patients with RA. The most frequent natural causes of death were cancer, cardiovascular disease, stroke and pneumonia.

CONCLUSION

In patients with RA, depression was a predictor of death but with a strength similar to that in matched comparators.

Utilization patterns and factors associated with persistence of new users of anti-osteoporosis treatment in Denmark: a population-based cohort study

Persistence with initial treatment was highest after 1 year, decreasing afterwards. Persistence was highest for denosumab followed by alendronate. We identified several factors associated with treatment persistence, some of which were the same irrespective of OTx agent, which could help target subgroups of patients in terms of social and healthcare support.

PURPOSE

To describe patient characteristics, persistence, and factors associated with the persistence of new users of the bisphosphonates (alendronate, risedronate, and ibandronate) and the RANKL inhibitor denosumab in Denmark.

METHODS

A population-based cohort study using health registries (2010-2018). We included alendronate (n = 128,590), risedronate (n = 892), ibandronate (n = 5,855), and denosumab (n = 16,469) users, aged ≥ 50 years.

RESULTS

The 1-year persistence was 68.2% in the alendronate cohort; 39.3% in the risedronate cohort; 56.3% in the ibandronate cohort; and 84.0% in the denosumab cohort. The 2-year persistence was 58.7% in the alendronate cohort; 28.0% in the risedronate cohort; 42.9% in the ibandronate cohort; and 71.9% in the denosumab cohort. The 4-year persistence was 46.3%, 15.4%, 29.6%, and 56.9%, respectively. Later years of treatment initiation were associated with lower persistence for alendronate (adjusted odds ratio (OR) with 95% CI was 0.86 (0.81-0.91) in 2016 compared to 2010), but not for risedronate (OR was 1.56 (0.60-4.06), ibandronate (OR was 0.92 (0.71-1.19) or denosumab (OR was 1.11 (0.87-1.43). Older age was associated with higher persistence for all medications and the same goes for the female sex except for ibandronate. Dementia was associated with higher persistence for alendronate but not denosumab, whereas prior osteoporosis treatment (OT) was the opposite. Several comorbidities were associated with lower persistence for alendronate, but not denosumab.

CONCLUSION

Persistence was highest for denosumab followed by alendronate. We identified several factors associated with treatment persistence, some of which were the same irrespective of OTx agent, which could help target subgroups of patients in terms of social and healthcare support.

OP0067 MORE THAN SIX-FOLD INCREASED MORTALITY RISK IN PATIENTS WITH INCIDENT RHEUMATOID ARTHRITIS AND DEPRESSION IN A LARGE COHORT WITH 10-YEAR FOLLOW-UP

Background

The occurrence of depression is increased in patients with rheumatoid arthritis (RA) compared with the background population. (1) Recently, we described that in RA the most frequent indication for filling antidepressant prescriptions is depression and the frequency of filling coincides with the occurrence of depression reported in the scientific literature. (2) In patients with stroke, depression defined as filling of antidepressants or a diagnosis with depression is associated with increased mortality risk and the risk is similar for both definitions of depression. (3)

Objectives

We used the first filling of antidepressants as proxy for depression with the objective to describe the mortality risk associated with depression in patients with incident RA.

Methods

We included patients diagnosed with incident RA (index date) from the nationwide DANBIO register (4) from January 1, 2008 to September 30, 2018. Participants were identified by unique personal registration numbers. Included patients were without a recorded filling of methotrexate (Anatomic Therapeutic Chemical code L01BA01) and antidepressants (N06A) in the Danish National Prescription Register or recorded hospital contacts with RA and depression (International Classification of Diseases (version 10) codes M05, M06, F32) in the Danish National Patient Register, three years prior to the index date. From the index date, we defined depression as first filling of antidepressants and collected death dates from the Danish Civil Registration System. The participants were followed until December 31, 2018 and all-cause mortality estimated in two dynamic risk periods: the period from the index date until first filling of antidepressants (if it occurred) and the period after filling of antidepressants. We calculated hazard rate ratios (HRR) by modelling filling of antidepressants as time-varying exposure for total follow-up and adjusted for potential confounders defined a priori: age, sex, comorbidity, cohabitation, employment status, highest attained education, and income. Cumulative mortality was described by Kaplan-Meier curves. Results were reported with 95% confidence intervals (CI).

Results

Among 11,071 RA patients followed for 56,993 person-years, 1,095 (10%) filled prescriptions for antidepressants. The median age at diagnosis was 61 years, 66% were female, and 64% diagnosed with seropositive RA. Adjusted HRR was highest in the age group <55 years but also increased between 55-70 years, >70 years, among females and males, and in patients diagnosed with seropositive and seronegative RA (Table 1). The cumulative mortality is seen in Figure 1.

Table 1.StrataHRR (95% CI)CrudeAdjustedAge, years<558.40 (4.20-16.80)6.66 (2.80-15.85)55-703.27 (2.35-4.54)3.30 (2.27-4.80)>702.97 (2.36-3.75)2.94 (2.26-3.83)SexFemale3.72 (2.95-4.70)2.91 (2.22-3.81)Male3.10 (2.32-4.15)3.70 (2.66-5.14)RA diagnosisSeropostive (M05)3.73 (2.99-4.65)3.45 (2.66-4.47)Seronegative (M06)2.85 (2.07-3.91)3.08 (2.17-4.37)Figure 1.

Conclusion

Depression, defined as first filling of antidepressants, was associated with more than six-fold increased mortality risk in patients with incident RA.

References

[1]Matcham F, et al. The prevalence of depression in rheumatoid arthritis: A systematic review and meta-analysis. Rheumatology 2013;52:2136-48.

[2]Pedersen JK, et al. No difference in antidepressant prescription in rheumatoid arthritis and controls. Results from a population-based, matched inception cohort. Scand J Rheumatol. 2021; Jun 29:1-7.

[3]Jørgensen TSH, et al. Incidence of depression after stroke, and associated risk factors and mortality outcomes, in a large cohort of Danish patients. JAMA Psychiatry 2016;73:1032-1040.

[4]Ibfelt EH, et al. The Danish nationwide clinical register for patients with rheumatoid arthritis: DANBIO. Clin Epidemiol 2016;8:737-42.

Acknowledgements

The study was supported by the Danish Rheumatism Association.

Disclosure of Interests

None declared.

Predictors for and outcomes after bone marrow biopsy in Scandinavian patients with chronic immune thrombocytopenia

OBJECTIVES

To examine predictors for bone marrow biopsy (BMB) and the outcome following BMB in patients with chronic immune thrombocytopenia (cITP).

METHODS

We identified patients diagnosed with cITP during 2009-2017 and obtained information on BMB, cITP treatment and subsequent thrombotic events, hospitalized bleeding, hematological cancer, and death using data from population-based healthcare databases and medical records in Denmark, Norway, and Sweden.

RESULTS

Among 4471 adults (≥18 years) with cITP, 1683 (37.6%) underwent BMB before cITP diagnosis, while cumulative BMB incidence after cITP diagnosis date was 3.1% at 1 year and 7.5% at 5 years. Predictors of having a BMB after cITP diagnosis included older age, male sex, low baseline platelet count, splenectomy, and number of cITP treatments. Compared with patients without BMB, patients with BMB had higher rates of thrombotic events (1 year adjusted hazard ratio [HR] 1.53 [95% CI, 0.92-2.54]), hospitalized bleeding episodes (1 year adjusted HR 1.72 [95% CI, 1.15-2.58]), hematological cancer (1 year adjusted HR 35.26 [95% CI 17.67-70.34]), and all-cause mortality (1 year adjusted HR 1.97 [95% CI, 1.44-2.68]).

CONCLUSION

Patients who undergo BMB after cITP diagnosis represent a subset of patients with more severe disease and increased rates of complications as well as hematological malignancies.

Chronic immune thrombocytopenia in Denmark, Sweden and Norway: The Nordic Country Patient Registry for Romiplostim

BACKGROUND

Population-based cohorts of immune thrombocytopenia (ITP) are useful for understanding occurrence, clinical characteristics and long-term clinical course. This paper describes the content of the Nordic Country Patient Registry for Romiplostim (NCPRR) and provides prevalence and incidence estimates of chronic ITP (cITP).

METHODS

The NCPRR, a cohort study established in 2009, includes all adult (≥ 18 years) patients in Denmark, Sweden and Norway with cITP (defined as ITP lasting > 12 months and platelet count < 100 × 10⁹/L), combining data from national health registries and medical records. The NCPRR currently includes prevalent cITP patients diagnosed before 2009 and incident cITP patients diagnosed during 2009-2016. The registry obtains clinical information for cITP patients, including comorbidities, treatments, laboratory values, and complete follow-up for various outcomes.

FINDINGS

The NCPRR currently includes 3831 patients with cITP (1258 prevalent; 2573 incident). In 2009, the prevalence of registered cITP was 10 · 0/100,000 (95%CI:9 · 1-11 · 0) adult persons in Denmark and 10 · 7/100,000 (95% CI: 9 · 9-11 · 4) adults in Sweden. During 2009-2016, the incidence rates of cITP per 100,000 person-years were 2 · 8 (95%CI: 2 · 6-3 · 0), 1 · 8 (95%CI: 1 · 7-1 · 9) and 2 · 1 (95%CI: 1 · 9-2 · 2) in Denmark, Sweden and Norway, respectively. Fifty-eight percent of cITP patients were women. At NCPRR inclusion, 30.2% were aged ≥ 70 years, 23% had a platelet count < 50 × 10⁹/L, 17.4% were splenectomized, 41% had prior ITP therapy, and 8.6% had severe comorbidity.

INTERPRETATION

The NCPRR provides population-based data on the epidemiology and characteristics of almost 4000 cITP patients and is a valuable resource for research.

FUNDING

This study was partly funded by a research grant from Amgen to Aarhus University.