Caroline E. Wyers

Risk of falling in patients with a recent fracture

BackgroundPatients with a history of a fracture have an increased risk for future fractures, even in short term. The aim of this study was to assess the number of patients with falls and to identify fall risk factors that predict the risk of falling in the first three months after a clinical fracture.MethodsProspective observational study with 3 months of follow-up in a large European academic and regional hospital. In 277 consenting women and men aged ≥ 50 years and with no dementia and not receiving treatment for osteoporosis who presented to hospital with a clinical fracture, fall risk factors were assessed according to the guidelines on fall prevention in the Netherlands. Follow-up information on falls and fractures was collected by monthly telephone interview. Incidence of falls and odds ratios (OR, with 95% confidence intervals) were calculated.Results512 consecutive patients with a fracture were regarded for analysis, 87 were not eligible for inclusion and 137 patients were excluded. No follow-up data were available for 11 patients. Therefore full analysis was possible in 277 patients.A new fall incident was reported by 42 patients (15%), of whom five had a fracture. Of the 42 fallers, 32 had one new fall and 10 had two or more.Multivariate analysis in the total group with sex, age, ADL difficulties, urine incontinence and polypharmacy showed that sex and ADL were significant fall risk factors. Women had an OR of 3.02 (95% CI 1.13–8.06) and patients with ADL-difficulties had an OR of 2.50 (95% CI 1.27–4.93).Multivariate analysis in the female group with age, ADL difficulties, polypharmacy and presence of orthostatic hypotension indicated that polypharmacy was the predominant risk factor (OR 2.51; 95% CI: 1.19 – 5.28). The incidence of falls was 35% in women with low ADL score and polypharmacy compared to 15% in women without these risk factors (OR 3.56: CI 1.47 – 8.67).Conclusion15% of patients reported a new fall and 5 patients suffered a new fracture within 3 months. Female sex and low ADL score were the major risk factors and, in addition, polypharmacy in women.

Evaluation of patients with a recent clinical fracture and osteoporosis, a multidisciplinary approach.

The aetiology of osteoporotic fractures is multifactorial, but little is known about the way to evaluate patients with a recent clinical fracture for the presence of secondary osteoporosis.The purpose of this study was to determine the prevalence of contributors to secondary osteoporosis in patients presenting with a clinical vertebral or non-vertebral fracture. Identifying and correcting these contributors will enhance treatment effect aimed at reducing the risk of subsequent fractures.In a multidisciplinary approach, including evaluation of bone and fall-related risk factors, 100 consecutive women (n = 73) and men (n = 27) older than 50 years presenting with a clinical vertebral or non-vertebral fracture and having osteoporosis (T-score ≤-2.5) were further evaluated clinically and by laboratory testing for the presence of contributors to secondary osteoporosis.In 27 patients, 34 contributors were previously known, in 50 patients 52 new contributors were diagnosed (mainly vitamin D deficiency in 42) and 14 needed further exploration because of laboratory abnormalities (mainly abnormal thyroid stimulating hormone in 9). The 57 patients with contributors were older (71 vs. 64 yrs, p < 0.01), had more vertebral deformities (67% vs. 44%, p < 0.05) and a higher calculated absolute 10-year risk for major (16.5 vs. 9.9%, p < 0.01) and for hip fracture (6.9 vs. 2.4%, p < 0.01) than patients without contributors. The presence of contributors was similar between women and men and between patients with fractures associated with a low or high-energy trauma.We conclude that more than one in two patients presenting with a clinical vertebral or non-vertebral fracture and BMD-osteoporosis have secondary contributors to osteoporosis, most of which were correctable. Identifying and correcting these associated disorders will enhance treatment effect aimed at reducing the risk of subsequent fractures in patients older than 50 years.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Trends in oral anti-osteoporosis drug prescription in the United Kingdom between 1990 and 2012: variation by age, sex, geographic location and ethnicity

INTRODUCTION Given the expected increase in the number of patients with osteoporosis and fragility fractures it is important to have concise information on trends in prescription rates of anti-osteoporosis drugs (AOD). METHODS We undertook a retrospective observational study using the UK Clinical Practice Research Datalink (CPRD) in the UK between 1990 and 2012 in subjects 50years or older, stratified by age, sex, geographic region and ethnicity. Yearly prescription incidence rates of any AOD and of each specific AOD were calculated as the number of patients first prescribed these AODs per 10,000person-years (py). RESULTS In women, yearly rates of first prescription of any AOD increased from 1990 to 2006 (from 2.3 to 169.7 per 10,000py), followed by a plateau and a 12% decrease in the last three years. In men, a less steep increase from 1990 to 2007 (from 1.4 to 45.3 per 10,000py) was followed by a plateau from 2008 onwards. Yearly rates of first prescription of any AOD increased up to the age of 85-89years (248.9 per 10,000py in women and 119.3 in men). There were marked differences between ethnic groups and regions. Bisphosphonates were the most frequently prescribed AODs: etidronate till 2000, and then subsequently alendronate. CONCLUSION We have demonstrated marked secular changes in rates of anti-osteoporosis drug prescription over the last two decades. The plateau (and decrease amongst women) in rates in recent years, set against an ever ageing population, is worrying, suggesting that the well-documented care gap in osteoporosis treatment persists. The differences in prescription rates by geographic location and ethnicity raise intriguing questions in relation to underlying fracture rates, provision of care and health behaviour. SUMMARY We studied the prescription incidence of anti-osteoporosis drugs (AOD) from 1990 to 2012 in the UK CPRD. Overall AOD prescription incidence showed a strong increase from 1990 to 2006, followed by a plateau in both sexes and a decrease amongst women in the last three years.

Cardiovascular Risk Factor Analysis in Patients with a Recent Clinical Fracture at the Fracture Liaison Service

Patients with a low bone mineral density have an increased risk of cardiovascular diseases (CVD) and venous thromboembolic events (VTE). The aim of our retrospective chart review was to investigate the prevalence of CVD, VTE, hypertension (HT), and diabetes mellitus type 2 (DM2) in patients with a recent clinical fracture visiting the Fracture Liaison Service (FLS). Out of 3057 patients aged 50–90 years, 1359 consecutive patients, who agreed and were able to visit the FLS for fracture risk evaluation, were included (71.7% women; mean age 65.2 yrs). Based on medical history, 29.9% had a history of CVD (13.7%), VTE (1.7%), HT (14.9%), and DM2 (7.1%) or a combination. Their prevalence increased with age (21% in patients aged 50–59 years to 48% in patients aged >80 years) and was higher in men than in women (36% versus 27%), but independent of bone mineral density and fracture type. Careful evaluation of medical history with respect to these risk factors should be performed in patients with a recent clinical fracture before starting treatment with medications that increase the risk of VTE or cardiovascular events, such as raloxifene, strontium ranelate, or NSAIDs.

A systematic review of economic evaluations of screening programmes for cardiometabolic diseases

Background The early detection and adequate management of cardiometabolic diseases (CMD) is becoming a priority to prevent future health problems and related healthcare costs. Aim This study systematically reviewed the economic evaluations of screening programmes for the early detection of persons at risk for CMD. Methods A systematic review was conducted using MEDLINE, Web of Science, NHSEED and the CEA registry to identify relevant articles published between 1 January 2005 and 1 May 2015. Two reviewers independently selected articles, systematically extracted data and critically appraised the study quality using the Extended Consensus on Health Economic Criteria (CHEC) List. Results From the initial 2820 studies identified, 17 were included. Six studies assessed whether screening would be cost-effective, seven aimed to determine the most efficient screening programme and four assessed the cost-effectiveness of existing programmes. There were 11 cost-utility analyses using quality-adjusted life years (QALYs) or disability-adjusted life years. Decision-analytic modelling (e.g. Markov model) was most frequently used (n = 10), followed by simulation models (n = 4), observational (n = 2) and trial-based (n = 1) studies. All studies assessing the cost per QALY gained of screening for cardiovascular diseases and diabetes mellitus (n = 8) were below a threshold of £30 000, while those assessing chronic kidney diseases (n = 2) were above the threshold. Conclusions: In view of the heterogeneity in study objectives, country setting, screening programmes, comparators, methodology and outcomes, it is not possible to make clear recommendations about the economic value of screening programmes for CMD. Developing further screening programmes and conducting thorough economic analysis, including usual care, is needed.

Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial

Abstract Background Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS). Methods Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein–enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested. Results One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4–185 days) in the intervention group versus control 35.5 days (3–183 days; plogrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68–1.41). Hospital LOS: 12.0 days (4–56 days) versus 11.0 days (3–115 days; p = .19; adjHR: 0.75; 95% CI: 0.53–1.06) and LOS in rehabilitation clinics: 19.5 days (0–174 days) versus 18.5 days (0–168 days; p = .82; adjHR: 1.04; 95% CI: 0.73–1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found. Conclusions Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Fracture liaison services: do they reduce fracture rates?:

The fracture liaison service (FLS) care is considered the most appropriate organizational approach for secondary fracture prevention. We performed a literature search to evaluate to what extent the introduction of a FLS reduced subsequent fracture rates. We identified five studies that compared subsequent fracture rates. These studies varied in study design, proportion of women, baseline and subsequent fracture type [vertebral fracture (VF), non-VF (NVF) or hip fractures], duration of follow-up, response rates of attending the FLS, as well as variables included in adjusted analyses (age, sex, baseline fracture, time dependency). In two studies comparing hospitals with and without a FLS, the adjusted hazard ratio (HR) for subsequent fractures was significantly lower in the FLS hospitals (HR: 0.84 during the first year, 0.44 during the second year for subsequent NVFs after baseline NVF, and 0.67 during the third year for subsequent VFs + NVFs after baseline VFs + NVFs). When comparing fracture rates before (pre-FLS) and after (post-FLS) introduction of a FLS, the adjusted HR for subsequent NVFs after baseline NVF was significantly lower in the post-FLS group after 2 years in one study (HR = 0.65) and nonsignificant in another study for subsequent hip fractures after baseline hip fracture. One study comparing pre-FLS and post-FLS with a follow-up of less than a year did not demonstrate a significant difference in subsequent fracture risk. In conclusion, only five FLS studies with heterogeneous study designs are available, three of them reported a lower subsequent fracture rate related to FLS care. Larger and long-term studies will be needed to further quantify the effect of FLS care on subsequent fracture risk.

Heeft het preventieconsult de toekomst

SamenvattingWyers CE, Walg CB, Evers SMAA, Ruwaard D. Heeft het preventieconsult de toekomst? Huisarts Wet 2014;57(6):286-9. Preventie draagt bij aan een betere gezondheid, maar wordt vaak opgevoerd als middel om de kosten van de gezondheidszorg te beperken. Er is een wildgroei aan commerciële screenings en preventieve interventies, onder andere via internet aangeboden. In reactie hierop heeft het NHG in 2011 de NHG-Standaard Het PreventieConsult Cardiometabool Risico (het preventieconsult) gepubliceerd, die in de huisartsenpraktijken vroegtijdige opsporing van hart- en vaatziekten, type-2-diabetes en nierfalen moet faciliteren.Op zichzelf past het preventieconsult helemaal in de ambitie die LHV en NHG hebben geformuleerd in de Toekomstvisie huisartsenzorg 2022, dat huisartsen zich gaan richten op wijkgebonden preventie, maar de implementatie verloopt traag. Het ontbreekt vooralsnog aan essentiële randvoorwaarden. Er moet structurele financiering zijn, de samenwerking met andere partijen moet goed geregeld zijn en ook moeten de haalbaarheid en kosteneffectiviteit van de interventies voldoende aangetoond zijn. Vooralsnog is er weinig bewijs dat het preventieconsult kosteneffectief is. Er is meer onderzoek nodig om zulk bewijs op tafel te krijgen.AbstractWyers CE, Walg CB, Evers SMAA, Ruwaard D. The cardiometabolic prevention consultation. Huisarts Wet 2014;57(6):286-9. While prevention programmes contribute to better health, they are also often applied to contain healthcare costs. As a result of the strong growth in the availability of commercial screening and intervention programmes, many of which are available via Internet, the Dutch College of General Practitioners (NHG) published, in 2011, the guideline The cardiometabolic prevention consultation (prevention consultation), to facilitate the early detection of cardiovascular disease, type 2 diabetes, and kidney failure. This guideline is consistent with the aim, formulated in the report ‘Primary care in 2022’, of the National Association of General Practitioners (LHV) and the NHG that general practitioners will focus on neighbourhood health prevention. However, implementation of these programmes is slow, due to the absence of structural funding and collaboration with other parties, and to the lack of evidence for the feasibility and cost effectiveness of these interventions. Further investigation of the cost effectiveness of the prevention consultation is needed.

PP241-MON QUALITATIVE ANALYSIS OF BARRIERS AND FACILITATORS FOR NUTRITIONAL INTERVENTION IN HIP FRACTURE PATIENTS

PP241-MON QUALITATIVE ANALYSIS OF BARRIERS AND FACILITATORS FOR NUTRITIONAL INTERVENTION IN HIP FRACTURE PATIENTS J. Breedveld-Peters1, P.L. Reijven2, C.E. Wyers1, A.A. Hendrikx1, A.D. Verburg3, J.M. Schols4,5, M.H. Prins1,6, T. van der Weijden7, P.C. Dagnelie1. 1Department of Epidemiology, CAPHRI School for Public Health, Maastricht University, 2Department Clinical Dietetics, Maastricht University Medical Centre, Maastricht, 3Department of Orthopaedic Surgery, Orbis Medical Centre, Sittard, 4Department of General Practice and Department of Health Service Research, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, 5Manager of the Medical and Paramedical Treatment Department, Vivre, 6Department of Medical Technology Assessment, Maastricht University Medical Centre, 7Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands