[Osteoporotic fractures - still a challenge, the Swedish National Hip Fracture Registry shows undertreatment of osteoporosis after hip fractures]. / Sekundärprevention ­ fortfarande en utmaning efter fragilitetsfraktur.

Yearly 16 000 osteoporosis related hip fractures occur in Sweden. They cause suffering for patients and high costs for society. Subsequent fractures can be reduced with osteoporosis diagnostics and treatment. 4 322 patients from two hospitals using Fracture Liaisson Services in Sweden were included to identify the rate of osteoporosis diagnostics and treatment during the first year after a hip fracture. Data between 2010-01-01 and 2018-12-31 were included from the Swedish National Hip Fracture Registry (Rikshöft). 99.2 % of all patients underwent FRAX risk assessment and DEXA was conducted on 17.3 % of patients. Women were more frequently examined with DEXA than men (21% vs 10.2 %). 6% received medical osteoporosis treatment after the fracture, women were treated more often than men (7% vs 4%). Conclusions: less than 10% received drug therapy after the first year after the hip fracture. Men underwent diagnostics and received treatment at a lower rate than women.

The impact of care process development and comorbidity on time to surgery, mortality rate and functional outcome for hip fracture patients: a retrospective analysis over 19 years with data from the Swedish National Registry for hip fracture patients, RIKSHÖFT.

For a long time the attention given to the hip fracture patient group was minor and without any certain consideration to their frailty. To improve the care for these patients Skane University Hospital in Lund has during the past 19 years worked actively with developing the care. This paper aims to describe what impact the care process development has had on functional outcome and mortality, as well as to analyze the impact of comorbidity and fracture type. METHODS: Patients older than 50 years with non-pathological cervical and trochanteric hip fracture admitted between Jan 1st 1999 and Dec 31st 2017 were included and data was retrieved from the National Quality Register for hip fracture patients, RIKSHÖFT. Variables regarding patient characteristics, fracture type, operation method, lead-times and outcome were analyzed. For comparison Fischer's exact test and Spearman's rank correlation coefficient was used for the categorical data and Pearson correlation coefficient for the continuous. To further analyze the effect over time a linear regression model was used. RESULTS: A total of 7827 patients were included. A significant shift in the overall morbidity was seen, with an increase in patients of higher ASA grade. No correlation was seen between outcome and the care process development. The mortality rate for the group as a whole the mortality rate had decreased over time. The total length of stay had decreased significantly over time. There was no statistically significant change in mortality rate over time when relating it to time-to-surgery. CONCLUSIONS: Although the patients display a higher morbidity over time, the mortality rate has not changed significantly, which might indicate an effect of the care process development. The care process development does not seem to impact on outcome as much as other factors. This study supports the possibility to create a more specific algorithm for hip fracture patients, taking specific subgroups into consideration.

Hip fractures - Treatment and functional outcome. The development over 25 years.

BACKGROUND: Nearly 18,000 individuals suffer from hip fracture in Sweden each year. The choice in operation method for femoral neck fractures has changed over the years as well as the overall management. Functional outcome after hip fracture is affected by several factors and the overall functional level for old people in Sweden has improved over the last decades. OBJECTIVE: To describe and analyse the functional outcome and choice of operation method for hip fracture patients between 1988 and 2012. PATIENTS AND METHODS: All patients with cervical or trochanteric hip fracture treated at Lund University Hospital from 1988 until 2012 were collected from the National Quality Register for hip fracture patients, RIKSHÖFT. Patients younger than 50 years and those with pathological fractures were excluded. Data regarding patient characteristics, fracture type, operation method and housing, walking ability and use of walk aids prefracture and at 4-months follow-up was retrieved and analysed. RESULTS: For this study 8723 patients were included with a mean age of 81.6 (men 79.3, women 82.5). The mean age significantly increased over the period studied. Sliding hip screw dominates as method of choice for the trochanteric fractures. For the cervical fractures there is a clear shift from osteosynthesis to arthroplasty. There is a significant decrease in functional outcome at follow-up compared to prefracture. No significant trend change can be seen over 25 years. Functional outcome are worse for the patients with trochanteric fracture. CONCLUSION: Although there have been changes in operation methods for hip fractures and the management has developed, our study does not show any effect on functional outcome over a 25-year period. The medical condition of these patients with increasing age seems to counteract efforts to improve the care.

Using national hip fracture registries and audit databases to develop an international perspective.

Hip fracture is the commonest reason for older people to need emergency anaesthesia and surgery, and leads to prolonged dependence for many of those who survive. People with this injury are usually identified very early in their hospital care, so hip fracture is an ideal marker condition with which to audit the care offered to older people by health services around the world. We have reviewed the reports of eight national audit programmes, to examine the approach used in each, and highlight differences in case mix, management and outcomes in different countries. The national audits provide a consistent picture of typical patients - an average age of 80 years, with less than a third being men, and a third of all patients having cognitive impairment - but there was surprising variation in the type of fracture, of operation and of anaesthesia and hospital length of stay in different countries. These national audits provide a unique opportunity to compare how health care systems of different countries are responding to the same clinical challenge. This review will encourage the development and reporting of a standardised dataset to support international collaboration in healthcare audit.

Bisphosphonate Use After Hip Fracture in Older Adults: A Nationwide Retrospective Cohort Study.

OBJECTIVES: The aim of this study was to investigate the association between bisphosphonate use and the risk of new fracture in a nationwide cohort of individuals with previous hip fractures, with emphasis on individuals above 80 years of age. DESIGN, SETTING, AND PARTICIPANTS: From a nationwide cohort with hip fracture (2006-2012) (n = 93, 601), each individual prescribed bisphosphonates after hip fracture (n = 5845) was matched with up to three individuals not prescribed bisphosphonates, resulting in a cohort of 21,363 individuals. MAIN OUTCOME MEASURE: A new hip fracture. RESULTS: During a mean follow-up period of 2.98 (range, 0.02-8) years, 4581 fractures occurred in the cohort. Before the initiation of bisphosphonate therapy, individuals later prescribed bisphosphonates had an increased risk of hip fracture (multivariable adjusted odds ratio [OR], 2.63; 95% confidence interval [CI], 2.23-3.24) compared with controls. In the period after bisphosphonate therapy initiation, individuals prescribed bisphosphonates had a lower risk of hip fracture (multivariable adjusted hazard ratio [HR], 0.76; 95% CI, 0.65-0.90) compared with controls. Similar effects were seen after the initiation of bisphosphonates in individuals aged more than 80 years (HR, 0.79; 95% CI, 0.62-0.99). In contrast, the initiation of bisphosphonate therapy did not influence the risk of injurious falls not resulting in fracture (HR, 0.95; 95% CI, 0.86-1.05). CONCLUSION: Bisphosphonate use was associated with a decreased risk of hip fracture in this nationwide cohort of older men and women, with similar risk reductions in individuals older than 80 years.

Geriatric Rehabilitation and Discharge Location After Hip Fracture in Relation to the Risks of Death and Readmission.

OBJECTIVES: To investigate the effects of geriatric rehabilitation on short-term risk of death and readmission after a hip fracture were investigated in a nationwide cohort. In addition, the association of discharge location (nursing home or patient's home) with the short-term risk of death was assessed. DESIGN, SETTING, AND PARTICIPANTS: The cohort consisted of 89,301 individuals at least 50 years of age, with a first hip fracture registered in the Swedish quality register RIKSHÖFT, the years 2004-2012. MEASURES: Short-term risk of death and readmission to hospital after discharge was compared at 8 hospitals, where most patients received inpatient care in geriatric wards, and those treated at 71 regular hospitals. RESULTS: The risks of death within 30 days of admission were 7.1% in patients admitted to geriatric ward hospitals and 7.4% in those treated at regular hospitals (multivariable-adjusted hazard ratio [HR] 0.91, 95% CI 0.85-0.97), whereas the odds of readmission within 30 days of discharge were 8.7% and 9.8%, respectively (multivariable-adjusted odds ratio 0.86, 95% CI 0.81-0.91). The risk of death was influenced by discharge location and inpatient length of stay (LOS). Thus, for patients discharged to short-term nursing homes with a LOS of at most 10 days, each additional day of LOS reduction increased the risk of death within 30 days of discharge by 13% (HR 1.13, 95% CI 1.08-1.18). This association was reduced in patients discharged to permanent nursing homes (HR 1.04, 95% CI 1.02-1.07), and not significant in those discharged to their own home (OR 1.00, 95% CI 0.91-1.10). CONCLUSION: The risks of death and readmission were lower in patients with hip fracture who received care in hospitals with geriatric wards. The risk of death after discharge increased with shorter LOS, especially in patients discharged to short-term nursing homes.

Sex effects on short-term complications after hip fracture: a prospective cohort study.

OBJECTIVES: To evaluate potential sex differences and other factors associated with complications within 4 months after a hip fracture. METHODS: A total of 1,915 patients ≥65 years (480 men) with hip fracture were consecutively included in a prospective multicenter cohort study. A review of medical records and patient interviews according to a study protocol based on the Standardized Audit of Hip Fractures in Europe (SAHFE, RIKSHÖFT) was performed. Sex differences in comorbidity according to the American Society of Anesthesiologists score and complications 4 months after a hip fracture were registered. Multivariate logistic regression analysis was performed to identify factors related to complications. RESULTS: Male sex was associated with worse general health according to the American Society of Anesthesiologists classification (P=0.005) and with more comorbidities (P<0.001). Male sex emerged as a risk factor for developing pneumonia (P<0.001), and additionally, 18% of the men suffered from cardiac complications compared with 13% of the females (P=0.018). Female sex was predisposed for urinary tract infections, 30% vs 23% in males (P=0.001). Mortality was higher in the male vs female group, both within 30 days (15% vs 10%, P=0.001) and at 4 months (24% vs 14%, P=0.001). Conditions associated with pneumonia were male sex, pulmonary disease, and cognitive impairment. Cardiac complications were associated with delayed surgery and cardiovascular and pulmonary disease. CONCLUSION: Before surgery, men with hip fracture already have a poorer health status and higher comorbidity rate than women, thus resulting in a twofold increased risk of pneumonia. Cognitive dysfunction and pulmonary disease contributed to pneumonia in men. Delayed surgery seems to increase the risk for cardiac complications. It is important to consider the sex perspective early on together with cardiopulmonary comorbidity and cognitive dysfunction to be able to counteract serious complications that may lead to death.

Screening for osteoporosis reduced new fracture incidence by almost half: a 6-year follow-up of 592 fracture patients from an osteoporosis screening program.

BACKGROUND AND PURPOSE: Fractures can be prevented if osteoporosis is identified and treated. In 2002, we initiated a screening program at our orthopedics department, in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and encouraged to see their doctor for decision on treatment regarding osteoporosis. The patients receive written documents containing information, DEXA results, and a letter to their doctor with suggestions regarding blood tests and treatment. In this 6-year follow-up study, we compared the fracture recurrence in 2 groups: patients screened for osteoporosis after fracture as described, and a historical control group with fracture patients who presented at our department 1 year before we started the screening intervention. METHODS: A questionnaire was sent to the 2 groups of fracture patients, those from before the time that we started the screening in 2002 and those who participated in the initial screening study in 2003. The questionnaire included questions on whether they had sustained further fractures, whether they had seen a doctor, and whether treatment had been initiated. RESULTS: 239 of the 306 unscreened patients (68%) and 219 of the 286 screened patients (77%) answered the questionnaire. In the unscreened group, 69 new fractures had occurred, in contrast to 39 in the screened group. The fracture risk was 42% lower in the screened group. Answers regarding treatment were incomplete in the unscreened group. INTERPRETATION: Screening of fracture patients for osteoporosis reduced fracture recurrence, which indicates that the screening procedure has resulted in treatment that prevents fractures.

Cost-effectiveness analysis of goal-directed hemodynamic treatment of elderly hip fracture patients: before clinical research starts.

BACKGROUND: Health economic evaluations are increasingly used to make the decision to adopt new medical interventions. Before such decisions, various stakeholders have invested in clinical research. But health economic factors are seldom considered in research funding decisions. Cost-effectiveness analyses could be informative before the launch of clinical research projects, particularly when a targeted intervention is resource-intensive, total cost for the trial is very high, and expected gain of health benefits is uncertain. This study analyzed cost-effectiveness using a decision analytic model before initiating a large clinical research project on goal-directed hemodynamic treatment of elderly patients with hip fracture. METHODS: A probabilistic decision analytic cost-effectiveness model was developed; the model contains a decision tree for the postoperative short-term outcome and a Markov structure for long-term outcome. Clinical effect estimates, costs, health-related quality-of-life measures, and long-term survival constituted model input that was extracted from clinical trials, national databases, and surveys. Model output consisted of estimated medical care costs related to quality-adjusted life-years. RESULTS: In the base case analysis, goal-directed hemodynamic treatment reduced average medical care costs by €1,882 and gained 0.344 quality-adjusted life-years. In 96.5% of the simulations, goal-directed hemodynamic treatment is less costly and provides more quality-adjusted life-years. The results are sensitive to clinical effect size variations, although goal-directed hemodynamic treatment seems to be cost-effective even with moderate clinical effect. CONCLUSION: This study demonstrates that cost-effectiveness analysis is feasible, meaningful, and recommendable before launch of costly clinical research projects.

The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture.

The purpose of this descriptive cohort study was to identify perioperative risk factors associated with postoperative outcome up to 4 months after surgery in elderly patients with hip fracture. Data were collected prospectively through the Swedish National Hip Fracture, the local Acute and Emergency, and Anesthesia registers, and retrospectively from medical and nursing records. The 428 patients (aged > or = 65 years) with hip fracture were consecutively included. Multiple logistic regression analyses were used to identify factors predicting each of 4 outcomes. Perioperative risk factors predicting death within 4 months after surgery were fasting time of 12 or more hours and blood transfusion of 1 U or more. Risk factors predicting postoperative confusion were postoperative oxygen saturation less than 90% and fasting time 12 hours or longer. Risk factors predicting in-hospital complications were transfusion of 1 or more units of blood, preoperative oxygen saturation less than 90%, and fasting time 12 hours or more. Risk factor predicting length of stay longer than 10 days was blood transfusion of 1 U or more. To minimize morbidity and mortality, providers should increase efforts to optimize the patients' oxygen saturation and hemoglobin level and reduce fasting time and waiting time for surgery.

Gender differences and cognitive aspects on functional outcome after hip fracture--a 2 years' follow-up of 2,134 patients.

BACKGROUND: hip fractures as well as cognitive dysfunction become increasingly prevalent in growing ageing populations. Hip fractures are approximately three times more common in elderly women. OBJECTIVE: we analysed outcome after hip fracture with respect to gender and cognitive function. DESIGN: population-based, prospective cohort study. SETTING: four university hospitals in Stockholm, Sweden. SUBJECTS: a total of 2,134 consecutive patients admitted with hip fracture during 2003. METHODS: gender differences in residence, walking ability and activity of daily living (ADL) were analysed at baseline, after 4 and 24 months in patients with and without intact cognitive function. RESULTS: women were older, more often living alone and had poorer walking ability (P < 0.001). Cognitive dysfunction was equally common by gender. Women were more often treated with a prosthesis (P < 0.001) and sent to rehabilitation (P < 0.001). In the cognitive dysfunction group, men had more co-morbidity (P < 0.001) and total loss of walking ability (P = 0.03), but more often resided in own homes (P = 0.03). There was no gender difference in ADL. CONCLUSION: men had a higher risk for loss of walking ability and death only in patients with cognitive dysfunction. Cognitive function was the most important factor for returning to own home and regain pre-fracture function.

Factors at admission associated with 4 months outcome in elderly patients with hip fracture.

The purpose of this descriptive cohort study was to describe patients with hip fracture on the basis of ASA physical status and to identify preoperative risk factors associated with postoperative outcome up to 4 months after surgery. Data were collected prospectively through the Swedish National Hip Fracture and Anesthetic registers and retrospectively from medical and nursing records. The 428 patients (aged > or = 65 years) with hip fracture were consecutively included. Multiple logistic regression analyses were used to identify factors predicting each of 4 outcomes. Risk factors for a poorer 4-month survival after hip fracture were ASA physical status 3 and 4, more extensive fractures, 85 years or older, male sex, and dependency in living. Mortality within 4 months was significantly associated with ASA physical status 3 and 4, age 85 years or older, male sex, dementia diagnosis, fewer than 8 correct answers on the Short Portable Mental Status Questionnaire, 4 or more prescribed drugs, hemoglobin level less than 100 g/L, creatinine level more than 100 micromol/L, dependency in living, inability to walk alone, and fracture other than undisplaced intracapsular. Elderly patients with hip fracture should be identified immediately at admission regarding risk factors leading to a poorer survival and more complications.

3-year follow-up of 215 fracture patients from a prospective and consecutive osteoporosis screening program. Fracture patients care!

BACKGROUND AND PURPOSE: Fractures can be prevented if osteoporosis is identified and treated. Starting in 2002, we have been using a screening program in which patients between 50 and 75 years of age with a wrist, shoulder, vertebral, or hip fracture are assessed by DEXA of the hip and spine and if osteoporotic or osteopenic, they are encouraged to see a doctor of their own choice. The patients receive documents containing information, the results of DEXA, and a letter to present to their doctor with suggestions regarding blood tests and treatment. Here we report the 3-year follow-up regarding compliance to the recommended treatment. METHODS: A questionnaire was sent to fracture patients who participated in the initial screening study from November 2002 through November 2003. Questions included whether they had seen a doctor, whether treatment had been initiated, and their opinions about osteoporosis. RESULTS: 215 of the 236 patients answered the questionnaire, with a mean follow-up of 39 months. 76/87 of those with osteoporosis, 70/99 of those with osteopenia, and 11/29 of those with normal BMD had seen a doctor. Anti-resorptive treatment was prescribed to two-thirds of the osteoporotic patients, to one-sixth of the osteopenic patients, and to none of the patients with normal bone density. Calcium-vitamin D supplementation as monotherapy was given to one-third of the osteoporotic patients, to half of the osteopenic patients, and to half of the normal patients. Only a few osteoporotic patients, one-third of the osteopenic patients, and half of the normal patients received no treatment. Compliance to treatment was 80% over 3 years in those treated. Most patients felt that they could influence their skeletal health. INTERPRETATION: Screening of fracture patients for osteoporosis effectively identifies patients with low bone mineral density and the patient can be trusted to seek appropriate medical advice for treatment of osteoporosis. Based on the bone scan diagnosis, the treatment that these patients received reflects current treatment guidelines well.

Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year.

Hip fractures are a major cause of hospital stay among the elderly, and result in increased disability and mortality. In this study from 1 April 2003 to 31 March 2004, the influence of optimised treatment of hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year were investigated. Comparisons were made between the first 210 patients in the period and the last 210 patients, who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24h, was not associated with reduced mortality, but was significantly associated with reduced length of stay (p<0.001). Significantly more cases of osteosynthesis for femoral neck fracture were reoperated compared with all other types of surgery (p<0.001) when reoperations with extraction of the hook pins in healed fractures were excluded. Mortality was significantly higher among men than women at 4 (p=0.025) and 12 (p=0.001) months after fracture and among medically fit patients with administrative delay to surgery compared with patients with no delay (p<0.001).

Long-term cost and effect on quality of life of osteoporosis-related fractures in Sweden.

BACKGROUND AND PURPOSE: Few economic or quality-of-life studies have investigated the long-term consequences of fragility fractures. This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral, and wrist fracture 13-18 months after the fracture, based on 684 patients surviving 18 months after fracture. PATIENTS AND METHODS: Data regarding resource use and quality of life related to fractures was collected using questionnaires at 7 research centers in Sweden. Information was collected using patient records, register sources, and by asking the patient. Quality of life was estimated using the EQ-5D questionnaire. Direct and indirect costs were estimated from a societal standpoint. RESULTS: The mean fracture-related cost 13-18 months after a hip, vertebral, or wrist fracture were estimated to be euro2,422, euro3,628, and euro316, respectively. Between 12 and 18 months after hip, vertebral, and wrist fracture, utility increased by 0.03, 0.05, and 0.02, respectively. Compared to prefracture levels, the mean loss in quality of life between 13 and 18 months after fracture was estimated to be 0.05, 0.11, and 0.005 for hip, vertebral, and wrist fracture. INTERPRETATION: The sample of vertebral fracture patients was fairly small and included a high proportion of fractures leading to hospitalization, but the results indicate higher long-term costs and greater loss in quality of life related to vertebral fracture than previously believed.

Fracture incidence in GH-deficient patients on complete hormone replacement including GH.

UNLABELLED: Fracture risk in GHD patients is not definitely established. Studying fracture incidence in 832 patients on GH therapy and 2581 matched population controls, we recorded a doubled fracture risk in CO GHD women, but a significantly lower fracture risk in AO GHD men. INTRODUCTION: The objective of this study was to evaluate fracture incidence in patients with confirmed growth hormone deficiency (GHD) on replacement therapy (including growth hormone [GH]) compared with population controls, while also taking potential confounders and effect modifiers into account. MATERIALS AND METHODS: Eight hundred thirty-two patients with GHD and 2581 matched population controls answered a questionnaire about fractures and other background information. Incidence rate ratio (IRR) and 95% CI for first fracture were estimated. The median time on GH therapy for childhood onset (CO) GHD men and women was 15 and 12 yr, respectively, and 6 and 5 yr for adult onset (AO) GHD men and women, respectively. RESULTS: A more than doubled risk (IRR, 2.29; 95% CI, 1.23-4.28) for nonosteoporotic fractures was recorded in women with CO GHD, whereas no risk increase was observed among CO GHD men (IRR, 0.61) and AO GHD women (IRR, 1.08). A significantly decreased incidence of fractures (IRR, 0.54; 95% CI, 0.34-0.86) was recorded in AO GHD men. CONCLUSIONS: Increased fracture risk in CO GHD women can most likely be explained by interaction between oral estrogen and the GH-IGF-I axis. The adequate substitution rate of testosterone (90%) and GH (94%) may have resulted in significantly lower fracture risk in AO GHD men.

Nutritional status among patients with hip fracture in relation to pressure ulcers.

BACKGROUND & AIMS: Patients with a hip fracture often have a poor nutritional status that is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention. METHODS: A quasi-experimental study of 478 patients consecutively included between April 1, 2003 and March 31, 2004. A new evidence-based clinical pathway was introduced on October 1, 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. RESULTS: The total number of patients with a hospital-acquired pressure ulcer was in the intervention group, 19 patients, and in the control group, 39 patients (p = 0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p = 0.05), calf circumference (CC) (p = 0.038) and body mass index (BMI) (p = 0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) <10th percentile and AMC <10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the 4 patients in the intervention group developed pressure ulcers. However, 2 of the 12 patients in the control group were affected. CONCLUSIONS: It is possible to reduce the development of hospital-acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. Results in this study indicate the value of the new clinical pathway, as number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.