Abstract
Background
Screening and management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. The objective was to determine which patients are at risk for not receiving anti-osteoporotic medication and screening immediately following open reduction internal fixation (ORIF) for hip fracture.
Methods
The 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried to identify patients ≥ 50 years old who underwent ORIF of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures. Patients with concurrent polytrauma, malignancy, and other fragility fractures were excluded. Patients taking osteoporotic medications immediately prior to hospitalization were excluded to prevent an overlap in the screening and/or antiresorptive medication initiation rates. Multi-variate logistic regression was used to assess for factors associated with not receiving anti-osteoporotic medication immediately postoperatively.
Results
A total of 6179 patients were identified of whom 3304 (53.5%) were treated at a facility with a documented standardized hip fracture care program. Only 28.5% (N = 1766) patients received anti-osteoporosis medication immediately following ORIF. Independent factors associated with increased odds of not initiating bone protective medication were those without a standardized hip fracture care program (odds ratio [OR] 1.80 [1.58–2.06], P < 0.001), length of stay ≤ 5 days (odds ratio [OR] 1.47 [1.28–1.69], P < 0.001), patients waiting > 1 day until operation (odds ratio [OR] 1.35 [1.13–1.60], P = 0.001), patients requiring a mobility aid preoperatively (odds ratio [OR] 1.29 [1.13–1.47], P < 0.001), and patients who could not weight bear as tolerated (WBAT) on postoperative day 1 (POD 1) (odds ratio [OR] 1.25 [1.06–1.47], P = 0.008).
Conclusion
Patients starting anti-osteoporotic medication immediately following a hip fracture in the United States remains low (28.5%). Standardized hip fracture care programs have the greatest impact with regards to initiating anti-osteoporotic medication following hip fracture.
Keywords: Hip fracture, NSQIP, Osteoporosis, Standardized hip fracture program
1. Introduction
Affecting more than 200 million people across the world, osteoporosis is global public health concern.1,2 Approximately 55% of all Americans aged 50 and over have osteoporosis and by 2020, it is estimated that more than 61 million elderly individuals in the United States will be diagnosed.3 Approximately 50% of women and 25% of men over age 50 will suffer some type of osteoporotic fragility fracture.4, 5, 6 Patients sustaining a hip fracture have more than triple the risk of a subsequent fracture, with the greatest risk within the first year post-fracture.7, 8, 9 Among those with hip fracture, bisphosphonates are an underutilized but effective treatment for secondary fracture prevention, with fewer than one-third of these patients receiving treatment.10, 11, 12, 13, 14, 15, 16
Treatment with anti-osteoporotic medication/therapy has the potential to reduce the economic burden of fragility fractures in the elderly population. It has been demonstrated that the rate of evaluation by DEXA scan and management of osteoporosis through pharmacotherapy is poor after fragility fractures of the spine.17 With robust randomized controlled trials demonstrating treatment efficacy and rising implementation of bone-health initiatives in the United States, it appears that osteoporosis remains relatively undiagnosed and undertreated.18, 19, 20, 21 Specifically, after hip fractures there was a continuous decline in the initiation of anti-osteoporotic medication, with prescription rates falling from 9.8% in 2004 to 3.3% in 2015.14 Therefore, the current study aims to utilize a national surgical database in order to determine which patients are at risk for not receiving anti-osteoporotic medication and screening immediately following open reduction internal fixation (ORIF) for hip fracture.
2. Methods
2.1. Database and patient selection
The 2018 ACS-NSQIP Targeted Procedure Hip Fracture file consisted of relevant variables for hip fracture cases treated with open reduction and internal fixation (ORIF; CPT-27236, CPT-27244, CPT-27245) collected from a total of 117 clinical sites. Using case-specific ID numbers, researchers are able to merge the hip fracture file with the larger ACS-NSQIP file to include further variables. The queried data set was filtered to identify patients ≥50 years old who underwent ORIF of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures. Patients with concurrent polytrauma and/or malignancy were excluded. Patients experiencing a concurrent fragility fracture of the spine, distal radius, proximal humerus, and/or those already taking osteoporotic medications immediately prior to hospitalization were excluded to prevent an overlap in the screening and/or antiresorptive medication initiation rates.
To ascertain risk factors associated with not receiving anti-osteoporotic medication immediately following surgery during the hospitalization, the following variables were considered: (1) patient demographics (age, gender, race/ethnicity), (2) comorbidities, (3) body mass index (kg/m2), (4) functional health status—independent (individual does not require assistance from another person for activities of daily living), partially dependent (requires some assistance), and dependent (requires total assistance), (5) hip-related factors (preoperative delirium, preoperative dementia, preoperative bone fracture protection medication), (6) preoperative use of mobility aid, (7) medical co-management during hospital stay, (8) implementation of a standardized hip fracture care program, (9) type and location of fracture, (10) type of anesthesia and American Society of Anesthesiologists (ASA) class, (11) transfer status (home, acute care hospital/inpatient, nursing home/chronic care facility, outside emergency department [ED], and unknown), (12) time from admission to operation (within 1 day or more than 1 day), (13) Length of hospital stay (less than 5 days or more than 5 days, (14) weight bearing status on postoperative day 1.
2.2. Statistical analysis
Unadjusted analysis to identify significant associations between clinical characteristics and not receiving postoperative bone protection medication was performed using Pearson χ2 test. All variables with a P value < 0.1 in unadjusted analysis were then entered into a multivariate logistic regression model while adjusting for each other. All variables with a P value < 0.05 from the multivariate regression model were identified as independent risk factors significantly associated with not receiving anti-osteoporotic medication following ORIF for hip fracture. Results from regression analysis have been reported as adjusted odds ratios (OR) and 95% confidence intervals (CI), along with their p values. Statistical analysis was performed using SPSS version 22 (IBM, Armonk, New York, 2016).
3. Results
3.1. Baseline clinical characteristics
A descriptive analysis of baseline demographics and clinical characteristics of all patients treated for hip fracture is shown in Table 1. Of the whole cohort, a majority of patients sustaining a hip fracture were >75 years of age (70%), female (65.3%), and white (71.3%). Fifty-four percent of patients were treated at a standardized hip fracture care program, and only 29% of patients were prescribed postoperative antiresorptive medication. Fifty-seven percent of patients had a hospital length of stay ≤5 days. Seventy-nine percent of patients underwent surgery ≤24 h after admission to the hospital.
Table 1.
Patient demographics of hip fracture cohort.
| Count | Column N % | ||
|---|---|---|---|
| Age Cohorts (years) | </ = 75 | 1851 | 30.0% |
| 76–86 | 2184 | 35.3% | |
| 87+ | 2144 | 34.7% | |
| BMI Groups | <25 | 3442 | 55.7% |
| 25–29 | 1766 | 28.6% | |
| 30–34.9 | 675 | 10.9% | |
| 35+ | 296 | 4.8% | |
| Gender | female | 4033 | 65.3% |
| male | 2146 | 34.7% | |
| Race | American Indian or Alaska Native | 30 | 0.5% |
| Asian | 108 | 1.7% | |
| Black or African American | 255 | 4.1% | |
| Native Hawaiian or Pacific Islander | 5 | 0.1% | |
| Unknown/Not Reported | 1375 | 22.3% | |
| White | 4406 | 71.3% | |
| Diabetes Mellitus | INSULIN | 491 | 7.9% |
| NO | 4966 | 80.4% | |
| NON-INSULIN | 722 | 11.7% | |
| Hypertension | No | 2153 | 34.8% |
| Yes | 4026 | 65.2% | |
| Current smoker | No | 5313 | 86.0% |
| Yes | 866 | 14.0% | |
| Dyspnea | AT REST | 60 | 1.0% |
| MODERATE EXERTION | 429 | 6.9% | |
| No | 5690 | 92.1% | |
| Functional health status Prior to Surgery | Independent | 4931 | 79.8% |
| Partially Dependent | 1053 | 17.0% | |
| Totally Dependent | 181 | 2.9% | |
| Unknown | 14 | 0.2% | |
| Ventilator dependent | No | 6169 | 99.8% |
| Yes | 10 | 0.2% | |
| History of Severe COPD | No | 5464 | 88.4% |
| Yes | 715 | 11.6% | |
| Ascites | No | 6163 | 99.7% |
| Yes | 16 | 0.3% | |
| Congestive heart failure (CHF) in 30 days before surgery | No | 5946 | 96.2% |
| Yes | 233 | 3.8% | |
| Acute renal failure (post-op) | No | 6142 | 99.4% |
| Yes | 37 | 0.6% | |
| Disseminated cancer | No | 6074 | 98.3% |
| Yes | 105 | 1.7% | |
| Open wound/wound infection | No | 5957 | 96.4% |
| Yes | 222 | 3.6% | |
| Steroid use for chronic condition | No | 5900 | 95.5% |
| Yes | 279 | 4.5% | |
| >10% loss body weight in last 6 months | No | 6074 | 98.3% |
| Yes | 105 | 1.7% | |
| Bleeding disorders | No | 5201 | 84.2% |
| Yes | 978 | 15.8% | |
| Pre-operative dementia | No | 4586 | 74.2% |
| Yes | 1593 | 25.8% | |
| Pre-operative delirium | No | 5283 | 85.5% |
| Unknown | 207 | 3.4% | |
| Yes | 689 | 11.2% | |
| Use of Mobility Aid | No | 2757 | 44.6% |
| Unknown | 317 | 5.1% | |
| Yes | 3105 | 50.3% | |
| Medical co-management | No | 643 | 10.4% |
| Yes-co-management throughout stay | 4697 | 76.0% | |
| Yes-partial co-management during stay | 839 | 13.6% | |
| Standardized hip fracture care program | No | 2875 | 46.5% |
| Yes | 3304 | 53.5% | |
| Type/location of fracture | Femoral neck fracture (subcapital, Garden types 1 and 2)-undisplaced | 567 | 9.2% |
| Femoral neck fracture (subcapital, Garden types 3 and 4)-displaced | 1774 | 28.7% | |
| Intertrochanteric | 3410 | 55.2% | |
| Other/cannot be determined | 92 | 1.5% | |
| Subtrochanteric | 336 | 5.4% | |
| Principal anesthesia technique | Epidural | 20 | 0.3% |
| General | 4420 | 71.5% | |
| Local | 1 | 0.0% | |
| MAC/IV Sedation | 520 | 8.4% | |
| Other | 6 | 0.1% | |
| Regional | 22 | 0.4% | |
| Spinal | 1190 | 19.3% | |
| ASA classification | 1-No Disturb | 45 | 0.7% |
| 2-Mild Disturb | 1038 | 16.8% | |
| 3-Severe Disturb | 3830 | 62.0% | |
| 4-Life Threat | 1255 | 20.3% | |
| 5-Moribund | 11 | 0.2% | |
| Prescription of post-op bone protection medication | No | 4413 | 71.4% |
| Yes | 1766 | 28.6% | |
| Postoperative use of mobility aid | N/A | 326 | 5.3% |
| No | 808 | 13.1% | |
| Unknown | 292 | 4.7% | |
| Yes | 4753 | 76.9% | |
| Weight bearing as tolerated (WBAT) on POD #1 | N/A (bed-ridden or other medical issues) | 649 | 10.5% |
| No | 1225 | 19.8% | |
| Unknown | 207 | 3.4% | |
| Yes | 4098 | 66.3% | |
| Transfer status | From acute care hospital inpatient | 400 | 6.5% |
| Not transferred (admitted from home) | 4552 | 73.7% | |
| Nursing home - Chronic care - Intermediate care | 607 | 9.8% | |
| Outside emergency department | 554 | 9.0% | |
| Transfer from other | 64 | 1.0% | |
| Unknown | 2 | 0.0% | |
| Discharge Destination | Against Medical Advice (AMA) | 8 | 0.1% |
| Expired | 132 | 2.1% | |
| Facility Which was Home | 339 | 5.5% | |
| Home | 1005 | 16.3% | |
| Hospice | 60 | 1.0% | |
| Multi-level Senior Community | 2 | 0.0% | |
| Unknown | 13 | 0.2% | |
| Rehab | 1849 | 29.9% | |
| Separate Acute Care | 170 | 2.8% | |
| Skilled Care, Not Home | 2579 | 41.7% | |
| Unskilled Facility Not Home | 22 | 0.4% | |
| Return to OR | No | 6019 | 97.4% |
| Yes | 160 | 2.6% | |
| Operative Time (min) | </ = 55 | 3065 | 49.6% |
| 56+ | 3114 | 50.4% | |
| Length of Stay (days) | </ = 5 | 3495 | 56.9% |
| 6+ | 2650 | 43.1% | |
| Days Until Operation | </ = 1 | 4873 | 78.9% |
| >1 | 1305 | 21.1% |
Univariate analysis showed that comparison of patients receiving postop osteoporosis medication versus those who did not receive osteoporosis medication were significantly different with regard to several preoperative and postoperative characteristics (Table 2).
Table 2.
Comparison of demographics of patients receiving antiosteoporosis medication versus not.
| No |
Yes |
P value | ||||
|---|---|---|---|---|---|---|
| Count | Column N % | Count | Column N % | |||
| Age Cohorts (years) | </ = 75 | 1322 | 30.00% | 529 | 30.00% | 0.45 |
| 76–86 | 1541 | 34.90% | 643 | 36.40% | ||
| 87+ | 1550 | 35.10% | 594 | 33.60% | ||
| BMI Groups | <25 | 2448 | 55.50% | 994 | 56.30% | 0.058 |
| 25–29 | 1273 | 28.80% | 493 | 27.90% | ||
| 30–34.9 | 464 | 10.50% | 211 | 11.90% | ||
| 35+ | 228 | 5.20% | 68 | 3.90% | ||
| Gender | female | 2833 | 64.20% | 1200 | 68.00% | 0.005 |
| male | 1580 | 35.80% | 566 | 32.00% | ||
| New Race | American Indian or Alaska Native | 12 | 0.30% | 18 | 1.00% | <.001 |
| Asian | 78 | 1.80% | 30 | 1.70% | ||
| Black or African American | 192 | 4.40% | 63 | 3.60% | ||
| Native Hawaiian or Pacific Islander | 4 | 0.10% | 1 | 0.10% | ||
| Unknown/Not Reported | 800 | 18.10% | 575 | 32.60% | ||
| White | 3327 | 75.40% | 1079 | 61.10% | ||
| Diabetes Mellitus | INSULIN | 369 | 8.40% | 122 | 6.90% | 0.161 |
| NO | 3532 | 80.00% | 1434 | 81.20% | ||
| NON-INSULIN | 512 | 11.60% | 210 | 11.90% | ||
| Current smoker | No | 3803 | 86.20% | 1510 | 85.50% | 0.491 |
| Yes | 610 | 13.80% | 256 | 14.50% | ||
| Dyspnea | AT REST | 50 | 1.10% | 10 | 0.60% | 0.02 |
| MODERATE EXERTION | 323 | 7.30% | 106 | 6.00% | ||
| No | 4040 | 91.50% | 1650 | 93.40% | ||
| Functional health status Prior to Surgery | Independent | 3479 | 78.80% | 1452 | 82.20% | 0.01 |
| Partially Dependent | 792 | 17.90% | 261 | 14.80% | ||
| Totally Dependent | 134 | 3.00% | 47 | 2.70% | ||
| Unknown | 8 | 0.20% | 6 | 0.30% | ||
| Ventilator dependent | No | 4405 | 99.80% | 1764 | 99.90% | 0.548 |
| Yes | 8 | 0.20% | 2 | 0.10% | ||
| History of Severe COPD | No | 3901 | 88.40% | 1563 | 88.50% | 0.905 |
| Yes | 512 | 11.60% | 203 | 11.50% | ||
| Ascites | No | 4399 | 99.70% | 1764 | 99.90% | 0.154 |
| Yes | 14 | 0.30% | 2 | 0.10% | ||
| Congestive heart failure (CHF) in 30 days before surgery | No | 4228 | 95.80% | 1718 | 97.30% | 0.006 |
| Yes | 185 | 4.20% | 48 | 2.70% | ||
| Hypertension | No | 1506 | 34.10% | 647 | 36.60% | 0.061 |
| Yes | 2907 | 65.90% | 1119 | 63.40% | ||
| Acute renal failure (post-op) | No | 4387 | 99.40% | 1755 | 99.40% | 0.877 |
| Yes | 26 | 0.60% | 11 | 0.60% | ||
| Currently on dialysis (pre-op | No | 4312 | 97.70% | 1733 | 98.10% | 0.306 |
| Yes | 101 | 2.30% | 33 | 1.90% | ||
| Disseminated cancer | No | 4333 | 98.20% | 1741 | 98.60% | 0.275 |
| Yes | 80 | 1.80% | 25 | 1.40% | ||
| Open wound/wound infection | No | 4248 | 96.30% | 1709 | 96.80% | 0.329 |
| Yes | 165 | 3.70% | 57 | 3.20% | ||
| Steroid use for chronic condition | No | 4216 | 95.50% | 1684 | 95.40% | 0.759 |
| Yes | 197 | 4.50% | 82 | 4.60% | ||
| >10% loss body weight in last 6 months | No | 4341 | 98.40% | 1733 | 98.10% | 0.515 |
| Yes | 72 | 1.60% | 33 | 1.90% | ||
| Bleeding disorders | No | 3693 | 83.70% | 1508 | 85.40% | 0.097 |
| Yes | 720 | 16.30% | 258 | 14.60% | ||
| Transfusion ≥ 1 units PRBCs in 72 h before surgery | No | 4222 | 95.70% | 1687 | 95.50% | 0.801 |
| Yes | 191 | 4.30% | 79 | 4.50% | ||
| Systemic Sepsis | None | 3967 | 89.90% | 1613 | 91.30% | 0.102 |
| Sepsis | 16 | 0.40% | 11 | 0.60% | ||
| Septic Shock | 3 | 0.10% | 1 | 0.10% | ||
| SIRS | 427 | 9.70% | 141 | 8.00% | ||
| Pre-operative dementia | No | 3243 | 73.50% | 1343 | 76.00% | 0.038 |
| Yes | 1170 | 26.50% | 423 | 24.00% | ||
| Pre-operative delirium | No | 3790 | 85.90% | 1493 | 84.50% | 0.117 |
| Unknown | 135 | 3.10% | 72 | 4.10% | ||
| Yes | 488 | 11.10% | 201 | 11.40% | ||
| Use of Mobility Aid | No | 1909 | 43.30% | 848 | 48.00% | 0.001 |
| Unknown | 246 | 5.60% | 71 | 4.00% | ||
| Yes | 2258 | 51.20% | 847 | 48.00% | ||
| Medical co-management | No | 433 | 9.80% | 210 | 11.90% | <.001 |
| Yes-co-management throughout stay | 3474 | 78.70% | 1223 | 69.30% | ||
| Yes-partial co-management during stay | 506 | 11.50% | 333 | 18.90% | ||
| Standardized hip fracture care program | No | 2255 | 51.10% | 620 | 35.10% | <.001 |
| Yes | 2158 | 48.90% | 1146 | 64.90% | ||
| Type/location of fracture | Femoral neck fracture (subcapital, Garden types 1 and 2)-undisplaced | 416 | 9.40% | 151 | 8.60% | 0.488 |
| Femoral neck fracture (subcapital, Garden types 3 and 4)-displaced | 1270 | 28.80% | 504 | 28.50% | ||
| Intertrochanteric | 2435 | 55.20% | 975 | 55.20% | ||
| Other/cannot be determined | 61 | 1.40% | 31 | 1.80% | ||
| Subtrochanteric | 231 | 5.20% | 105 | 5.90% | ||
| Principal anesthesia technique | Epidural | 18 | 0.40% | 2 | 0.10% | <.001 |
| General | 3207 | 72.70% | 1213 | 68.70% | ||
| Local | 1 | 0.00% | 0 | 0.00% | ||
| MAC/IV Sedation | 392 | 8.90% | 128 | 7.20% | ||
| Other | 4 | 0.10% | 2 | 0.10% | ||
| Regional | 18 | 0.40% | 4 | 0.20% | ||
| Spinal | 773 | 17.50% | 417 | 23.60% | 0.157 | |
| ASA classification | 1-No Disturb | 36 | 0.80% | 9 | 0.50% | |
| 2-Mild Disturb | 743 | 16.80% | 295 | 16.70% | ||
| 3-Severe Disturb | 2706 | 61.30% | 1124 | 63.60% | ||
| 4-Life Threat | 918 | 20.80% | 337 | 19.10% | ||
| 5-Moribund | 10 | 0.20% | 1 | 0.10% | ||
| Postoperative use of mobility aid | N/A | 218 | 4.90% | 108 | 6.10% | <.001 |
| No | 610 | 13.80% | 198 | 11.20% | ||
| Unknown | 240 | 5.40% | 52 | 2.90% | ||
| Yes | 3345 | 75.80% | 1408 | 79.70% | ||
| Weight bearing as tolerated (WBAT) on POD #1 | N/A (bed-ridden or other medical issues) | 493 | 11.20% | 156 | 8.80% | <.001 |
| No | 914 | 20.70% | 311 | 17.60% | ||
| Unknown | 135 | 3.10% | 72 | 4.10% | ||
| Yes | 2871 | 65.10% | 1227 | 69.50% | ||
| Transfer status | From acute care hospital inpatient | 280 | 6.30% | 120 | 6.80% | 0.144 |
| Not transferred (admitted from home) | 3248 | 73.60% | 1304 | 73.80% | ||
| Nursing home - Chronic care - Intermediate care | 459 | 10.40% | 148 | 8.40% | ||
| Outside emergency department | 381 | 8.60% | 173 | 9.80% | ||
| Transfer from other | 44 | 1.00% | 20 | 1.10% | ||
| Unknown | 1 | 0.00% | 1 | 0.10% | ||
| Discharge Destination | Against Medical Advice (AMA) | 8 | 0.20% | 0 | 0.00% | <.001 |
| Expired | 118 | 2.70% | 14 | 0.80% | ||
| Facility Which was Home | 259 | 5.90% | 80 | 4.50% | ||
| Home | 730 | 16.50% | 275 | 15.60% | ||
| Hospice | 56 | 1.30% | 4 | 0.20% | ||
| Multi-level Senior Community | 1 | 0.00% | 1 | 0.10% | ||
| Unknown | 7 | 0.10% | 6 | 0.30% | ||
| Rehab | 1337 | 30.30% | 512 | 29.00% | ||
| Separate Acute Care | 70 | 1.60% | 100 | 5.70% | ||
| Skilled Care, Not Home | 1823 | 41.30% | 756 | 42.80% | ||
| Unskilled Facility Not Home | 4 | 0.10% | 18 | 1.00% | ||
| Return to OR | No | 4296 | 97.30% | 1723 | 97.60% | 0.628 |
| Yes | 117 | 2.70% | 43 | 2.40% | ||
| Operative Time (min) | </ = 55 | 2206 | 50.00% | 859 | 48.60% | 0.338 |
| 56+ | 2207 | 50.00% | 907 | 51.40% | ||
| Length of Stay (days) | </ = 5 | 2597 | 59.10% | 898 | 51.30% | <.001 |
| 6+ | 1798 | 40.90% | 852 | 48.70% | ||
| Days Until Operation | </ = 1 | 3448 | 78.20% | 1425 | 80.70% | 0.027 |
| >1 | 964 | 21.80% | 341 | 19.30% | ||
Unadjusted analysis carried out using Pearson chi-squared tests.
3.2. Risk factors associated with not receiving osteoporosis medication postoperatively
Following adjusted analysis, significant risk factors associated with increased odds of not initiating bone protective medication postoperatively were those without a standardized hip fracture care program (odds ratio [OR] 1.80 [1.58–2.06], P < 0.001), length of stay ≤ 5 days (odds ratio [OR] 1.47 [1.28–1.69], P < 0.001), patients waiting > 1 day until operation (odds ratio [OR] 1.35 [1.13–1.60], P = 0.001), patients requiring a mobility aid preoperatively (odds ratio [OR] 1.29 [1.13–1.47], P < 0.001), and patients who could not weight bear as tolerated on postoperative day 1 (odds ratio [OR] 1.25 [1.06–1.47], P = 0.008, Table 3).
Table 3.
Multivariate analysis for significant independent predictors of not receiving antiosteoporosis medication after hip fracture surgery.
| Predictors of Not Receiving Medication | Adjusted OR (95% CI) | P Value |
|---|---|---|
| WBAT on POD 1 | ||
| Yes | Ref | |
| No |
1.25 (1.06–1.47) |
P = 0.008 |
| Mobility Aid Preoperatively | ||
| No | Ref | – |
| Yes |
1.29 (1.13–1.47) |
<0.001 |
| Time to Operation (days) | ||
| ≤1 | Ref | – |
| >1 |
1.35 (1.13–1.60) |
0.001 |
| Length of Stay | ||
| >5 days | Ref | – |
| ≤5 days |
1.47 (1.28–1.69) |
<0.001 |
| Standardized Hip Fracture Care Program | ||
| Yes | Ref | – |
| No | 1.80 (1.58–2.06) | <0.001 |
4. Discussion
Utilizing a national surgical database of more than 6000 hip fractures, we found that in individuals >50 years of age sustaining a hip fracture, less than a third were initiated on antiresorptive medication during their acute hospital stay. The implementation of a standardized hip fracture care program was demonstrated to be the greatest predictor of antiresorptive medication initiation in these patients. Further hospital and patient level factors may be impacting individuals who are less likely to receive prescriptions. With recent evaluations demonstrating that osteoporotic vertebral fractures are common and underrecognized in hip fracture patients, early screening and risk factor evaluation impacting medication initiation in this population would be valuable.22,23
The most notable and predictable finding of this study is that patients treated within a hospital without a standardized hip fracture program (SHFP) were more likely to not be initiated on antiresorptive medication compared to those in a standard hip fracture program. In the United States and other countries, SHFPs have been implemented in an attempt to improve patient outcomes and decrease costs due to geriatric hip fractures.24, 25, 26, 27 These programs involve standardized protocols including admission checklists, perioperative order sets, multidisciplinary evaluation and comanagement, postoperative rehabilitation, and discharge criteria. In the context of prior hip fracture literature, our results compare to Arshi et al. who demonstrated lower 30-day readmission rates and increased initiation rate of bone protective medications in patients treated at SHFPs.25 Other studies have demonstrated the positive impact that standardized hip fracture programs have on geriatric hip fractures regarding decreased 30-day mortality in higher risk patients.24
Other patient- and hospital-level factors in the United States appear to affect whether someone is initiated on anti-osteoporotic medication. Patients with a shorter hospital stay (≤5 days), patients waiting > 1 day until operation, patients requiring a mobility aid preoperatively, and patients who could not weight bear on POD 1 were less likely to start medication during their hospital stay. It is possible that those with shorter hospital stay were healthier or sustained a more minor hip fracture which is supported by prior evaluations.28 Also, an increased length of stay could have been affected by the presence of a SHFP, which has been shown to impact length of stay and ability to weight bear on POD 1 in this population.25 Standardized multidisciplinary care and protocol-driven guidelines may delay discharge in exchange for patient optimization. In comparison to prior studies that primarily compared the presence or absence of a SHFP and noted no difference in time from admission to operation, we noted that time to operation affected initiation rate of medication.25 Those who were surgically treated >24 h after admission were less likely to be initiated on medication. Finally, in comparison to other studies involving initiation rates of anti-osteoporotic medication within 1 year following vertebral or hip fracture, we did not find any patient demographics (race, gender, age) as risk factors.17,29 Because specific hip fracture care guidelines are not consistent from hospital to hospital in the United States, the results in the present study may be impacted by other factors not measured. The main hypothesized reason for lack of antiosteoporotic medication initiation is potentially because the medication was not prescribed by the clinician. There may be a lack of knowledge or understanding by the treating physician, a lack of a standardized protocol, and/or a lack of multidisciplinary team-based model of care.
From a quality-based perspective, there is a need to identify which specialty providers (endocrinologists vs. orthopaedic surgeons) should take responsibility of these patients after the initial hospitalization. In our institution, orthopaedic surgeons refer all fragility fractures seen in the clinic/emergency room to endocrinology for further evaluation/management. Due to a busy clinic schedule, it can take months before these fracture patients are actually evaluated by an endocrinologist. Given the long wait times, a significant proportion of patients may lose interest in obtaining screening by DEXA or receiving treatment for their osteoporosis. One way to combat this is to consider launching fracture liaison services (FLS) or fragility fracture programs. These programs consist of a team of practitioners that function to serve as the main hub for all fragility fracture referrals, and are responsible for coordinating appropriate evaluation, management and follow-up in these patients. According to recent research, these FLS programs have been effective in increasing the rates of osteoporosis screening, treatment, and medication adherence in affected individuals, while also resulting in significant cost-savings for the health-care system.30
Screening and secondary fracture prevention programs have been established in a growing number of countries as a result of some initiatives.31, 32, 33, 34 The International Osteoporosis Foundation (IOF) launched the Capture the Fracture Campaign in 2012 with the goal of reducing secondary fragility fractures globally.35 In the context of other countries who have taken a proactive approach on this topic, specifically the United Kingdom (UK), the United States may require implementation of similar guidelines laid out by the United Kingdom’s National Osteoporosis Society (NOS).36,37 In the UK, for many years, national guidance on hip fracture care optimization coupled with multi-disciplinary care including orthogeriatric input has revolutionized patient care and outcomes in the UK.33,38 Because protocols in the United States may lack standardization, adherence to protocols at rates similar to more proactive countries is unlikely at the present time and could explain the results seen in the current study.
There are some limitations to our study. The ACS-NSQIP Targeted Hip fracture database does not give details with regard to functional outcomes or reoperation/readmission beyond 30 days. This may be of value to target patients most at risk for future fragility fractures and worthy of further investigation. Second, the NSQIP only records the presence or absence of a hip fracture standardized program. With differences in the types of programs being utilized by hospitals, future databases should record more granular data with regard to specific components that were implemented. Unfortunately, the ACS-NSQIP does not contain data related to the number and types of anti-osteoporotic medications used before and after surgery. The database only indicates if the patient was currently taking medication preoperatively, and if they were prescribed medication after surgery. Longer follow-up would allow for longitudinal tracking of at risk patients. Finally, despite allowing for analysis of a large patient sample, the ACS-NSQIP Targeted Hip Fracture records data from only select hospitals.
5. Conclusion
The proportion of patients starting anti-osteoporotic medication immediately following a hip fracture remains low 28.5%. Standardized hip fracture care programs have the greatest impact with regards to initiating postoperative anti-osteoporotic medication following hip fracture. Providers who treat patients with sentinel hip fractures should be more diligent in their efforts to diagnose and treat the underlying osteoporosis to reduce the burden of future fragility fractures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended.
Ethical committee statement
This study did not require approval from the Biomedical Institutional Review Board of The Ohio State University.
Declaration of competing interest
The authors received no funding for this study and report no conflicts of interest.
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