Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013: a UK study

Abstract

Fragility fractures of the hip have a major impact on the lives of patients and their families. This study highlights significant geographical variation in secondary fracture prevention with even the highest performing regions failing the majority of patients despite robust evidence supporting the benefits of diagnosis and treatment.

Introduction: The purpose of the study is to describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999-2013 in the UK.

Methods: We used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to 5 years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI).

Results: Thirteen thousand sixty-nine patients (76 % female) diagnosed with a hip fracture during 1999-2013 were identified. Eleven per cent had any anti-osteoporosis drug prescription in the 6 months prior to the index hip fracture. In the 0-4 months following a hip fracture, 5 % of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51 % in 2011 and then decreasing to 39 % in 2013. The independent predictors (OR (95 % CI)) of treatment initiation included gender (male 0.42 (0.36-0.49)), BMI (0.98 per kg/m² increase (0.97-1.00)) and geographic region (1.29 (0.89-1.87) North East vs. 0.56 (0.43-0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally, an additional 3214 hip fracture patients would be initiated on therapy every year.

Conclusions: Significant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture.

Keywords: Epidemiology; Geographic variation; Hip fracture; Osteoporosis; Primary care data; Secondary fracture prevention.

Figure 1

Percentage of patients on any anti-osteoporosis medicine 6 months prior to primary hip fracture and 0-4 months following primary hip fracture by geographical region within the Clinical Practice Research Datalink, 1999-2013, UK Legend: Bars show the percentage of patients prescribed any anti-osteoporosis medication in the 6 months prior to and within 4 months post index hip fracture.

Figure 2

Prescription rates of any anti-osteoporosis medication after primary hip fracture by geographical region during 1999-2004 (2a) and during 2005-13 (2b) within the Clinical Practice Research Datalink, UK Legend: This figure shows for each time period, the proportion of patients alive and followed up within CPRD receiving a prescription of anti-osteoporosis medication.