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. 2024 Aug 21;39(8):1071-1082.
doi: 10.1093/jbmr/zjae100.

Following hip fracture, hospital organizational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: a record-linkage study

Rita Patel  1 , Andrew Judge  1   2   3 , Antony Johansen  4   5 , Muhammad K Javaid  2 , Xavier L Griffin  6   7 , Tim Chesser  8 , Jill Griffin  9 , Elsa M R Marques  1 ; REDUCE Study Group; Yoav Ben-Shlomo  10 , Celia L Gregson  1   11
Collaborators, Affiliations

Following hip fracture, hospital organizational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: a record-linkage study

Rita Patel et al. J Bone Miner Res. .

Abstract

Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organizational factors predict prescription of post-hip fracture AOM and refracture risk. A cohort of 178 757 patients aged ≥60 yr who sustained a hip fracture in England and Wales (2016-2019) was examined and followed for 1 yr. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organizational reports. Multilevel models determined organizational factors, independent of patient case-mix, associated with (1) AOM prescription and (2) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) yr old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission, while 50 354 (28%) died during 1-yr follow-up, 12 240 (7%) refractured. Twelve organizational factors were associated with AOM prescription, for example, orthogeriatrician-led care compared to traditional care models (odds ratio [OR] 4.65 [95% CI, 2.25-9.59]); AOM was 9% (95% CI, 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126 d (IQR 59-234). Eight organizational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72 h of admission had an 18% (95% CI, 2%-31%) lower refracture risk, weekend physiotherapy provision had an 8% (95% CI, 3%-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95% CI, 2%-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95% CI, 3%-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist, and occupational therapist involvement in secondary fracture prevention post hip fracture; notably, fracture risk reductions were seen within 12 mo of hip fracture.

Keywords: fracture prevention; fragility fracture; health services research; osteoporosis; refracture.

Plain language summary

Patients who have broken (fractured) a hip are at risk of having another fracture soon after. They have complex needs to avoid more fractures, which include being prescribed bone-strengthening medicines and taking measures to prevent falls. This study looked at which of the measurements, that describe how well a hospital is organized, are associated with whether bone-strengthening medicine is prescribed and the chance of having another fracture. We used data from 178 757 patients aged over 60 yr who had a hip fracture at 172 English and Welsh hospitals, linked to their hospital records, and other datasets that describe hospital services. Overall, 57% of patients were prescribed bone-strengthening medicines, and 7% went on to have another fracture. Bone-strengthening medicines were more likely to be prescribed in hospitals where patient care was led by a consultant specializing in the care of older people with fractures (called orthogeriatricians) and in hospitals which routinely checked patients’ bone health. Patients attending hospitals that provided orthogeriatrician assessment to all patients within 72 h of being admitted, physiotherapy services at the weekend, or where occupational therapists attended meetings aimed at improving hospital services had a lower chance of having another fracture.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organization for the submitted work; since completing the analyses, R.P. is now funded by CeramTec UK Ltd. on an unrelated study; A.Jo. is the clinical lead for the National Hip Fracture Database, at the Royal College of Physicians, London. T.C. is the past British Orthopaedic Association (BOA) representative and previously sat on the board of the Falls and Fragility Fracture Audit Project (which includes the National Hip Fracture Database), he helped set up and perform many of the BOA multidisciplinary peer reviews for hip fractures, he has design and educational contracts with Stryker, Acumed, and Swemac. M.K.J. has received honoraria, unrestricted research grants, travel, and/or subsistence expenses from: Amgen, Consilient Health, Kyowa Kirin Hakin, UCB, Abbvie, Sanofi, and Besin healthcare. E.M.R.M. has received research funding from CeramTec UK Ltd. A.Ju. has received consultancy fees from Freshfields, Bruckhaus, Derringer, and Anthera Pharmaceuticals Ltd. J.G. has an educational contract with Stryker.

Data declaration: This publication is based on data collected by or on behalf of the Healthcare Quality Improvement Partnership, who have no responsibility or liability for the accuracy, currency, reliability, and/or correctness of this publication.

Figures

Figure 1
Figure 1
The association between organizational factors and anti-osteoporosis medication (AOM) prescription, accounting for patient case-mix and other organizational factors (N = 178 470). OR > 1 indicates more likely to have anti-osteoporosis medicine (AOM) prescribed. Organizational factors adjusted for case-mix (age group, sex, ASA classification, hip fracture type, pre-fracture residence, and pre-fracture mobility) and mutually adjusted for all backward selected factors shown in Table S2. Factors with P-value<0.1 shown. AMT, abbreviated mental test; ASA, American Society of Anesthesiologists; CI, confidence interval; ED, emergency department; NHFD, National Hip Fracture Database; op, operative; OR, odds ratio; QI, quality improvement; T&O, trauma and orthopedics.
Figure 2
Figure 2
Days to refracture from 30 d and up to 365 d post hip fracture admission N = 12 240.
Figure 3
Figure 3
The association between organizational factors and refracture in the year post hip fracture, accounting for patient case-mix and other organizational factors. N = 178 757, OR > 1 indicates increased risk of refracture. Organizational factors adjusted for case-mix (age group, sex, ASA classification, hip fracture type, pre-fracture residence, and pre-fracture mobility) and mutually adjusted for all backward selected factors shown in Table S4. Factors with P-value<.1 shown. ASA, American Society of Anesthesiologists; CI, confidence interval; NHFD, National Hip Fracture Database; op, operative; OR, odds ratio; OT, occupational therapist; QI, quality improvement; T&O, trauma and orthopedics.
See this image and copyright information in PMC

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