The impact of in-hospital initiation of a surgeon-led, anti-osteoporotic medication algorithm for patients with fragility hip fractures: a quasi-experimental study

Abstract

Introduction: Secondary fracture prevention is essential to current hip fracture management. However, many patients are discharged without the appropriate anti-osteoporotic medication (AOM). This study aims to evaluate the impact of the implementation of an in-hospital, surgeon-led AOM algorithm on patients with fragility hip fractures. The three outcome events of interest assessed were (a) the AOM initiation (b) the persistence to medication at 2 years of follow-up and (c) the secondary fracture incidence within 2 years of AOM initiation in the treated and control groups.

Materials and methods: This was a three-arm controlled before-after quasi-experimental study. A group of hospitalized patients with low-energy hip fractures who were prescribed AOM according to the surgeon-led AO algorithm between March 2020 and May 2022, were compared with a group of concurrent control patients who refused the treatment over the same 2 year period, and a group of historical control patients who were hospitalized for hip fragility fractures in 2 years before the algorithm was introduced (February 2018 to February 2020). AOM initiation rates, 2 year medication persistence, and risks of secondary osteoporotic fracture were assessed and compared between groups.

Results: In this study, we enrolled 598 patients (mean age 82 ± 8 years, 78% female). Post-fracture AOM initiation increased from 15% (41/281) before to 67% (213/317) after introducing the algorithm. Medication persistence after 2 years of AOM initiation was 56% (95% confidence interval [CI] 49-63%) in treated patients and 52% (95% CI 36-66%) in historical controls. Secondary osteoporotic fractures occurred in 15/213 (7%) treated patients, 8/104 (8%) concurrent control patients, and 20/281 (7%) historical-control patients over an average follow-up of 20.4 months. Multivariable Cox regression analysis did not demonstrate significantly different fracture risks in historical controls (cause-specific hazard ratio [csHR] 0.92; 95%CI 0.45-1.89) or concurrent controls (csHR 1.08; 95% CI 0.45-2.57) compared to treated patients.

Conclusion: The AO Foundation algorithm can increase AOM initiation at hospital discharge, retaining high medication persistence 2 years post-fracture. A longer follow-up period is required to evaluate the algorithm's effect on secondary fracture prevention.

Keywords: Antiosteoporosis medication; Fragility fracture; Hip fracture; Medication persistence; Osteoporosis; Secondary fracture.