Increased fracture risk in patients aged 70 years and older with a hip fracture

Transcription

1 Increased fracture risk in patients aged 70 years and older with a hip fracture A retrospective study of the presence of a treatment indication with calcium-regulating therapy Sophie Osseweijer-Bronsgeest Msc, MANP

2 disclosure of the interests of the speaker (potential) conflicts of interest none Relevant relationships for this meeting none 2

3 Introduction: hip fractures Per year: 13,480 patients of 70 years and older (hip, and femoral fractures) Expected increase of 40% 1 Associated with High morbidity 1,2 High mortality 1,2 Higher risk of new fracture 1,2 High healthcare costs 1 1 Nederlands Interdisciplinair Demografisch Instituut; Sociaal en Cultureel Planbureau; LeBlanc KE et al. 2014; 2 NHG standaard fractuurpreventie 3

4 Introduction: fracture prevention Previous studies on a fracture after a hip fracture: High age is a risk factor 3-5 Female gender could be a risk factor 4-6 Co-morbidities could be a risk factor 5 Only 29% of the patients with a hip fracture will return to the hospital for additional diagnostics 7 Treatment with calcium regulating therapy reduces the fracture risk with 50% 8,9 3 Vochteloo AJ et al, 2012; 4 Colón-Emeric CS et al., 2011; 5 Shen SH et al. 2014; 6 Lee KH et al., 2014; 7 Eekman DA et al., 2014; 8 CBO Richtlijn osteoporose en fractuurpreventie,2011; 9 Maraka S et all, 2015; 4

5 Introduction: fracture prevention Guidelines after a hip fracture : The Netherlands: only treat when osteoporosis is proven, so everyone has to undergo diagnostics Are we preforming too much diagnostics? UK and USA: advice is to treat all patients over 80 years with a hip fracture, so no diagnostics necessary. Do we start too much medical treatment? 5

6 Introduction: goal and questions How many patients with a hip fracture of 70 years and older, admitted to the (Geriatrics Trauma Unit) GTU at Spaarne Gasthuis Hoofddorp in 2014 and 2015, have a treatment indication with calcium-regulating therapy. Is there a connection between the presence of this treatment indication and age, gender, type of fracture or comorbidities? Can one of these variables be used as a new diagnostic criterion? 6

7 Method: data acquisition Dependent variable Independent variabele Indicator Treatment indication with calciumregulating therapy Presence of a vertebral fracture at least grade 2 (> 25% height loss) DEXA T-score <-2,0 Already diagnosed with osteoporosis in the past Age Gender Type fracture Age in Years Male Female Frature of the femur Fracture of the Hip Comorbidities CCI (Charlston Comorbidity index 7

8 8

9 Method: data acquisition Dependent variable Independent variabele Indicator Treatment indication with calciumregulating therapy Presence of a vertebral fracture at least grade 2 (> 25% height loss) DEXA T-score <-2,0 Already diagnosed with osteoporosis in the past Age Gender Type fracture Age in Years Male Female Fracture of the femur Fracture of the Hip Comorbidities CCI (Charlston Comorbidity index 9

10 10

11 Method: data acquisition Dependent variable Independent variabele Indicator Treatment indication with calciumregulating therapy Presence of a vertebral fracture at least grade 2 (> 25% height loss) DEXA T-score <-2,0 Already diagnosed with osteoporosis in the past Age Gender Type fracture Age in Years Male Female Fracture of the femur Fracture of the Hip Comorbidities CCI (Charlston Comorbidity index 11

12 12

13 Results: comparing the groups Characteristics of 341 patients with a hip fracture recorded at the GTU in Hoofddorp in 2014 and 2015 divided in without of with diagnostics for the treatment indication with calcium regulating therapy (n = 341). Characteristic Total group without diagnostics (n=104) Totale group with diagnostics (n=237) P-value 1 Gender Age Fracture CCI 5 Female n(%) 61 (59) 177 (75) 0,03 2 Male n(%) 43 (41) 60 (25) Average (SD) 85,2 (6,9) 82,9 (7,0) 0,55 3 Hip n (%) 55 (53) 135 (57) 0,34 2 Femur n (%) 49 (47) 102 (43) Average 2,9 (2.0) 2,2 (1,8) 0,38 3 Median 3 (1,3-4) 2 (1-3) 1 Significant if P< 0,05 2 Chi-square test 3 T-test 5 Charston Comorbidity index 13

14 Results: univariate analyses Characteristics of patients admitted to the GTU in Hoofddorp in 2014 and 2015 with a hip fracture in which diagnostics is performed to investigate treatment indication with calciumregulating therapy due to increased fracture risk (n = 237) Characteristic Indication present (n=208, 88%) Indication not present (n=29, 12%) P value 1 Indication for treament bases on Gender Age Diagnosis in the past n(% 4 ) 58 (28) n/a Vertebral fracture n(% 4 ) 97 (47) n/a DEXA T score <-2,0 n(% 4 ) 53 (25) n/a Female n(% 4 ) 159 (76) 18 (62) 0,10 5 Male n(% 4 ) 49 (24) 11 (38) Average (SD) 83,7 (6,8) 77,6 (5,9) <0, Age 79 or less n(% 4,% 2 ) 52 (25,73) 19 (66,27) Age 80 or more n(% 4,% 2 ) 156 (75,94) 10 (34,6) Type of fracture Hip n(% 4 ) 115 (55) 20 (69) 0,23 5 Femur n(% 4 ) 93 (45) 9 (31) CCI 7 Average (SD) 2,3 (1,7) 2,0 (2,1) 0,49 6 Median 2 (0-3) 1 (1-3) 1 Significant if P <0,005; 4 Column percentages; 5 Chi-square test; 6 T-test; 7 Charlston Comorbidity index 14

15 Results: Roc analysis Sensitivity: 75% (95% CI: 68-81%) Specificity: 66% (95% CI: 45-81%) Positive predictive value: 94% (95% CI: 88-97%) Negative predictive value: 27% (95% CI: 17-39%) 15

16 Discussion Diagnostics increase costs en burdens the patiënt 71% of the patients won t come back for diagnostics 7, so they will not receive treatment. Treatment with calcium regulating therapy lowers healthcare costs and improves the quality of life 8,10 Side effects of calcium regulating therapy are inferior to the risks of no treatment. 8,11,12 Limitations In this study there where only 29 patiënts where a treatment indication was not present Generalization The variables of this population correspond to data from Central Bureau of Statistics in the Netherlands and also to a large MCT from the Netherlands. 3,13 3 Vochteloo AJ et al, 2012; 7 Eekman DA et al., 2014; 8 CBO Richtlijn osteoporose en fractuurpreventie,2011; 10 NOF Clinician s Guide to Prevention and Treatment of Osteoporosis, 2014; 11 Lyles KW et al, 2007, 12 Brouwers JRBJ, 2016; 13 RIVM

17 Concluding. Within this study group an indication for treatment with calcium regulating therapy is present at 88% of the participants. At the age of 80 years and above this was 94%. The independent predictor for the presence of a treatment indication was the increasing age. The ROC analysis calculated a cut-off value of 79 years (80 years and older) for the presence of a treatment indication with calcium-regulating therapy. No evidence was found for gender, CCI and type of fracture as a predictive factor. 17

18 Practical implications In daily practice, it s no problem to treat patients with a hip fracture of 80 years and older for the increased fracture risk without additional diagnostics for osteoporosis. This saves costs and effort. Also the treatment can be started earlier. By taking down the barrier of diagnosis in the elderly with a hip fracture, more elderly people will be treated with calcium regulating therapy, which will prevent fractures in the future. 18

19