The authors had earlier conducted a retrospective cohort study from 2008 to 2011 in Jeju Island, among 945 hip fracture patients above 50 years of age. Of these 945 patients, 344 patients (36.4%) underwent a bone mineral density test and 218 patients (23.1%) received treatment for osteoporosis. The purpose of this study was to determine whether a patient education program could improve osteoporosis management after hip fracture. The data of the previous study was used for comparison.
From November 1, 2014 to September 30, 2015, 190 patients above 50 years of age who were admitted for hip fractures at six different hospitals, were enrolled in the present study. During the hospitalization period, patients underwent education sessions and were provided brochures. Patients were evaluated for diagnosis and treatment of osteoporosis at six months after discharge and were followed-up for at least a year.
Of the 222 patients with hip fractures, 190 patients (37 men, 153 women) were enrolled at six hospitals in 2015. Dual energy X-ray absorptiometry was performed on 115 patients (60.5%) and 92 patients (48.4%) were prescribed medication for osteoporosis at the time of discharge. A total of 43.7% and 40.2% of the patients were found to be compliant with osteoporosis medication at 6 months and 12 months follow-up respectively.
This interventional multicenter study demonstrated that a patient education program in patients with hip fractures can improve compliance to osteoporosis medication up to 12 months of follow-up.
Hip fracture is most serious complication of osteoporosis related fractures and is associated with several adverse effects in the elderly. The incidences of hip fracture in global populations are reporting that number and incidence of hip fracture are increasing trends.[
To minimize complications after hip fracture, appropriate osteoporosis medication are recommend to reduce risks of subsequent fractures and mortality.[
Previously we reported that increased awareness of orthopaedic surgeons after educations improved the detection rate of osteoporosis from 20.1% to 45% and treatment rates from 15.1% to 32.2%.[
Therefore, we designed additional intervention studies for patients with hip fracture are required to further improvement of osteoporosis treatment rates after hip fracture. This prospective intervention multicenter study was to determine whether an education program after surgery in patients with hip fracture could increase the osteoporosis treatment rate after a hip fracture, and to confirm maintenance of osteoporosis medications.
The design and protocol of this study was approved by the Institutional Review Board (IRB) at our hospital. Patients were informed their medical data might be used in a scientific study and provided consent.
This prospective interventional multicenter study was performed on patients over 50 years of age who were admitted for a hip fracture between November 1, 2014 and September 30, 2015 at the six hospitals. There are six hospitals (one university hospital and five general hospitals) on the island with orthopedic department and emergency admission facilities and all hospitals used dual energy X-ray absorptiometry (DXA) to determine bone mineral densities. Medical charts and radiological records were reviewed. Patients who met the diagnostic criteria of a femoral neck or intertrochanteric fractures based on the International Classification of Diseases, 10th revision (ICD-10; S720, S721) and who were over 50 years of age at fracture diagnosis were enrolled. The exclusion criteria were; a non-resident of Jeju Island, a pathologic bone fracture (metastasis), serious medical illness including chronic renal failure, cancer history, mental illness, and refusal of participating study. Diagnosis at admission, mechanism of injury, detection of osteoporosis (DXA), and procedures performed during hospitalization, and discharge medications were then extracted and analyzed.
We calculated the required study sample size using the 2008 to 2011 data, in which the initiation rate of osteoporosis treatment was 23.1% (218/945 patients).[
Prior to start intervention study, all of orthopaedic surgeons and assistants in the cohort completed standardization for patient's education. To standardization of patient's education, all orthopaedic surgeon and participant were provided with education sessions at prior to study. The education program included the relationship between osteoporosis and hip fracture, necessity of DXA for the detection of osteoporosis, importance of osteoporotic drugs in its treatment and routine follow-up for medication. After acquiring informed consent, patients at six hospitals were provided with education sessions during admission and brochures for increasing osteoporosis management. These education sessions involved providing information on the knowledge of osteoporosis, exercise and foods for preventing osteoporosis, the efficacy of DXA for the diagnosis of osteoporosis, the effectiveness of osteoporotic drugs and the importance of follow-up for the management of osteoporosis and of routine orthopaedic follow-up. Diagnosis at admission, mechanism of injury, detection of osteoporosis (DXA), procedures performed during hospitalization, and discharge medications were extracted from hospital records and analyzed. Osteoporosis treatment was defined as medication including a selective estrogen receptor modulator (SERM), bisphosphonate, or calcitonin therapy or parathyroid hormone (PTH) therapy. Treatment initiation and duration were confirmed by reviewing medical records at 6 months and 12 months after discharge from hospital.
Mortality status of the patients was identified from hospital record and/or interview with patient's family. In addition, a death certificates at the National Registry Office were search for information on patients lost to follow-up.
The primary study outcome was detection rate of osteoporosis (DXA) and rate of osteoporosis medication at 6 months after discharge from hospital. Secondary outcome was treatment rate of osteoporosis at 12 months follow-up.
The χ2 test was used to analyze categorical variables.
The design and protocol of this study were approved by the IRB at the Jeju National University Hospital (JNUH-IRB No. 2014-12-001). Informed consent was submitted by all subjects when they were enrolled.
During study periods, 222 patients that sustained a hip fracture and who were treated at one of the six participating hospitals were identified as possible candidates for this study. Thirty-two patients were excluded for the following reasons; nine for a high-energy injury resulting from a traffic accident or a fall from height, three because they were non-residents, three for mental illness, five for chronic renal failure, three for previous cancer history, five for bedridden status, and four who refused informed consents (
Eight of the 190 patients had received a diagnosis of osteoporosis prior to hip fracture, but only two of these eight were taking prescribed osteoporosis medications at time of admission. After education sessions, DXA was performed on 115 patients (60.5%) during admission and first visit of out-patients clinics after discharge; at the hip and spine in 90 and at the spine in 25. Of them, there were 95 patients (82.6%) in osteoporosis (T-score≤−2.5), 16 patients (13.9%) in osteopenia (−2.5<T-score<−1) and four patients in normal.
Of these 115 patients, 92 patients (80%) were prescribed osteoporosis medications (73 patients [79.3%] in bisphosphonates, 16 patients in SERM, and 3 in PTH) at time of discharge and first visit of out-patients clinic after discharge. Other anti-osteoporotic drugs, such as, calcitonin, and hormone replacement therapy were not prescribed. At six months follow-up, 83 patients (72.2%) were maintained osteoporosis medications (67 patients in bisphosphonates, 13 patients in SERM, and 3 in PTH). Six patients were stopped medication due to gastrointestinal-related complication and 3 patients were loss of follow-up. At 12 months follow-up, 74 patients (64.3%) were maintained osteoporosis medications (63 patients in bisphosphonates and 11 patients in SERM). Two patients were refused osteoporosis medications due to difficulty of medication and/or complications. Six patients were died during follow-up. One patient was lost of follow-up at 12 months follow-up.
Undertreatments of osteoporosis in patients with hip fracture are notorious and considering problems to overcome. We found that improvement of patient's awareness through education could lead to increase rate of detection and treatment of osteoporosis after hip fracture. Comparing with previous reports (36.4% of BMD testing and 23.1% of osteoporosis medication) in the same cohort,[
Several interventional studies for improving osteoporosis management following hip fracture have demonstrated that patients and/or physicians education can lead to improvement of initiation rate of anti-osteoporosis medications in patients with hip fracture.[
In terms of medication persistence in interventional study, for preventive effect of osteoporotic fracture, anti-osteoporosis medication should be taken for minimum 6 months. [
So far, intervention studies have involved one or two specific centers, and it is difficult to extrapolate their results at other university and local hospitals. The results of this multicenter study could be shown possibility to expendable an effective and easily applied intervention method in osteoporotic patients with a hip fracture. The fracture liaison services for hip fracture patients have been introducing since last decade. Fracture liaison services are proven as an effective method to address the post-fracture care gap, cost effectiveness, and to reduce the risk of secondary fracture.[
This study has some limitations. First, this study was performed in various hospital settings within the same cohort, although education programs were standardized in all institutions. Second, the medical care system in Korea is not a same to other countries, because orthopedic surgeons undertake the role of primary care physicians after surgery. Therefore, the results of intervention programs in this study might be difficult to generalize in the other countries. However, recent studies have shown that the active participation of orthopedic surgeons is possible to improve osteoporosis treatment in patients with hip fracture. Finally, comparing control study, two hospitals had to exclude because of IRB permission. This change might have influenced on the outcomes.
In conclusion, the osteoporosis detection and medication rate after hip fracture increased two fold after the multimodal approach with orthopaedic surgeon and patients. This interventional multicenter study demonstrate that patients education program in patients with hip fracture can improve osteoporosis medication and well maintained up to 12 months follow-up and could be possible to potentially converse to fracture liaison service.
This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Korea (grant number : HI13C1522, HI15C1189).
No potential conflict of interest relevant to this article was reported.
DXA, dual energy X-ray absorptiometry.
RCT, randomized controlled trial; BMD, bone mineral density; Tx, treatment.