- Email: [email protected]
Compliance with a pharmacological secondary fracture prevention policy
Injury, Int. J. Care Injured (2006) 37, 718—720
www.elsevier.com/locate/injury
Compliance with a pharmacological secondary fracture prevention policy Marilyn Norman, Martyn J. Parker * Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK Accepted 3 January 2006
KEYWORDS Fracture prevention; Hip fracture; Osteoporosis; Compliance
Summary The aim of this study was to monitor the compliance of a specific group of patients to the initiation of pharmacological fracture prevention therapies, in particular calcium and Vitamin D3 supplements. We used a cohort of 276 patients admitted to one hospital with an acute hip fracture. Therapy was started in hospital and compliance checked at out patient follow-up. Written and verbal advice was given to support therapy. The mean age was 80.8 years and 82% were female. One hundred and ninety-nine patients were alive at one year from injury. For these patients 22 (11.1%) were on therapy prior to fracturing their hip. Of the remainder, 111/177 (62.7%) stated they were taking therapy to reduce the risk of fractures. These results demonstrate that an aggressive policy of prescribing can result in good levels of compliance with therapy. # 2006 Elsevier Ltd. All rights reserved.
Introduction A hip or proximal femoral fracture is the commonest reason for an elderly person to be admitted to an acute orthopaedic ward. Following a hip fracture there is a reduction in mobility and activities of daily living by 20—35% and for those admitted from their own homes about 14% will be unable to continue living at home.7 A survey of the attitudes of older women found that 80% would rather be dead than experience the loss of independence and quality of life that may occur after a hip fracture.8 * Corresponding author. Tel.: +44 1733 874000; fax: +44 1733 875013. E-mail addresses: [email protected], [email protected] (M.J. Parker).
Calcium and Vitamin D supplementation has been advocated as a measure to reduce the risk of further fractures after a hip fracture.9 Compliance with such therapy has not been reported. We have studied the effectiveness of an aggressive prescribing policy for calcium and Vitamin D supplementation after a hip fracture to assess compliance and reasons for failure to follow recommended therapy.
Patients and methods Between November 2002 and September 2003, 290 patients were admitted to one district general hospital with an acute hip fracture. All the patients were admitted to one ward specialising in hip frac-
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.01.003
Compliance with a pharmacological secondary fracture prevention policy ture treatment, with information on all patients collected prospectively as part of an ongoing audit and research project on hip fractures. From these 290 patients, 11 were excluded due to their age being less than 60 years and a further three were excluded because the fracture was pathological from disseminated malignant tumour. A further 19 patients who died without being discharged from hospital were also excluded from the study. Whilst in hospital all patients were given verbal advice regarding drugs to reduce the risk of further fractures and received an information booklet on hip fractures, this included additional advice on pharmacological methods to reduce the risk of hip fracture. The policy of the unit was that all hip fracture patients should be discharged home having been prescribed calcium and Vitamin D supplements. Six weeks after discharge, surviving patients were reviewed in a hip fracture clinic and those who did not attend were contacted by phone to check continued compliance. This attendance at clinic always included further discussion on preventive therapy. Additional written information could also be given at this visit. If the patient gave their consent the General Practitioner was asked to continue the supply of calcium and Vitamin D and this was mentioned in the clinic letter to the General Practitioner. One-year following the date of the hip fracture, compliance was assessed for all surviving patients by either assessment in the hip fracture clinic or a follow-up phone call to the patient or their carers.
Results One hundred and ninety-nine patients survived to one year from injury. One hundred and sixty-four (82.4%) were female. The average age was 80.8 years. One hundred and fifty-six patients lived in their own homes, 28 were in residential homes, 7 in nursing homes and 8 patients were a hospital inpatient at the time the fracture was sustained. One hundred and ninety-seven of the fractures were treated operatively and two conservatively. At the time of admission with the hip fracture 22 patients (11.1%) were already taking a bone strengthening drug. These medications were calcium and Vitamin D (9 patients), bisphosphonate (10 patients) or hormone replacement therapy (3 patients). Having discounted the above patients this left 177 to monitor their compliance over the year (Fig. 1). Table 1 gives the number of patients taking therapy at the first clinic follow-up visit and at one-year from injury. For the patients in whom therapy was contraindicated at one year, two had carcinoma, two hypercalcaemia and one renal stones. Thirty-
Figure 1
719
Flow diagram of participants.
Table 1 Numbers taking calcium and Vitamin D at one year and reasons for not taking therapy Six weeks One year follow-up follow-up Taking calcium and Vitamin D 111 Taking bisphosphonate 4 Therapy contraindicated 4 Gastric side effects 4 Other side effects 2 Refused to take 2 Not given at hospital discharge 18 Not renewed after discharge 25 Lost to follow-up or unsure 7
103 8 5 5 2 4 — 35 15
Total
177
177
five patients at one year had not been prescribed any therapy after discharge and a further 11 declined to take therapy due to side effects. In total 111 out of 177 (62.7%) patients were taking therapy to reduce the risk of further fractures.
Discussion Calcium and Vitamin D supplement can help reduce fractures in the elderly and are recommended for those who have sustained a hip fracture.9 In a randomised trial of 3270 elderly residents of nursing and apartments homes for the elderly, Chapuy et al. reported a relative risk reduction of 43% for hip fractures and 32% for all non-vertebral fractures,
720 for those allocated to receive calcium and Vitamin D.1 A later study of 389 participants reported a 60% reduction in all fractures after using 500 mg calcium and 700 mg of Vitamin D over a three year follow-up.2 Many elderly people have a diet which does not contain the daily recommended daily allowance of calcium.11,6 More recently however the multi-centre RECORD trial has questioned the effectiveness of calcium and Vitamin D after a fracture in the elderly.10 Vitamin D is commonly deficient in the elderly and especially if patients are housebound.5 As age advances cutaneous production of Vitamin D decreases along with metabolism of Vitamin D, thereby leading to a decrease in calcium absorption. Elderly patients are less likely to enjoy a diet rich in Vitamin D of which only around 10—20% is actually absorbed from the diet.3 Bisphosphonates are an alternative therapy, but at present the evidence for the effectiveness of these drugs in those aged over 80 years is limited.9 For patients in our study most of the patients taking therapy were still taking therapy at one year from injury. The majority were taking calcium and Vitamin D, with only a small number taking bisphosphonates. Initially at the first follow-up point, 18 had not been prescribed the supplements. This may be due to a failure at the time of discharge or in communication if the patient was transferred to another ward that was not aware of the prescribing policy. For these patients and those who requested, extra written information was provided and verbal advice and a further letter sent to the patients’ General Practitioner requesting them to continue prescribing the supplements. Overall we felt compliance was better than we had expected, as many of these patients were on a number other medications. We feel that it was a combination of our aggressive prescribing policy and possible the free provision of medications for these patients, that resulted in better compliance than that reported in an earlier study.4 We accept that our information was entirely based on the patient or their carer giving us accurate informa-
M. Norman, M.J. Parker tion on their compliance and that it is inevitable a few patients may have provided incorrect information. Despite these limitations we feel that our study demonstrates that an aggressive prescribing policy for fracture prevention therapy may be effective.
References 1. Chapuy MC, Arlot ME, Duboeuf F. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327:1637—42. 2. Dawson-Hughes B, Harris SS, Krall EA, Gerad ED. Effect of calcium and Vitamin D supplementation on bone density in men and women 65 years of age and older. N Engl J Med 1997;337:670—6. 3. Heany R. Nutrition and risk for osteoporosis. In: Marcus R, Feldman D, Kelsey J, editors. Osteoporosis. London: Academic Press; 1996 [Chapter 22]. 4. Leil Y, Castel H, Bonneh DY. Impact of subsidising effective anti-osteoporosis drugs on compliances with management guidelines in patients following low impact fractures. Osteoporos Int 2003;14:490—5. 5. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev 2001;22(4):477— 501. 6. Raab CA, Gregerson D, Shaw JM, Snow C. Postmenopausal women take steps to reduce osteoporosis risk. Women’s Health Issues 1999;9(4):211—8. 7. Rosell PAE, Parker MJ. Functional outcome after hip fracture: a 1-year prospective outcome study of 275 patients. Injury 2003;34:529—32. 8. Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Br Med J 2000;320:341—5. 9. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fracture in older people; a national clinical guideline, No. 56. Edinburgh: Royal College of Physicians; 2002 [www.sign.ac.uk]. 10. The RECORD Trail Group. Oral Vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (randomised evaluation of calcium or Vitamin D, RECORD): a randomised placebo-controlled trial. Lancet 2005;365:1621—8. 11. Zablah EM, Reed DB, Hegsted M, Keenan MJ. Barriers to calcium intake in African American women. J Hum Nutr Diet 1999;12:123—32.
www.elsevier.com/locate/injury
Compliance with a pharmacological secondary fracture prevention policy Marilyn Norman, Martyn J. Parker * Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK Accepted 3 January 2006
KEYWORDS Fracture prevention; Hip fracture; Osteoporosis; Compliance
Summary The aim of this study was to monitor the compliance of a specific group of patients to the initiation of pharmacological fracture prevention therapies, in particular calcium and Vitamin D3 supplements. We used a cohort of 276 patients admitted to one hospital with an acute hip fracture. Therapy was started in hospital and compliance checked at out patient follow-up. Written and verbal advice was given to support therapy. The mean age was 80.8 years and 82% were female. One hundred and ninety-nine patients were alive at one year from injury. For these patients 22 (11.1%) were on therapy prior to fracturing their hip. Of the remainder, 111/177 (62.7%) stated they were taking therapy to reduce the risk of fractures. These results demonstrate that an aggressive policy of prescribing can result in good levels of compliance with therapy. # 2006 Elsevier Ltd. All rights reserved.
Introduction A hip or proximal femoral fracture is the commonest reason for an elderly person to be admitted to an acute orthopaedic ward. Following a hip fracture there is a reduction in mobility and activities of daily living by 20—35% and for those admitted from their own homes about 14% will be unable to continue living at home.7 A survey of the attitudes of older women found that 80% would rather be dead than experience the loss of independence and quality of life that may occur after a hip fracture.8 * Corresponding author. Tel.: +44 1733 874000; fax: +44 1733 875013. E-mail addresses: [email protected], [email protected] (M.J. Parker).
Calcium and Vitamin D supplementation has been advocated as a measure to reduce the risk of further fractures after a hip fracture.9 Compliance with such therapy has not been reported. We have studied the effectiveness of an aggressive prescribing policy for calcium and Vitamin D supplementation after a hip fracture to assess compliance and reasons for failure to follow recommended therapy.
Patients and methods Between November 2002 and September 2003, 290 patients were admitted to one district general hospital with an acute hip fracture. All the patients were admitted to one ward specialising in hip frac-
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.01.003
Compliance with a pharmacological secondary fracture prevention policy ture treatment, with information on all patients collected prospectively as part of an ongoing audit and research project on hip fractures. From these 290 patients, 11 were excluded due to their age being less than 60 years and a further three were excluded because the fracture was pathological from disseminated malignant tumour. A further 19 patients who died without being discharged from hospital were also excluded from the study. Whilst in hospital all patients were given verbal advice regarding drugs to reduce the risk of further fractures and received an information booklet on hip fractures, this included additional advice on pharmacological methods to reduce the risk of hip fracture. The policy of the unit was that all hip fracture patients should be discharged home having been prescribed calcium and Vitamin D supplements. Six weeks after discharge, surviving patients were reviewed in a hip fracture clinic and those who did not attend were contacted by phone to check continued compliance. This attendance at clinic always included further discussion on preventive therapy. Additional written information could also be given at this visit. If the patient gave their consent the General Practitioner was asked to continue the supply of calcium and Vitamin D and this was mentioned in the clinic letter to the General Practitioner. One-year following the date of the hip fracture, compliance was assessed for all surviving patients by either assessment in the hip fracture clinic or a follow-up phone call to the patient or their carers.
Results One hundred and ninety-nine patients survived to one year from injury. One hundred and sixty-four (82.4%) were female. The average age was 80.8 years. One hundred and fifty-six patients lived in their own homes, 28 were in residential homes, 7 in nursing homes and 8 patients were a hospital inpatient at the time the fracture was sustained. One hundred and ninety-seven of the fractures were treated operatively and two conservatively. At the time of admission with the hip fracture 22 patients (11.1%) were already taking a bone strengthening drug. These medications were calcium and Vitamin D (9 patients), bisphosphonate (10 patients) or hormone replacement therapy (3 patients). Having discounted the above patients this left 177 to monitor their compliance over the year (Fig. 1). Table 1 gives the number of patients taking therapy at the first clinic follow-up visit and at one-year from injury. For the patients in whom therapy was contraindicated at one year, two had carcinoma, two hypercalcaemia and one renal stones. Thirty-
Figure 1
719
Flow diagram of participants.
Table 1 Numbers taking calcium and Vitamin D at one year and reasons for not taking therapy Six weeks One year follow-up follow-up Taking calcium and Vitamin D 111 Taking bisphosphonate 4 Therapy contraindicated 4 Gastric side effects 4 Other side effects 2 Refused to take 2 Not given at hospital discharge 18 Not renewed after discharge 25 Lost to follow-up or unsure 7
103 8 5 5 2 4 — 35 15
Total
177
177
five patients at one year had not been prescribed any therapy after discharge and a further 11 declined to take therapy due to side effects. In total 111 out of 177 (62.7%) patients were taking therapy to reduce the risk of further fractures.
Discussion Calcium and Vitamin D supplement can help reduce fractures in the elderly and are recommended for those who have sustained a hip fracture.9 In a randomised trial of 3270 elderly residents of nursing and apartments homes for the elderly, Chapuy et al. reported a relative risk reduction of 43% for hip fractures and 32% for all non-vertebral fractures,
720 for those allocated to receive calcium and Vitamin D.1 A later study of 389 participants reported a 60% reduction in all fractures after using 500 mg calcium and 700 mg of Vitamin D over a three year follow-up.2 Many elderly people have a diet which does not contain the daily recommended daily allowance of calcium.11,6 More recently however the multi-centre RECORD trial has questioned the effectiveness of calcium and Vitamin D after a fracture in the elderly.10 Vitamin D is commonly deficient in the elderly and especially if patients are housebound.5 As age advances cutaneous production of Vitamin D decreases along with metabolism of Vitamin D, thereby leading to a decrease in calcium absorption. Elderly patients are less likely to enjoy a diet rich in Vitamin D of which only around 10—20% is actually absorbed from the diet.3 Bisphosphonates are an alternative therapy, but at present the evidence for the effectiveness of these drugs in those aged over 80 years is limited.9 For patients in our study most of the patients taking therapy were still taking therapy at one year from injury. The majority were taking calcium and Vitamin D, with only a small number taking bisphosphonates. Initially at the first follow-up point, 18 had not been prescribed the supplements. This may be due to a failure at the time of discharge or in communication if the patient was transferred to another ward that was not aware of the prescribing policy. For these patients and those who requested, extra written information was provided and verbal advice and a further letter sent to the patients’ General Practitioner requesting them to continue prescribing the supplements. Overall we felt compliance was better than we had expected, as many of these patients were on a number other medications. We feel that it was a combination of our aggressive prescribing policy and possible the free provision of medications for these patients, that resulted in better compliance than that reported in an earlier study.4 We accept that our information was entirely based on the patient or their carer giving us accurate informa-
M. Norman, M.J. Parker tion on their compliance and that it is inevitable a few patients may have provided incorrect information. Despite these limitations we feel that our study demonstrates that an aggressive prescribing policy for fracture prevention therapy may be effective.
References 1. Chapuy MC, Arlot ME, Duboeuf F. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327:1637—42. 2. Dawson-Hughes B, Harris SS, Krall EA, Gerad ED. Effect of calcium and Vitamin D supplementation on bone density in men and women 65 years of age and older. N Engl J Med 1997;337:670—6. 3. Heany R. Nutrition and risk for osteoporosis. In: Marcus R, Feldman D, Kelsey J, editors. Osteoporosis. London: Academic Press; 1996 [Chapter 22]. 4. Leil Y, Castel H, Bonneh DY. Impact of subsidising effective anti-osteoporosis drugs on compliances with management guidelines in patients following low impact fractures. Osteoporos Int 2003;14:490—5. 5. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev 2001;22(4):477— 501. 6. Raab CA, Gregerson D, Shaw JM, Snow C. Postmenopausal women take steps to reduce osteoporosis risk. Women’s Health Issues 1999;9(4):211—8. 7. Rosell PAE, Parker MJ. Functional outcome after hip fracture: a 1-year prospective outcome study of 275 patients. Injury 2003;34:529—32. 8. Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Br Med J 2000;320:341—5. 9. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of hip fracture in older people; a national clinical guideline, No. 56. Edinburgh: Royal College of Physicians; 2002 [www.sign.ac.uk]. 10. The RECORD Trail Group. Oral Vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (randomised evaluation of calcium or Vitamin D, RECORD): a randomised placebo-controlled trial. Lancet 2005;365:1621—8. 11. Zablah EM, Reed DB, Hegsted M, Keenan MJ. Barriers to calcium intake in African American women. J Hum Nutr Diet 1999;12:123—32.