Eller-Florentina JC 10 28 14

SURVIVAL AND FUNCTIONAL OUTCOMES

AFTER HIP FRACTURE AMONG NURSING HOME

RESIDENTS

Alvin C. York VA Medical CenterLipscomb University College of Pharmacy

Florentina EllerOctober 27, 2014

Overview

Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014 Aug;174(8):1273-80. doi: 10.1001/jamainternmed.2014.2362

Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes Hospitalized for hip fractures July 1, 2005- June 30, 2009

Overview

Study goals: Characterize patterns of survival and new total

dependence in locomotion, 6 months and 1 year after hip fracture (HF)

Describe changes in 7 activities of daily living (ADL) after HF

Identify risk factors associated with survival after HF and a composite outcome of death or new total dependence in locomotion with 6 months after HF

Neuman MD. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014

Background

Hip fracture: A break in the upper quarter

of the femur.

Causes: Fall or direct blow to the side

of the hip. Osteoporosis, cancer, or stress

injuries

Epidemiology: 300,000 HFs each year In nursing homes 2x to sustain

HFs Worse outcomes after fracture

AAOS. Hip Fractures. Ortho Info. http://orthoinfo.aaos.org/topic.cfm. Accessed 10/17/14

Hip Fracture

Symptoms: Pain over thigh or groin High discomfort when flexing

or rotating the hip Shorter leg then the other

If completely broken The leg is held in a still

position, rotated outward Aching of groin or thigh

Starts a period of time before break

With stress injury or cancerDiagnosis: X-ray of hip and femur MRI- for incomplete, hidden

fractures


Hip Fracture: 2014 AAOS Guidelines Treatment

Surgery within 48 hours of fracture

Aspirin or clopidogrel use should not delay surgery

Venous thromboembolism prophylaxis (VTE) is recommended

Improvement in functional outcome post HF: Interdisciplinary care

programs for patients with mild to moderate dementia

Supervised occupational

and physical therapy

Prevention: Calcium and/or Vitamin D

Reduces fall risk and prevents fractures in the elderly

Patients should be evaluated and treated for osteoporosis after sustaining a hip fracture 5-10x increased risk of

a second hip fracture


MethodsCollection of Data:1. Nurses clinical assessments

Minimum Data Set (MDS) Standardized and validated For all residents in certified Medicare/Medicaid nursing

homes from 2005-2009

2. Medicare provider analysis and review files (MedPAR) Inpatient hospital claims for Medicare beneficiaries from

2005-2009

3. Medicare beneficiary summary file

Neuman MD. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med.

2014

Baseline Characteristics


Baseline Characteristics

Neuman MD. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern

Med. 2014http://www.fpnotebook.com. Charlson Comorbidity

Index

Comorbidities for Charlson score

1 each: MI, CHF, PVD, cerebrovascular disease, dementia, COPD, connective tissue disease, PUD, T2DM (uncomplicated), liver disease.

2 each: moderate to severe CKD, T2DM with end organ damage, leukemia, hemiplegia, leukemia, lymphoma, solid tumor.

3 each: liver disease, moderate to severe.

6 each: Malignant metastatic solid tumor, AIDS.

http://www.fpnotebook.com/



Baseline Characteristics and Acute Management


7 ADL:

(1)Locomotion on the nursing home

(2) Dressing

(3) personal hygiene

(4) using the toilet

(5) Transferring between surfaces

(6)Getting in and out of bed

(7) Eating

INTERTROCHANTERIC AND FEMORAL NECK FRACTURES HEMIARTHROPLASTY

http://www.newyorkinjurycasesblog.com/2013http://www.anuvratclinics.com

http://www.newyorkinjurycasesblog.com/2013

http://www.newyorkinjurycasesblog.com/2013

OutcomesPrimary: Death from any cause within 180 days of

hospital admissionSecondary: Post-fracture self-performance for each of the 7

ADLs Composite outcome of death by 180 days or

new total dependence in locomotion after HF Mortality at 365 days and a composite outcome

of death by 365 days or new total dependence in locomotion within 365 days


Statistical Analysis Kaplan-Meier survival curves

To characterize baseline features and outcomes

Multivariate Cox proportional hazards model To measure the adjusted association of baseline patient

factors and acute fracture management with post-fracture survival.

Multivariate Poisson regression model To measure the relative risks (RRs) of mortality

associated with specific patient factors and fracture management approaches.


Results

Of 60,111 patients, 21, 766 (36.2%) died by 180 days after fracture

Median survival time after fracture was 377 days (IQR, 70-1002 days)

Of the 52, 734 patients who were not totally dependent in locomotion at baseline, 28, 225 (53.5%) either died or were newly dependent in locomotion within 180 days

Among patients who survived to 180 days, new total dependence in locomotion occurred in 9,438 of 33, 947 (27.8%)


Results


Results

For patients with at least 1 year of available follow up data:

Among 52, 914 patients, 24, 883 (47.0%) died by 365 days.

Among 46,842 patients who were not totally dependent in locomotion at baseline, 28 114 (60.5%) either died or experienced new total dependence in locomotion within 365 days.

Among the 24, 984 patients without total dependence in locomotion at baseline and who survived 365 days after fracture, 6,618 (26.5%) were totally dependent in locomotion at 365 days


Results


Predictors of Adverse Outcomes

Neuman MD. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med.

2014





Strengths Large study with reliable results ( ~66,000 residents of

certified nursing homes)

Statistically significant results for 1ry and 2ry outcomes

Accurate collection of data ( standardized MDS, MedPAR files, Medicare beneficiary summary file)

1 year follow-up data

Appropriate statistical tests to analyze the primary outcome and baseline risk factors

Appropriate study design to look multiple outcomes (retrospective cohort)

Limitations Might not apply to the VA population:

75% of subjects were women 91% were white 25% had only 1 comorbidity; 23% had 2 comorbidities

In this retrospective cohort study, the authors assumed which baseline factors might influence HF outcomes- thus, there is a chance of missing a few ( Smoking? Soda intake? Diet? Certain medications –omeprazole?

Time from admission into the nursing home to first HF could have been one of the baseline risk factors ?

Conclusions from Study

Among long- term nursing home residents:

> 1: 3 patients die, 180 days post HF ( 1:2 for men)

1 out of every 2 patients with some type of baseline independence in locomotion, either die or develop new total dependence in locomotion within 6 months after HF

Factors significantly associated with decreased survival after HF are: nonoperative fracture management, male sex, increasing age, high levels of comorbidity, advanced cognitive impairment , nonfemoral neck fractures and increasing baseline ADL dependence .


Clinical Pearls: Osteoporosis

Diagnostic assessment

Bone mineral density (BMD) test using DEXA for: Women ≥ 65 yo and men ≥70 yo Postmenopausal women and men > 50-69 yo if risk

factors present Postmenopausal women and men over > 50 yo with

history of fracture(s)

BMD used for: Diagnosis of bone loss and osteoporosis Monitoring the effectiveness of therapy Predicting the future risk for fractures

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. 2014


Pharmacologic treatment

If T-scores < -2.5 at the femoral neck, total hip or lumbar spine

If postmenopausal women and men ≥ 50 yo with: low bone mass (Tscore : -1.0 and -2.5, osteopenia) AND 10-year hip fracture probability > 3% OR 10-year major osteoporosis-related fracture probability

> 20% based on the U.S.-adapted WHO absolute fracture

risk model (FRAX®; www.NOF.org and www.shef.ac.uk/FRAX).

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of

Osteoporosis. 2014


FDA-approved pharmacologic treatments:

Bisphosphonates Alendronate/Fosamax Ibandronate/Boniva Risedronate/ Actonel Zoledronic acid/ Reclast

Calcitonin/ Fortical /Miacalcin

Estrogen agonist/antagonist-SERM (raloxifene/Evista)

Estrogens and/or hormone therapy

Tissue-selective estrogen complex (conjugated estrogens/bazedoxifene- Duavee)

Parathyroid hormone 1-34 (teriparatide/Forteo)

RANK ligand inhibitor (denosumab/Prolia)National Osteoporosis Foundation. Clinician's

Guide to Prevention and Treatment of Osteoporosis. 2014


Monitoring: BMD testing

1 -2 years after initiating treatment; every 2 years thereafter

At longer intervals For patients without major risk factors AND Have an initial T-score in the normal or upper low

bone mass range


Osteoporosis. 2014

Pharmacist’s Role

Assess risk factors for falls and offer appropriate modifications: Correction of vitamin D insufficiency Avoidance of CNS depressant medication Monitoring of anti-HTN medication Visual correction when needed

Advise on cessation of tobacco smoking and avoidance of excessive alcohol intake


Osteoporosis. 2014

Pharmacist’s Role

Advise on adequate amounts of Ca2+ from diet: 1,000 mg daily for men 50-70 yo 1,200 mg daily for women ≥ 51 yo and men ≥ 71 yo Dietary supplements if diet is insufficient

Advise on vitamin D intake: 800-1,000 IU daily (supplements if necessary) for ≥ 50

yo

Recommend regular weight-bearing and muscle-strengthening exercise

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. 2014

QUESTIONS?

Documents

Eller-Florentina JC 10 28 14