Sang-Rim Kim, Kwang Woo Nam, Yong-Geun Park, Sung-Rak Lee*, In Im**, Yong-Chan Ha***

Department of Orthopaedic Surgery, College of Medicine, Jeju National University,Department of Orthopaedic Surgery, Halla General Hospital, Jeju *,

Department of Orthopaedic Surgery, Hankook General Hospital, Jeju **,Department of Orthopaedic Surgery, College of Medicine , Chung-Ang University ***

Orthopaedic surgeon’s awareness can improve Orthopaedic surgeon’s awareness can improve osteoporosis treatment following hip fracture. osteoporosis treatment following hip fracture.

A prospective cohort studyA prospective cohort study

Treatment Rate of Osteoporosis after Hip FractureTreatment Rate of Osteoporosis after Hip Fracture

6% Gardner MJ et al in 2002 (JBJS-A)

19.9% Judy AG et al in 2002 (Oteoporosis Int)

8.6% Ha et al in 2002 ( J Korean Orthop Assoc)

Detection and management of osteoporosis in Jeju (2005)

IntroductionIntroduction

Results of Retrospective Cohort Study in 2005Results of Retrospective Cohort Study in 2005

Hip fracture patients over 50 years : 174 patients

Detection of osteoporosis : 35 patients (20%)

Management of osteoporosis: 27 patients (15.5%)

Prescription drug : Bisphosphonate 25 patients (92.5%)

HRT 1 patients, SERM 1 patients

IntroductionIntroduction

Results of Retrospective Cohort Study in 2005Results of Retrospective Cohort Study in 2005

IntroductionIntroduction

설문조사 설문조사 (17(17 명명 ))

Detection of osteoporosis : 15 명 (88.2%)

Management of osteoporosis: 17 명 (100%)

처방약제 Bisphosphonate 17 명 (100%)

실제관리율 실제관리율

Detection of osteoporosis : 35 명 (20%)

Management of osteoporosis: 27 명 (15.5%)

처방약제 Bisphosphonate 25 명 (92.5%) HRT-1 명 . SERM-1 명

≠≠

The Purpose of Study

To determine whether a orthopaedic surgeon education program would increase the percentage of patients receiving treatment for osteoporosis following a hip fracture

To know barriers against management of osteoporosis in patients with a hip fracture

Prospective Intervention Study

Materials & MethodsMaterials & Methods

Duration : 1st Jan, 2007 - 31st Dec, 2007

Material : Patients over 50 years of age who lived in Jeju island and sustained a femoral neck or intertrochateric fracture

Method : Reviewed hospital record.– The admitting diagnosis, mechanism of injury, detection of

osteoporosis, procedures performed during hospitalization, and discharge medications

– 2007 population data in Jeju-Do by national statistical office

Prospective Intervention StudyMaterials & MethodsMaterials & Methods

Detection of osteoporosis : dual energy X-ray absorptiomety (DXA)

Treatment : selective estrogen receptor modulator, or hormone replacement therapy, or bisphosphonate, or calcitonin therapy

Follow-up: average 1 year– repeated review of the medical records at 6 months and one year

after discharge

Statistical power & sample size justificationStatistical power & sample size justification

15.5 % of initiation of osteoporosis treatment in the 2005 data

Significance level of 5%

80% statistical power

Estimated sample size according to treatment rate after intervention

Materials & MethodsMaterials & Methods

Expected treatment rate after intervension

Size of difference

Sample size

20.5% 5% 512

25.5% 10% 149

30.5% 15% 74

35.5% 20% 45

40.5% 25% 31

minimum 180 patients

“ 208 patients in our study ”

(drop-out rate of 20%)

22 orthopedic surgeons who worked at 8 hospitals

Orthopaedic surgeon education

: Two times

Campaign poster or Brochure for the mouse pad

InterventionIntervention

Materials & MethodsMaterials & Methods

Patient Follow-upPatient Follow-up

Materials & MethodsMaterials & Methods

• Patients were interviewed by telephone or direct contact to evaluate their compliance to the osteoporosis treatment at six months after discharge and were followed-up for a minimum of one year

ResultsResultsPatient No. : 208 cases

Mean age : 79.1 years(range, 52 -99 years)

Gender : Man - 34 cases, Woman - 174 cases

Mean hospital follow-up : 8.8 months(range, 1-24 months)

Neck fracture : 107 cases(51%) Intertrochanter Fx : 101cases(49%)

Coexisting medical disease Patients

Hypertension and heart problem 84(40.4%)

Diabetes 35(16.8%)

Depression & dementia 32(15.4%)

Previous stroke 27(13%)

Pneumonia & COPD 18(8.7%)

Cancer 6(2.9%)

Others 18(8.7%)

ResultResult

DXA

Prior to hip fracture 7(3.4%)

After hip fracture 94(45.2%)

Osteoporosis(-2.5≥ T-score) 93(44.7%)

Osteopenia(-1> T-score>2.5) 1(0.5%)

Bisphosphonate medication Prior to hip fracture 2(1%)

After hip fracture 67(32.2%)

Duration of bisphosphonate medication

< 6 months 25(12%)

≥ 6 months 42(20.2%)

Mean period of medication (months) 9.5(range, 1-24)

ResultResult

Before intervention

(2005 data)

After intervention

(2007 data)

Detection of osteoporosis

(DXA)20%(35/174) 45.2%(94/208)

Initiation of osteoporosis management 15.5%(27/174) 32.2%(67/208)

Comparison data before and after intervention demonstrate that detection and initiation of medication osteoporosis are increased more than two fold.

ResultResult

MortalityMortality

<<

22 patients(10,6%) within 6months

30 patients(14.4%) at 12 months

38 patients at the final follow-up

ResultResult

Osteoporosis Osteoporosis medication groupmedication group

(7/67)

Non-osteoporosis Non-osteoporosis medication group medication group

(31/141)

InterviewInterview

Participation in interview : 137 patients

- Passed away : 38 patients - live alone the old with dementia or deafness : 8 patients - to moved and changed telephone : 25 patients

ResultResult

Question Response No(%) of patient with medication

(56)

No(%) of patient without

medication (81)

No(%) of questionnaire

(137)

Have you heard osteoporosis from your doctor?

Yes 26(46.4) 29(35.8) 55(40.1)

No 30(53.6) 52(64.2) 82(59.9)

Did you examine bone mineral density at the hospital?

Yes 25(44.6) 24(29.6) 49(60.5)

No 27(48.2) 50(61.7) 77(56.2)

Have you received anti-osteoporosis drug?

Yes 40(71.4) 0 40(29.2)

No 16(28.6) 73(90.1) 89(65)

Why don’t you start osteoporosis treatment?

Don’t feel necessity to treat

osteoporosis 0 47(58) 47(34.3)

Economic reason 0 4(4.9) 4(2.9)

Transport problem 0 4(4.9) 4(2.9)Medical insurance

problem 0 1(1.2) 1(0.7)

Others 0 14(17.3) 14(10.2)

ResultResult

DiscussionsDiscussions

Intervention methods to improve osteoporosis

System of the country Harrington JT et al in 2002 Arhritis Rheum

Patient`s education Gardner MJ et al in 2005 JBJS-A

Doctor`s awareness Gardner MJ et al in 2002 JBJS-A

Intervention for clinicians to increase treatment rates

Orthopaedic surgeon─ role the first health-care providers to evaluate patients

with fractures─ their improved awareness for identifying patients with

osteoporosis has shown to benefit from intervention

Intervention for improving osteoporosis management following hip fracture

: Orthopaedic surgeon > Physician - Miki RA et al in 2008 JBJS

DiscussionDiscussion

Barrier to initiate osteoporosis treatment─ patients, physician, orthopaedic surgeon and medical

care system - Bogoch ER et al in 2006 JBJS

─ ten kinds of barrier - Kaufman JD et al in 2003 JBJS

they insisted importance of the orthopaedic surgeon’s role to overcome of the barriers.

Most common barrier according to questionaire : Patients did not feel to necessity of osteoporosis

medication

DiscussionDiscussion

Consideration for the limitation

1. Orthopaedic surgeon association society and public mess media are also enlightening the importance of osteoporosis medication following fragility fracture

2. Medical care system is quite different developed country

3. This study is performed various leveled hospital in same cohort.

4. 25 patients could not contact with directly and indirectly method..

5. Interventional education program was not validated

DiscussionDiscussion

Thank you for your attention!!Thank you for your attention!!