Predictors of re-fracture amongst patients managed within a secondary fracture prevention program: a 7-year prospective study
- 481 Downloads
This 7-year prospective observational study determined the predictors of re-fracture amongst 234 patients managed within a Secondary Fracture Prevention programme. Poor compliance, multiple co-morbidities, corticosteroid therapy, low hip bone mineral density (BMD) or low body weight were all significantly associated with re-fracture in patients commenced on long-term anti-resorptive therapy.
Risk factors for osteoporotic fracture amongst treatment-naïve patients are well established. In contrast, predictors of re-fracture in patients optimally managed within a Secondary Fracture Prevention (SFP) programme are ill-defined.
This prospective observational study included 234 subjects with incident osteoporotic fractures managed long-term by the Concord SFP programme. Using Cox proportional hazards models, predictors of re-fracture were analysed separately for patients commenced on specific pharmacotherapy (group 1, N = 171) and subjects receiving calcium and/or vitamin D supplements only (group 2, N = 63). Relevant anthropometric, clinical and technical data were documented at each visit. Compliance and persistence were analysed as time-varying covariates.
During a mean follow-up of 5.2 (range 3.5–7.3) years, 20.9 % of all subjects re-fractured (26.3 % in group 1, 6.3 % in group 2). Multivariate predictors of re-fracture in group 1 were significant co-morbidity (HR 2.04 if >3, 95 % CI 1.10–3.79, p = 0.024), corticosteroid use (HR 1.75, 95 % CI 1.12–2.73, p = 0.013) and total hip BMD (HR 1.36 per 0.1 g/cm2 decrease, 95 % CI 1.08–1.70, p = 0.008). In contrast, gender, prevalent fractures and lumbar spine BMD were not associated with re-fracture. Amongst patients with complete compliance data, a medication possession ratio of ≤ 50 % (HR 3.36, 95 % CI 1.32–8.53, p = 0.011) and low body weight (HR 1.04 per 1-kg decrease, 95 % CI 1.003–1.08, p = 0.032) were significantly associated with re-fracture.
Amongst patients managed within a dedicated SFP programme, poor compliance, multiple co-morbidities, corticosteroid therapy, low hip BMD or low body weight are all associated with increased risk of re-fracture. This subgroup of patients therefore require intensive management including strategies to improve compliance.
KeywordsAnti-resorptive Compliance Osteoporosis Persistence Re-fracture predictors Secondary fracture prevention programme
We thank Caroline Sullivan, Kathy Wu, Anna Lih, Paul Lee, Veena Jayadev, Rohit Rajagopal, Damien Smith, Belinda Poon, Chris Muir, Bev White, Lynley Robinson and Klaus Sommer and his team for their invaluable contributions to data collection and entry.
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.
Conflicts of interest
- 9.Ganda K, Schaffer A, Pearson S, Seibel MJ (2014) Compliance and persistence to oral bisphosphonate therapy following initiation within a secondary fracture prevention program: a randomised controlled trial of specialist vs. non-specialist management. Osteoporos Int 25:1345–1355Google Scholar
- 16.Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24:393–406Google Scholar
- 17.(2010) Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. The Royal Australian College of General Practitioners, South MelbourneGoogle Scholar
- 30.Prieto-Alhambra D, Pages-Castella A, Wallace G, Javaid MK, Judge A, Nogues X, Arden NK, Cooper C, Diez-Perez A (2014) Predictors of fracture while on treatment with oral bisphosphonates: a population-based cohort study. J Bone Miner Res 29:268–274Google Scholar
- 35.Sampalis JS, Adachi JD, Rampakakis E, Vaillancourt J, Karellis A, Kindundu C (2011) Long-term impact of adherence to oral bisphosphonates on osteoporotic fracture incidence. J Bone Miner ResGoogle Scholar
- 42.Bauer DC, Black DM, Garnero P, Hochberg M, Ott S, Orloff J, Thompson DE, Ewing SK, Delmas PD, Fracture Intervention Trial Study G (2004) Change in bone turnover and hip, non-spine, and vertebral fracture in alendronate-treated women: the fracture intervention trial. J Bone Miner Res 19:1250–1258PubMedCrossRefGoogle Scholar
- 44.(2009) NSW re-fracture admission data 2002–2008 analysis discussion. Greater Metropolitan Clinical Taskforce SydneyGoogle Scholar