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Geographic variation in secondary fracture prevention after a hip fracture during 1999–2013: a UK study

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Abstract

Summary

Fragility fractures of the hip have a major impact on the lives of patients and their families. This study highlights significant geographical variation in secondary fracture prevention with even the highest performing regions failing the majority of patients despite robust evidence supporting the benefits of diagnosis and treatment.

Introduction

The purpose of the study is to describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999–2013 in the UK.

Methods

We used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to 5 years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI).

Results

Thirteen thousand sixty-nine patients (76 % female) diagnosed with a hip fracture during 1999–2013 were identified. Eleven per cent had any anti-osteoporosis drug prescription in the 6 months prior to the index hip fracture. In the 0–4 months following a hip fracture, 5 % of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51 % in 2011 and then decreasing to 39 % in 2013.

The independent predictors (OR (95 % CI)) of treatment initiation included gender (male 0.42 (0.36–0.49)), BMI (0.98 per kg/m2 increase (0.97–1.00)) and geographic region (1.29 (0.89–1.87) North East vs. 0.56 (0.43–0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally, an additional 3214 hip fracture patients would be initiated on therapy every year.

Conclusions

Significant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture.

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Acknowledgments

The ReFRESH study group consists of Dr. Andrew David Judge, Dr. Muhammad Kassim Javaid, Professor Nigel Arden, Professor Cyrus Cooper, Professor Andrew Farmer, Dr. Daniel Prieto-Alhambra, Dr. Jose Leal, Professor Michael Goldacre, Professor Alastair Gray, Dr. Janet Lippett, Dr. Rachael Gooberman-Hill and Laura Graham.

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Authors and Affiliations

  1. NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK

    A. Shah, D. Prieto-Alhambra, S. Hawley, A. Delmestri, C. Cooper, A. Judge & M. K. Javaid

  2. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    D. Prieto-Alhambra, C. Cooper, A. Judge & M. K. Javaid

  3. Royal Berkshire NHS Foundation Trust, Reading, UK

    J. Lippett

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  1. A. Shah
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Corresponding author

Correspondence to M. K. Javaid.

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Conflicts of interest

AS, SH and AD have no competing financial interests relevant to the submitted work. DPA, JL, CC, MKJ and AJ received grants from NIHR HS&DR during the conduct of the study. Outside the submitted work, MKJ reports personal fees from Lilly UK, Amgen, Sevier, Merck, Medtronic, Internis, Consilient Health, Stirling Anglia, Mereo Biopharma and Optasia. He serves on the Scientific Committee of the National Osteoporosis Society and International Osteoporosis Foundation; DPA received grants from Bioiberica S.A. and Amgen Spain S.A.; CC received personal fees from Servier, Amgen, Eli Lilly, Merck, Medtronic and Novartis. AJ has received consultancy, lecture fees and honoraria from Servier, UK Renal Registry, Oxford Craniofacial Unit, IDIAP Jordi Gol, Freshfields Bruckhaus Deringer, has held advisory board positions (which involved receipt of fees) from Anthera Pharmaceuticals, INC., and received research sponsorship from ROCHE.

Role of the funding source

This work was supported by the National Institutes of Health and Research (NIHR) Health Services and Delivery Research programme HS&DR) (project number 11/1023/01); and from the Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, University of Oxford. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS or the Department of Health. This study is based in part on data from the Clinical Practice Research Datalink obtained under licence from the UK Medicines and Healthcare products Regulatory Agency. The funding source had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, or in the preparation, review or approval of the manuscript.

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A Judge and MK Javaid are joint last authors.

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Shah, A., Prieto-Alhambra, D., Hawley, S. et al. Geographic variation in secondary fracture prevention after a hip fracture during 1999–2013: a UK study. Osteoporos Int 28, 169–178 (2017). https://doi.org/10.1007/s00198-016-3811-4

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