Eller-Florentina JC 10 28 14

Alvin C. York VA Medical Center
Lipscomb University College of Pharmacy
Florentina Eller
October 27, 2014

 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

 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

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

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 cancer
Diagnosis:
 X-ray of hip and femur
 MRI- for incomplete, hidden
fractures

 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

Collection 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

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

Neuman MD. Survival and functional outcomes after hip fracture among
nursing home residents. JAMA Intern Med. 2014
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/2013
http://www.anuvratclinics.com

Primary:
 Death from any cause within 180 days of hospital
admission
Secondary:
 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

 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.

 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%)

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

Neuman MD. Survival and functional outcomes after hip fracture

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

 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)

 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 ?

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 .

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

 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

 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

Eller-Florentina JC 10 28 14

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