Risk Of Second Fracture Research Articles

Penalised semi-parametric copula method for semi-competing risks data: application to hip fracture in elderly

Abstract Hip fracture is a severe complication in the elderly. The affected people are at a higher risk of second fracture and death occurrence, and the best treatment for hip fractures is still being debated. Aside from the treatment, many factors, such as comorbidity conditions, may be associated with second fracture and death occurrence. This study aims to identify effective treatments and important covariates and estimate their effects on the progression of second fracture and death occurrence in hip fracture elderly patients using the semi-competing risks framework, because death dependently censors a second fracture but not vice versa. Due to the complex semi-competing risks data, performing variable selection simultaneously for second fracture and death occurrence is difficult. We propose a penalised semi-parametric copula method for semi-competing risks data. Specifically, we use separate Cox semi-parametric models for both margins and employ a copula to model the two margins’ dependence. We develop a coordinate-wise optimisation algorithm that takes into account the data structure and copula function’s complexities. Simulations show that the proposed method outperforms the traditional penalised marginal method. We apply the proposed method to a population-based cohort study of hip fracture elderly patients, providing new insights into their treatment and clinical management.

PMS74 - THE ROLE OF MONITORING COMPLIANCE TO GUIDELINES IN PREVENTING THE RISK OF SECOND FRACTURE AND DEATH IN PATIENTS WITH OSTEOPOROSIS: A RETROSPECTIVE ADMINISTRATIVE DATABASE ANALYSIS.

To assess the relationship between osteoporosis-related pharmacological treatment use, patterns and adherence and risk of second fracture or death in an Italian real-world setting. A retrospective cohort analysis using a north-eastern Italian region’s administrative database was conducted. Osteoporotic patients with a first hospitalization for fracture of femur with replacement or vertebral column between 1 January 2011 and 30 June 2015 were included. The use of post-fracture treatment, treatment patterns, among antiosteoporosis medication (AOM) and supplementation with calcium or vitamin D (Ca/VitD), and adherence using Medication Possession Ratio(MPR) were analyzed. Cox regression models were used to estimate the risk of incidence of osteoporosis-related re-fractures, among femur with replacement, vertebral column, radius and ulna, and all-cause death from the hospitalization-index until 30 June 2016. Follow-up costs were calculated per patient per year (PPPY). 7,391 patients had a first fracture, mean (SD) age was 80 (10) years, 89% were female.After the hospitalization-index, 5,702 (71.9%) patients had osteoporosis-related treatment: 380 (4.8%) had AOM only, 2,549 (32.1%) AOM and Ca/VitD and 2,773 (35.0%) Ca/VitD only. Over a median follow-up of 2.3 years, re-fracture rate was 27/1000 patient-years and death rate was 105/1000 patient-years. Risk of re-fracture decreased among treated patients(HR=0.42, 95%CI 0.35-0.51), those withCa/VitD in addition to AOM (HR=0.64, 95%CI 0.43-0.94) and those adherent (MPR≥80%) to treatment (HR=0.16, 95%CI 0.11-0.24). Risk of mortality decreased among treated patients (HR=0.38, 95%CI 0.34-0.41), those with AOM and Ca/VitD (HR=0.41, 95%CI 0.33-0.50)and increased for adherent patients(HR=1.63, 95%CI 1.38-1.92). On average,PPPY costs resulted €6,884.75 among not treated patients, and €5,477.71, €4,258.16 and €4,626.03,for AOM only, AOM and Ca/VitD and Ca/VitD only groups, respectively. This real-world study suggests that the relevance of monitoring of compliance to guidelines in terms of treatment use, patterns and adherence may improve patients' prognosis.

Impact of prescription drugs on second fragility fractures among US Medicare patients.

Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.

Is Withholding Osteoporosis Medication After Fracture Sometimes Rational? A Comparison of the Risk for Second Fracture Versus Death

Undertreatment of osteoporosis is common, even for high-risk patients. Among the reasons for undertreatment may be a clinician's perception of a lack of treatment benefit, particularly in light of patients' expected future mortality. Among US Medicare beneficiaries, we evaluated the risk for second fracture versus death in the 5 years following a hip, clinical vertebral, and wrist/forearm fracture. Using data from 1999 to 2006 for a random 5% sample of US Medicare beneficiaries, we identified individuals who experienced an incident hip, clinical vertebral, or wrist/forearm fracture in 2000 or 2001. We evaluated the risk for a second incident fracture versus death in the following 5 years. Results were stratified by age, gender, race/ethnicity, and medical comorbidities. In light of the competing mortality risk, and assuming 30% efficacy of an osteoporosis medication to prevent a second fracture, we calculated the number of individuals needed to treat (NNT) for 5 years after first fracture to prevent 1 additional subsequent fracture. We identified 18,853, 12,751, and 7635 persons with an incident hip, clinical vertebral, and wrist/forearm fracture, respectively. Although the 5-year risk of death usually exceeded the risk for second fracture across age, gender, racial groups, and primary fracture type (median ratio of death to second fracture=1.4, interquartile range 0.9, 2.0), the 5-year risk for second fracture was high, varying from a low of 13% to a high of 43%. Across demographic groups, the NNT to prevent a second fracture was low, ranging from 8 to 46. Among older persons with hip, clinical vertebral, or wrist/forearm fracture, although the risk for death was usually greater than the risk for a second fracture, both were high. The relatively low NNT to prevent 1 additional subsequent fracture fell within a range generally considered acceptable for secondary prevention strategies.