Preventing fractures in elderly people
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7406.89 (Published 10 July 2003) Cite this as: BMJ 2003;327:89All rapid responses
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We wish to add a pragmatic point to the excellent review by Woolf and Akesson [1]. Unfortunately much of what are listed as risk factors for osteoporosis and falls is not widely recorded in General Practice computer records; making it difficult to systematically identify the patients at high risk [2]. GP data relating to risk factors for osteoporotic fracture can be classified into three groups (Table 1):
A) Where recording is likely to be good or a surrogate marker exists – e.g. drugs prescribed for that condition.) Repeat prescribing data is of very high quality in UK General Practice as it saves the doctor time [3].
B) Where recording is patchy,
C) Where recording is absent or problematic.
Whilst it is known that previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids identify their 10-year risk of hip fracture [4], such scales are difficult to use if the required data is not available.
What is needed is to be able to predict fracture risk from the data held already. The research needed to answer this question should be commissioned as a matter of urgency. This would improve the management of patients with risks of fracture in primary care, while the coding and classification system is “developed” to make it easier for general practitioners to record low impact fractures. Our recommendation is that all adult fractures should qualified as high or low impact, as a matter of routine - just as they are currently classified open or closed.
TABLE 1: LEVELS OF RECORDING OF RISK FACTORS FOR OSTEOPOROTIC FRACTURES AND FALLS: GROUP A: RECORDING GOOD OR A SURROGATE EXISTS: 1) BMI (Body Mass Index) <_19. xmlns:b="urn:x-prefix:b" xmlns:patchy="urn:x-prefix:patchy" xmlns:c="urn:x-prefix:c" xmlns:problematic="urn:x-prefix:problematic" _2="_2" treatment="treatment" with="with" corticosteroids.="corticosteroids." _3="_3" previous="previous" low="low" body="body" weight="weight" _4="_4" rheumatoid="rheumatoid" arthritis="arthritis" _5="_5" chronic="chronic" liver="liver" disease="disease" _6="_6" inflammatory="inflammatory" bowel="bowel" _7="_7" coeliac="coeliac" _8="_8" smoking="smoking" _9="_9" excessive="excessive" alcohol="alcohol" consumption="consumption" raised="raised" liverenzymes="liverenzymes" can="can" be="be" found="found" in="in" practices="practices" automated="automated" links="links" to="to" pathology="pathology" labs.="labs." _10="_10" parkinsons="parkinsons" probably="probably" via="via" drugs="drugs" that="that" are="are" only="only" used="used" manage="manage" _11="_11" glaucoma="glaucoma" also="also" through="through" search="search" for="for" _12="_12" alzheimers="alzheimers" and="and" _13="_13" epilepsy="epilepsy" group="group" b:_="b:_" recording="recording" is="is" patchy:_="patchy:_" _1="_1" radiographic="radiographic" evidence="evidence" of="of" osteoporosis="osteoporosis" or="or" vertebral="vertebral" deformity="deformity" both="both" unlike="unlike" there="there" no="no" automatic="automatic" posting="posting" x-ray="x-ray" results="results" into="into" gp="gp" records="records" thoracic="thoracic" kyphosis="kyphosis" confirmation="confirmation" cataracts="cataracts" macular="macular" degeneration="degeneration" partially="partially" sighted="sighted" registered="registered" blind="blind" vertibrobaislar="vertibrobaislar" insufficiency="insufficiency" cerebrovascular="cerebrovascular" transient="transient" ischaemic="ischaemic" attacks="attacks" c:_="c:_" absent="absent" problematic:_="problematic:_" loss="loss" height="height" this="this" difficult="difficult" as="as" many="many" gps="gps" have="have" recorded="recorded" based="based" on="on" the="the" patients="patients" verbal="verbal" statements="statements" fracture="fracture" after="after" energy="energy" trauma="trauma" very="very" hard="hard" from="from" _="_" primary="primary" care="care" patchy="patchy" rarely="rarely" does="does" it="it" indicate="indicate" if="if" was="was" reduced="reduced" lifetime="lifetime" exposure="exposure" oestrogen="oestrogen" menopause="menopause" hysterectomy="hysterectomy" _45="_45" years="years" date="date" associated="associated" sometimes="sometimes" data="data" entered="entered" practice="practice" changed="changed" computer="computer" system="system" maternal="maternal" hip="hip" a="a" code="code" _12i4="_12i4" but="but" used.="used." calcium="calcium" intake="intake" physical="physical" inactivity="inactivity" vit="vit" d="d" deficiency="deficiency" sunlight="sunlight" general="general" deterioration="deterioration" ageing="ageing" poor="poor" postural="postural" control="control" walking="walking" speed="speed" weak="weak" legs="legs" slow="slow" reaction="reaction" times.="times." hypoglycaemia="hypoglycaemia" hypotension="hypotension" syncope="syncope" hypotensive="hypotensive" multiple="multiple" drug="drug" therapy="therapy" pre="pre"/>
References:
[1] Woolf A D, Akesson K. Preventing fractures in elderly people. BMJ 2003; 327: 89-94
[2] de Lusignan S, Chan T, Wells S, Cooper A, Harvey M, Brew S, Wright M. Can the patients with osteoporosis, who should benefit from the implementation of the National Service Framework for Older People, be identified from General Practice computer records? A pilot study that illustrates the variability of computerised medical records and problems with searching computerised medical records. Accepted for publication: Public Health.
[3] Roland MO, Zander LI, Evans M, Morris R, Savage RA. Evaluation of a computer assisted repeat prescribing programme in a general practice. BMJ 1985;291:456-8.
[4] Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet. 2002 Jun 1;359(9321):1929-36.
Competing interests:
SdeL and NJH are in receipt of an unconditional eductional grant from MSD for the Primary Care Data Quality Programme
Competing interests: TABLE 1: LEVELS OF RECORDING OF RISK FACTORS FOROSTEOPOROTIC FRACTURES AND FALLS:GROUP A: RECORDING GOOD OR A SURROGATE EXISTS:1) BMI (Body Mass Index)
Dear Editor,
We have done retrospective analyses of all the patients suffering fracture
intertrochanteric or intracapsular neck fractures above age of 50 years. The most common cause besides stroke, neuroleptic drugs, imbalance
which are related to direct impact on greater trochanter leading to
fracture ; indirect torsional stress was also found to be the major cause
in Indian males.
On critical analysis for establishing the cause it was
found that when they try to wear undergarments they have to stand on one
leg strain on weight bearing hip is seven times the normal and centre of
gravity is shifted forwards and as soon as they rotate they have the
fracture of the osteoporotic neck or the trochanter. This leads to fall.Trauma also occurs due to fall after fracture had occured.This
questions the role of hip protectors in such mode of trauma to
trochanteric fractures. We recommend that waist belt should be elastic in
undergarments as compared from that of string which has to be tied every
time.
Secondly aged should wear clothes while sitting on a higher stool;
rather than standing on one leg which increases the strain on the affected
hip.
Indian or third world countries are more osteoporotic for the same
age that of the third world countries. this was well established by our
analysis as the mean age of the fracture trochanter was 55 in Indian set
up.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir, Ref. Clinical review 12th July 03
Preventing fractures in elderly people
I read with interest Professor Woolf’s review of what is being done
and what should be done to prevent fractures in elderly people.
An engineer colleague and myself are developing an inflatable
“Jacket”. Within this jacket are balloons, which protect the hips, the
chest, the back, the face and the back of the head. On evidence that a
fall is inevitable, they inflate in less than 0.2 seconds. The balloons
draw air into other spaces in the jacket as they inflate.
We have a working prototype of the jacket (which is proof of the
concept) and a lot of data from the sensor. If it were to come to the
market and be used, it might complete the armamentarium against fractures
in those liable to fall.
We are calling it FALLSAFE
Dr Stephen Taylor
retired GP
DSAWTaylor@aol.com
Brian Hudson
retired engineer.
Anthony D Woolf, Kristina Akesson Preventing fractures in elderly
people
BMJ 2003; 327; 89; 94 12th July.
Competing Interests: none. Self financed
Competing interests:
None declared
Competing interests: No competing interests
We would like to congratulate Woolf and Akesson on an excellent
review of the identification and management of Osteoporosis in people over
65. It is very readable and a concise guide for those at the practical end
of osteoporosis and falls management – primary care.
It highlights the true value of the “over 75” annual check in
identifying fallers and those at risk of falling, helping to establish a
base for the falls register. However it lacks in the details of the
practical issues involved in case-finding in primary care. We agree that
the approach should be either opportunistic or proactive, but would refer
readers to the National Osteoporosis Society’s Primary care strategy for
osteoporosis and falls, that is available for downloading from the NOS
website – www.NOS.org.uk – and that has been distributed to all PCOs in
the country.
A review of data relating to osteoporosis in Primary Care by the
Kent, Surrey and Sussex research network highlights the variable recording
of identifiable risk factors for either osteoporosis or falls unless there
is a specific interest within the practice. The NOS has produced a set of
osteoporosis related READ codes for use in general practice, also
available for downloading from the website, and is completing a similar
set of falls related codes, encompassing all the risk factors discussed by
Woolf and Akesson.
Finally in their discussion of monitoring response to treatment, it
should be emphasised that peripheral densitometry is not currently
suitable for this purpose, only densitometry of the lumbar spine and hip.
However we strongly endorse the view that the burden of osteoporosis in
the elderly can be reduced now, given a pro-active approach by practices
and their PCOs.
Competing interests:
MH has received support from Shire and MSD, PB has received support from Shire, MSD and P & G
Competing interests: No competing interests
Sir, May I add my congratulations for this excellent review (1). My
only criticism is that it is a very circumscribed medical approach. To
really make an impact on this huge and growing epidemic, there is a large
evidence base about the value of a multidisciplinary approach(2,3). I
would assert the importance of a strategy that ensures the medical
profession acts in tandem with therapists, nurses, dieticians,
pharmacists, and colleagues in health education. Further, to really impact
on the issue, we have tried an approach that attracts the attention of
older persons themselves, their family or friends, and/or members of their
community. This has included a leaflet (entitled 'Checkmate') that aims to
warn those at risk, and those in contact with them, of the dangers of
falling and a simple check list(4). It has been widely distributed to all
those who have regular contact with elderly persons. We have targeted
other groups according to their perceived risk, and the strategy appears
on our web-site(4). It is too great a problem for one profession to take
exclusive rights!
References:
1. Woolf A D and Akesson K. Preventing fractures in elderly people.
BMJ 2003; 327: 89-94
2. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M,
Koch ML, Trainor K, Horwitz RI. A multifactorial intervention to reduce
the risk of falling among elderly people living in the community. N Engl J
Med. 1994 Sep 29;331(13):821-7.
3. Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C.
Prevention of falls in the elderly trial (PROFET): a randomised controlled
trial. Lancet 1999;353: 93-7.
Competing interests:
Member of local multidisciplinary falls prevention group
Competing interests: No competing interests
In this splendid article, there is no mention of the calcium
compounds which might be prescribed to give the (daily?) dose of 1200mg.
Could a supplement be published, giving this information? It is also
unfortunate that there has to be recourse to the internet to discover the
contents of the tables which do not appear in the printed version.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Congratulations for this excellent review (1). Although the measurement
bone densitometry is useful to assess the risk of future fractures, but
caution should be exercised. Bone densitometry measurement in spine in the
elderly may cause difficulty in interpretation due to presence of
degenerative changes and may show bone mass artifactually elevated.
Measurement of bone densitometry at hip has the highest predictive value
for hip fracture (2).
Dr J Hossain
Consultant Physician
Department of Elderly care
William Harvey Hospital
Ashford
Kent TN24 OLZ
References:
1.Woolf A D and Akesson K. Preventing fractures in elderly people. BMJ
2003; 327:
89-94
2. Kanis JA. Diagnosis of osteoporosis and assessment of fracture
risk. Lancet 2002;339:1929-35.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
It is a timely review for fracture prevention in the elderly (1). The
authors states malabsorption syndrome is a contributory factor for
osteoporosis. Coeliac disease has been overlooked . It is common,affects
upto 20% patients older than 60 years of age, can cause osteoporosis and
fracture. This condition as common 1 in 200 to 300 in Europe and North
America. It is important to note that in coeliac disease, diarrhoeal
symptoms may be absent in adult patients 2 in about 50% cases and iron
deficiency anaemia is the most common presentation and other laboratory
abnormalities may co-exist (2).
Dr S Hossain
House Surgeon
Department of Surgery
Princess Royal University Hospital
Orpington
Kent BR6 8ND
References:
1.Woolf A D and Akesson K. Preventing fractures in elderly people. BMJ
2003; 327: 89-95
2. Farrell R J and Kelly C P. Current concepts: Celiac Sprue. New England
Journal of Medicine 2002; 346(3): 180-88.
Competing interests:
None declared
Competing interests: No competing interests
Excellent article . However the simple , low cost, and immediately
effective HIP PROTECTORS are not emphasized enough. This device is
underused , mainly because it is
not known enough among patients and doctors as well.
And why - if efficient in nursing homes - should we doubt
its efficiency in the community ?
Hip protectors should be recommended and used for primary
as well for secondary prevention of hip fractures and knowledge of this
alternative should be disseminated.
Competing interests:
None declared
Competing interests: No competing interests
ECONOMIC APPROPRIATENESS OF THE EXPENDITURE FOR ALENDRONATE: COST-EFFECTIVENESS ANALYSIS OF NATIONAL PRESCRIPTION DATA IN ITALY
One important pharmacological
approach for preventing fractures in women with menopausal osteoporosis is the
chronic administration of an oral biphosphonate. Alendronate, given for 5 or
more years, is the most widely prescribed agent for this clinical indication.
The review of Woolf and Akesson (1) discusses the clinical effectiveness of this
agent, but does not address the issue of its cost-effectiveness. In this
contribution, we present an analysis where an innovative index for assessing
economic appropriateness (2,3) is determined for this treatment and is then
compared with those calculated previously for other drug classes. The main
advantage of this method lies in its extreme simplicity of application (2,3).
Briefly, this innovative
method of cost-effectiveness analysis (2,3) interprets the value of national
expenditure (EXPEND) for a given drug class (or for single pharmacological
agent; in this case alendronate) and, in particular, assigns an index to the
treatment(s) under examination wherein the health gain (EHG) theoretically
expected from EXPEND (according to current benchmarks of cost effectiveness) is
compared with the amount of health presumably gained in the “real” patients
(real health gain, or RHG, estimated using epidemiological data and
evidence-based information). Because saving one year of life (irrespective of
whether the year is unadjusted or adjusted for quality of life) is generally
valued around 10,000 Euros (or 10,000 US dollars), spending appropriately an
amount of money equal to EXPEND is expected to yield a survival gain (or EHG)
of at least EXPEND/10,000 years of life. On the other hand, the value of RHG is
calculated from the nation-wide number of patients receiving the treatment (Npatients)
multiplied by the average gain in quality-adjusted survival per patient (GAINQALYs).
GAINQALYs relies on the availability of an ad-hoc study that
has estimated the average gain in quality-adjusted survival for the patients
receiving the treatment examined. Comparing the EHG (e.g. 65,400 years of life
for the 2002 expenditure for statins in Italy) with the RHG (e.g. 107,114 years
of life for statins in Italy) yields the final index, which is favourable when
RHG>EHG and unfavourable when RHG
In the first semester of 2003, 62 million
Euros have been spent on alendronate (personal
communication by Bruzzone M and Puca E, Italian Ministry of Health, October
2003). To interpret this finding, our analysis
proceeds according to the steps outlined in Table 1.
The value of EHG is 6,212 years of
life. To determine RHG, the cost of alendronate treatment for a semester = is
assumed to be 525.6 Euros per patient because each daily dose costs, on
average, 1.44 Euros (data from the website of the Italian Ministry of Health).
If one accepts that the average treatment duration (4) is 5 years (i.e. 10
semesters) and that the first semester 2003 reflects a steady-state condition,
the new users of alendronate are one tenth of the total population receiving
these drugs in the first semester 2003 (N=236,371), hence, Nexposedpatients is changed to 23,637.
The aim of alendronate treatment is
to alleviate disease-related symptoms and to improve the patients’ quality of
life. According to the data presented by Johnell et al., starting a new
treatment with alendronate in 23,637 Italian patients produces a
quality-adjusted survival gain of 0.08 years per patient (with 3% annual
discount) or 0.093 years per patient (with no discounting). Hence, RHG = 0.08
years x 23,637 = 1,891 years of quality-adjusted survival gain (with 3% annual
discount) or RHG = 0.093 years x 23,637 = 2,198 years of quality-adjusted
survival gain (with no discounting).
Comparing the EHG of 6,212 years of
life with the RHG of either 1,891 years or 2,198 years shows that spending on alendronate
seems to be quite inappropriate for our national health system (at least at the
current price level for these agents). This amount of health of about 2,000
years of life (i.e. RHG) has in fact been bought at a three-fold price than the
average (as shown by the finding that RHG is one third of EHG). In our previous studies, this index was
favourable for statins (2) and highly unfavourable for coxibs (3).
Some questions on whether this
approach to evaluate economic expenditures is acceptable have already been
raised, and comments on the weaknesses of this method have been presented as
well (2,3). However, despite these limitations, our results show that
alendronate has probably been recognised an excessive price in Italy in
comparison with the clinical benefit is produces. Hence, its present
generalised reimbursement status in patients with postmenopausal osteoporosis
might need some form of revision.
REFERENCES
1. Woolf AD, Akesson K. Preventing fractures
in elderly people. BMJ 2003;12;327(7406):89-95.
2. Messori A, Santarlasci B,
Trippoli S, Vaiani M. Spending on statins. eBMJ
http://bmj.com/cgi/eletters/327/7420/933-b#38400, 20 Oct 2003
3. Messori A, Santarlasci B, Trippoli
S, Vaiani M. Economic appropriateness of the
expenditure for coxibs: cost-effectiveness analysis of national prescription
data in Italy. eBMJ
http://bmj.com/cgi/eletters/327/7420/933-b#39700, 5 Nov 2003
4. Johnell O, Jonsson B, Jonsson L, Black D. Cost effectiveness of
alendronate (Fosamax) for the treatment of osteoporosis and prevention of
fractures. Pharmacoeconomics 2003;21(5):305-14.
Table 1. Formulas
on which our method is based and their application to the alendronate
analysis.*
EXPECTED HEALTH GAIN
(EHG)
REAL HEALTH GAIN
(RHG)
-formulas:
EHG (years or QALYs) = EXPEND /10,000
Nexposed patients = EXPEND/ (COST1DDD
x DAYSexpend)
Nbeginners = Nexposedpatients /
(DAYStreatment / DAYSexpend)
RHG = N beginners x GAINQALYs
-alendronate analysis:
EHG = 62,118,205 /10,000 = 6,212 years or QALYs
According to Johnell et al. (4) (QALYs gain with discounting of
3%):
Nexposed patients= 62,118,205 / (1.44 x 182.5) =
236,371
Nbeginners = 236,371/
[(365 x 5) / (365 x 0.5)] =23,637
RHG = 23,637 x 0.08 = 1,891
QALYs
According to Johnell et al. (4) (QALYs gain with no
discounting):
Nexposed patients = see above
N beginners =
see above
RHG = 23,637 x 0.093 =
2,198 QALYs
*ABBREVIATIONS:
-
EXPEND = expenditure in Euros
observed over a time interval equal to DAYSexpend (in days)
-
Nexposedpatients
= overall number of patients exposed to the treatment over the time interval
of DAYSexpend
-
COST1DDD = cost in
Euros of a single DDD
-
Nbeginners = number of patients who begin
the treatment over the time interval of
DAYSexpend
-
DAYStreatment = duration of the treatment (in days); for example, 5
years of alendronate treatment give DAYStreatment = 1,825 days
Competing interests:
None declared
Competing interests: