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

Purpose 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 five 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 13,069 patients (76% female) diagnosed with a hip fracture during 1999-2013 were identified. 11% had any anti-osteoporosis drug prescription in the six 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 to then decrease 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 3,214 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. </p

Models of care for the delivery of secondary fracture prevention after hip fracture:a health service cost, clinical outcomes and cost-effectiveness study within a region of England.

Background Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals. Objectives To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes. Design A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care. Setting Eleven acute hospitals in a region of England. Participants Qualitative study – 43 health professionals working in fracture prevention services in secondary care. Interventions Changes made to secondary fracture prevention services at each hospital between 2003 and 2012. Main outcome measures The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture. Data sources Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13, n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013, n = 11,243). Results Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician. Conclusion In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered. Future work Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients. Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford

Living in chronic times [Curator]

‘Living In Chronic Times’ responds to “a contemporary ‘war’ on death”. Through a comprehensive investigation with an interdisciplinary survey of arts and health practitioners, Lippett aims to question the cause and affect of a chronically ‘death anxious’ population. She will highlight the paradoxical relationship between false understandings of mortality as a ‘curable’ human condition, particularly at a time of acute funding cuts to the NHS resulting in longer waiting times, dehumanised ‘care’ and an uncanny ‘acceptance’ of unethical or undignified endings. A multilayered project, ‘Living In Chronic Times’ will investigate such false understandings in relation to the recent phenomena of digital legacy and death services that Lippett suggests manipulate contemporary death anxiety in order to profit from our growing web-based labour before, and after, we die. Thursday 7th July / Deptford Cinema, London Screening (1) Oreet Ashery, ’Revisiting Genesis’ (x12 episodes) with supporting film by Duncan Loudon Curator led Panel Discussion. Panel: Oreet Ashery (Artist and Director) Martin O’Brien (Bambi) Vanda Playford (Nurse Jackie) Duncan Loudan (Artist) Tuesday 12th July / Chisenhale Studios, London Workshop 1 : Chronic Time / Ethics Of Care 3 talks and curator led panel discussion Sarah Lippett, ‘Time, Storytelling, Illness and Death’ Martin O’Brien, ’Performing The Chronic Body’ Lisa Baraitser and Laura Salisbury, ‘Waiting Times: Waiting and Care in the Time of Modernity’ Wednesday 13th July / Chisenhale Studios Workshop 2 : Digital Ethics Exhibition: Sarah Derat, ‘Birth Of Anaesthesia’, Video Installation, 2012 Evening: Talk between curator and artist Sarah Derat Thursday 14th July / Chisenhale Studios Workshop 3 : (Anti) Ageing Reading Group: Lynne Segal: ‘Out Of Time : The Pleasures and Perils of Ageing’ Deptford Cinema, London Screening (2) In collaboration with the Richard Saltoun Gallery, London Friedl Kubelka, ‘Me too, too, me too’ and Other Stories (45 mins) and curatorial talk Friday 15th July Workshop 4 : Dawn of The (Digital) Dead ’Digital Legacy Writing Workshop’ led by Samantha Lippett Rachel McRae, ‘Level 350’, Performance and Q&A Saturday 16th July Workshop 5 : Endings / Breaking The Taboo Reading group with texts by: Marion Coutts, ‘The Iceberg : A Memoir’ Atul Gawande, ‘Being Mortal : Medicine and What Matters In The End’ Emma Berentsen, ‘The Last Supper’, Performative Dinner Thomas Cameron, ’At 6 with 7’, Sound Performance and Drinks Ceremon

Digital&Dead at South London Gallery [Curator]

The event considered recent psychosocial shifts in our relationship with death following the growth of digital communication and social media. Inspired by the recent development of memorial websites and the ‘Facebook graveyard’, participants are invited to consider their own digital legacies through a demonstration of Rachel McRae's and Sarah Derat's Augmented Reality work Digital&Dead (2017), as well as a part-screening of the award winning Revisiting Genesis (2016) by artist Oreet Ashery. Has the algorithm made us eternal, or undead and what is the appropriate way to memorialise the deceased, post-body, in an age after the Internet

Impact of an intervention to control Clostridium difficile infection on hospital- and community-onset disease; an interrupted time series analysis

Strategies to reduce rates of Clostridium difficile infection (CDI) generally recommend isolation or cohorting of active cases and the reduced use of cephalosporin and quinolone antibiotics. Data supporting these recommendations come predominantly from the setting of epidemic disease caused by ribotype 027 strains. We introduced an initiative involving a restrictive antibiotic policy and a CDI-cohort ward at an acute, 820-bed teaching hospital where ribotype 027 strains account for only one quarter of all CDI cases. Antibiotic use and monthly CDI cases in the 12 months before and the 15 months after the initiative were compared using an interrupted time series analysis and segmented regression analysis. The initiative resulted in a reduced level of cephalosporin and quinolone use (22.0% and 38.7%, respectively, both p <0.001) and changes in the trends of antibiotic use such that cephalosporin use decreased by an additional 62.1 defined daily doses (DDD) per month (p <0.001) and antipseudomonal penicillin use increased by 20.7 DDD per month (p = 0.011). There were no significant changes in doxycycline or carbapenem use. Although the number of CDI cases each month was falling before the intervention, there was a significant increase in the rate of reduction after the intervention from 3% to 8% per month (0.92, 95% CI 0.86-0.99, p = 0.03). During the study period, there was no change in the proportion of cases having their onset in the community, nor in the proportion of ribotype 027 cases. CDI cohorting and restriction of cephalosporin and quinolone use are effective in reducing CDI cases in a setting where ribotype 027 is endemi

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Objective: Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013