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Summary: A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture. Purpose/introduction: To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice. Methods: The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses. Results: One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7–63.5) H-FLS patients relative to 20.9% (95% CI: 13.3–28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%). Conclusion: A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings. [ABSTRACT FROM AUTHOR]

Summary: A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture. Purpose: To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance). Methods: Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital. Results: Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance). Conclusions: An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females. [ABSTRACT FROM AUTHOR]

Summary: Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor.Introduction: To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture.Methods: Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients.Results: By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not.Conclusion: While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income.Trial registration: ClinicalTrials.gov: NCT01401556 [ABSTRACT FROM AUTHOR]

Summary The extent of Canadian provincial variation in hip fracture surgical timing is unclear. Provinces performed a similar proportion of surgeries within three inpatient days after adjustment. Time to surgery varied by timing of admission across provinces. This may reflect different approaches to providing access to hip fracture surgery. Introduction The aim of this study was to compare whether time to surgery after hip fracture varies across Canadian provinces for surgically fit patients and their subgroups defined by timing of admission. Methods We retrieved hospitalization records for 140,235 patients 65 years and older, treated surgically for hip fracture between 2004 and 2012 in Canada (excluding Quebec). We studied the proportion of surgeries on admission day and within 3 inpatient days, and times required for 33%, 66%, and 90% of surgeries across provinces and by subgroups defined by timing of admission. Differences were adjusted for patient, injury, and care characteristics. Results Overall, provinces performed similar proportions of surgeries within the recommended three inpatient days, with all provinces requiring one additional day to perform the recommended 90% of surgeries. Prince Edward Island performed 7.0% more surgeries on admission day than Ontario irrespective of timing of admission (difference = 7.0; 95% CI 4.0, 9.9). The proportion of surgeries on admission day was 6.3% lower in Manitoba (difference = − 6.3; 95% CI − 12.1, − 0.6), and 7.7% lower in Saskatchewan (difference = − 7.7; 95% CI − 12.7, − 2.8) compared to Ontario. These differences persisted for late weekday and weekend admissions. The time required for 33%, 66%, and 90% of surgeries ranged from 1 to 2, 2–3, and 3–4 days, respectively, across provinces by timing of admission. Conclusions Provinces performed similarly with respect to recommended time for hip fracture surgery. The proportion of surgeries on admission day, and time required to complete 33% and 66% of surgeries, varied across provinces and by timing of admission. This may reflect different provincial approaches to providing access to hip fracture surgery. [ABSTRACT FROM AUTHOR]

Introduction: To explore physiotherapists' perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. Methods: A qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at 7 hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. Results: Four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum; and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting 'postoperative physiotherapy' as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. Conclusion: Physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care while allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written, and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles. [ABSTRACT FROM AUTHOR]

The original version of this article, published on 22 July 2020, unfortunately contained a mistake. [ABSTRACT FROM AUTHOR]

Introduction: The incidence of total knee arthroplasty (TKA) performed in Canada is steadily increasing; however, 9% to 19% of all TKA patients experience little or no improvement in physical function and pain relief postoperatively. A lack of consensus exists about the factors associated with these poor outcomes. Determining baseline characteristics and demographics associated with increased pain and negated postoperative functional status could assist in identifying patients who are less likely to benefit from this operation. If these factors are modifiable, they could be addressed before TKA to improve postoperative outcome; if not, patients could be given realistic postoperative expectations. Objective: To identify modifiable and non-modifiable baseline patient demographics associated with poor pain and physical function scores on the Western Ontario McMaster Osteoarthritis Index (WOMAC) at 3 to 5 years following TKA. Methods: This was a secondary analysis of prospectively collected data from the Alberta Arthroplasty Study, a large randomized clinical trial. We performed initial descriptive analyses and compared baseline scores between responders and non-responders as well as univariate linear regression for the following independent variables: age, gender, group allocation, body mass index (BMI), categorical comorbidities (≤ 2 or ≥ 3 conditions), presence of back pain, diabetes status, presence of lung disease, smoking status, baseline Medical Outcomes Study 36-item Short Form (SF-36) mental health (MH) scores, baseline WOMAC physical function scores and baseline WOMAC pain scores. This initial model building step was performed twice: once with WOMAC pain scores and once with WOMAC function scores as the dependent variable. A multivariate regression was then developed using purposeful selection techniques. Final stability of the model was assessed using forward and backward stepwise regression methods to determine agreement among significant variables; variance inflation factors were calculated to test for collinearity. Results: A total of 388 patients consented to further evaluation 3 to 5 years after TKA. We observed significant improvements in both WOMAC pain and function scores. In the multivariate analyses, older age, presence of back pain, and overweight or obesity were indicators of both worse pain levels and inferior functional status. Better preoperative WOMAC pain and SF-36 MH scores were associated with improved postoperative pain levels. Higher WOMAC function and SF-36 MH scores at baseline were predictive of better functional outcomes post-TKA. Coefficients of determination (R[sup 2]) were 0.15 for the pain model and 0.19 for the function model. Conclusion: Older age is associated with poorer pain outcomes several years post-TKA; however, older individuals experienced changes in pain similar to that of younger patients. Thus, older age should not be a limiting factor when considering candidates for TKA. Increased BMI was also a significant predictor of long-term pain and function scores. Interventions to manage BMI and back pain should be considered preoperatively to maximize TKA outcomes. Based on the identified risk factors, patient expectations may be revised regarding outcomes. Low R[sup 2] values indicate limited ability of the model to predict patient outcomes 3 to 5 years following surgery. Future research may consider including more psychosocial variables in medically based models when assessing TKA outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Loss of locking plate fixation has been reported in proximal humeral fractures, particularly in older patients with poor bone density. In such fractures, the medial support between the humeral head and shaft is occasionally missing, resulting in varus collapse of the construct. A biomechanical study was performed to understand the behaviour of the interface of these fractures fixed with a locking plate fixation with and without augmentation. The augmentation consisted of an intramedullary fibular allograft (bone peg) that has been reported for use in these fractures. METHODS: Six embalmed pairs of specimens were utilized; each pair of specimens had one humerus repaired with the locking plate fixation, and the other humerus repaired with the plate fixation and bone peg. The constructs were tested in bending to determine the relative movement between the humeral head and the shaft under bending loads, and the failure loads of both constructs. Digital Imaging Correlation was used to determine the relative movement. FINDINGS: The bone peg increased the failure load of the constructs by 1.72 (SD 0.54) times (P=0.02). The relative movement was measured by comparing the initial stiffness of both constructs. Initial stiffness of the construct was increased 3.84 (SD 1.92) times (P=0.005) with the use of the bone peg. INTERPRETATION: The intramedullary bone peg significantly decreases the relative movement at the interface. Further studies are needed to accurately determine the effect this reduction has on the healing process, and overall clinical result. [ABSTRACT FROM AUTHOR]

Introduction: Delays to surgery after hip fracture have been associated with mortality Uncertainty remains as to what timing benchmark should be utilized as a marker of quality of care and how other patient factors might also influence the impact of time to surgery on mortality. The goal of this study was to determine how time to surgery affects 30- and 90-day mortality by age and to explore the impact of preoperative comorbid burden and sex., Participants: We used population-based administrative data from a Canadian province collected from 01April2008 to 31March2015. Of 12,713 Albertans 50-years and older who experienced a hip fracture and underwent surgery within 100 h of admission, 11,996 (94.8%) provided data., Methods: Time to surgery was analyzed in hours from admission to surgery. Age and the interaction between age and time to surgery were evaluated using logistic regression. Charlson co-morbidity score and sex were also considered in the analysis. Survival was evaluated at 30-and 90-days post hip fracture using a provincial registry., Results: The average age of the cohort was 79.6 ± 11.2 years and 8,412 (70.1%) were female. Overall, 586 (4.9%) patients died within 30-days and 1,023 (8.5%) died within 90-days of hip fracture. Mortality increased significantly with increasing time to surgery (30-day mortality odds ratio [OR] = 1.03; 95%CI 1.01-1.05: 90-day mortality OR = 1.03; 95% CI 1.01-1.04). Mortality also increased substantially with increasing age; those ≥85 years were 19.63 (95% CI 6.83-67.33) and 15.66 (95%CI 7.20-37.16) times the odds more likely to die relative to those between 50-64 years of age at 30-days and 90-days postoperatively respectively. Further, those who were ≥85 years were more significantly affected by increasing time to surgery than those who were 50-64 years of age at both 30-days (p = 0.04) and 90-days (p = 0.025) post-fracture. Males and those with a higher comorbid burden also had higher odds of dying after controlling for time to surgery (p < 0.001) CONCLUSION: Time to surgery following hip fracture may have a differential effect on 30- and 90-day survival dependent on age. Older patients appear to be at higher risk of dying with surgical delays than younger patients., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Total hip replacement (THR) and total knee replacement (TKR) (arthroplasty) surgery for end-stage osteoarthritis (OA) are ideal candidates for optimization through an algorithmic care pathway. Using a comparative effectiveness study design, we compared the effectiveness of a new clinical pathway (NCP) featuring central intake clinics, dedicated inpatient resources, care guidelines and efficiency benchmarks vs. the standard of care (SOC) for THR or TKR., Methods: We compared patients undergoing primary THR and TKR who received surgery in NCP vs. SOC in a randomised controlled trial within the trial timeframe. 1,570 patients (1,066 SOC and 504 NCP patients) that underwent surgery within the study timeframe from urban and rural practice settings were included. The primary endpoint was improvement in Western Ontario and McMaster University osteoarthritis index (WOMAC) overall score over 12 months post-surgery. Secondary endpoints were improvements in the physical function (PF) and bodily pain (BP) domains of the Short Form 36 (SF-36)., Results: NCP patients had significantly greater improvements from baseline WOMAC scores compared to SOC patients after adjusting for covariates (treatment effect=2.56; 95% confidence interval (CI) [1.10-4.01]). SF-36 BP scores were significantly improved for both hip and knee patients in the NCP (treatment effect=3.01, 95% CI [0.70-5.32]), but SF-36 PF scores were not. Effects of the NCP were more pronounced in knee patients., Conclusion: While effect sizes were small compared with major effects of the surgery itself, an evidence-informed clinical pathway can improve health related quality of life (HRQoL) of hip and knee arthroplasty patients with degenerative joint disorder in routine clinical practice for up to 12 months post-operatively. CLINICALTRIALS.GOV IDENTIFIER: NCT00277186., (Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)