Subsequent fracture in nursing home residents with a hip fracture: A competing risks approach

Hebrew SeniorLife, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.22). 09/2008; 56(10):1887-92. DOI: 10.1111/j.1532-5415.2008.01918.x
Source: PubMed

ABSTRACT To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death.
Dynamic cohort study.
Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts.
Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site.
Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture.
The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture.
Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Fractures are one of the most costly consequences of falls in elderly patients in nursing homes. To compare the cost-effectiveness of a 'multifactorial fracture prevention program' provided by a multidisciplinary team with 'no prevention' in newly admitted nursing home residents. We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses. Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of 21,353 per quality-adjusted life-year. The total costs for SHI/LCI would result in 1.7 million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses. Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.
    The European Journal of Health Economics 05/2014; 137(S 03). DOI:10.1007/s10198-014-0605-5 · 2.10 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The risk factors associated with fractures have been well-characterized in community dwelling populations, but have not been clearly defined in long-term care (LTC) settings. The objective of this review was to identify risk factors for fractures in LTC settings. We searched MEDLINE, the Cochrane Library, EMBASE and CINAHL up to June 2014, scanned reference lists of articles and consulted with experts in the field to identify relevant prospective cohort studies that evaluated risk factors associated with fracture incidence in LTC. We included studies that assessed the association between risk factors included in the WHO-Fracture Risk Assessment Tool (FRAX(R)) or other predictors relevant to LTC (psychotropic medications, cognitive impairment, mobility, and falls). All articles were screened and extracted by two authors. Available data on the association between a given risk factor and fracture incidence were pooled when possible. We used the GRADE criteria to provide a summary of evidence. The GRADE approach defines the quality of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest. We identified 13 prospective cohort studies which examined fracture incidence among LTC residents. Most predictors showed moderate increases in fracture risk, but the quality of the evidence was often low. Moderate quality evidence showed that prior fractures and falls may moderately increase the risk of fractures. Being a woman and cognitive impairment are probably associated with a small increase. The effect of mobility and psychotropic medication use is still uncertain primarily due to the various definitions used in the studies and difficulty summarising the results. In addition to criteria used in the FRAX assessment tool, such as a previous fracture and female gender, we found that falls and cognitive impairment are also associated with a small to moderate increases in the risk of fractures in LTC. Developing an assessment tool that includes risk factors that are specific to LTC may improve the identification of individuals who can benefit from fracture prevention programs in these settings.
    BMC Geriatrics 12/2014; 14(1):130. DOI:10.1186/1471-2318-14-130 · 2.00 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: CONTEXT: Following fracture there is increased risk of re-fracture and premature mortality. These outcomes, particularly premature mortality following re-fracture, have not previously been studied together to understand overall mortality risk. OBJECTIVES: This study examined the long-term cumulative incidence of subsequent fracture and total mortality with mortality calculated as a compound risk and separated according to initial and re-fracture. DESIGN: Community dwelling participants aged 60+ from Dubbo Osteoporosis Epidemiology Study with incident fractures, followed prospectively for further fractures and deaths from 1989-2010. OUTCOME MEASURES: Subsequent fracture and mortality ascertained using cumulative incidence competing risk models allowing 4 possible outcomes: death without re-fracture, death following re-fracture, re-fracture but alive and event-free. RESULTS: There were 952 women and 343 men with incident fracture. Within five years following initial fracture, 24% women and 20% men re-fractured; and 26% women and 37% men died without re-fracture. Of those who re-fractured, a further 50% of women and 75% of men died, so total five-year mortality was 39% in women and 51% in men. Excess mortality was 24% in women and 27% in men. While mortality following re-fracture occurred predominantly in the first five years post initial fracture, total mortality (post initial and re-fracture) was elevated for 10 years. Most of the 5-10 year excess mortality was associated with re-fracture. The long term (>10 yr) re-fracture rate was reduced, particularly in the elderly due to their high mortality rate. The 30% alive beyond 10 years post fracture were at low risk of further adverse outcomes. CONCLUSION: Re-fractures contribute substantially to overall mortality associated with fracture. The majority of the mortality and re-fractures occurred in the first 5 years following the initial fracture. However, excess mortality was observed for up to 10 years post fracture, predominantly related to that following re-fracture.
    Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 04/2013; DOI:10.1002/jbmr.1968 · 6.59 Impact Factor


1 Download
Available from