Compliance with a pharmacological secondaryfracture prevention policy

Marilyn Norman, Martyn J. Parker *

Injury, Int. J. Care Injured (2006) 37, 718—720

www.elsevier.com/locate/injury

Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK

Accepted 3 January 2006

KEYWORDSFracture prevention;Hip fracture;Osteoporosis;Compliance

Summary The aim of this study was to monitor the compliance of a specific group ofpatients to the initiation of pharmacological fracture prevention therapies, inparticular calcium and Vitamin D3 supplements. We used a cohort of 276 patientsadmitted to one hospital with an acute hip fracture. Therapy was started in hospitaland compliance checked at out patient follow-up. Written and verbal advice wasgiven to support therapy. The mean age was 80.8 years and 82% were female. Onehundred and ninety-nine patients were alive at one year from injury. For thesepatients 22 (11.1%) were on therapy prior to fracturing their hip. Of the remainder,111/177 (62.7%) stated they were taking therapy to reduce the risk of fractures. Theseresults demonstrate that an aggressive policy of prescribing can result in good levelsof compliance with therapy.# 2006 Elsevier Ltd. All rights reserved.

Introduction

A hip or proximal femoral fracture is the commonestreason for an elderly person to be admitted to anacute orthopaedic ward. Following a hip fracturethere is a reduction inmobility and activities of dailyliving by 20—35% and for those admitted from theirown homes about 14% will be unable to continueliving at home.7 A survey of the attitudes of olderwomen found that 80% would rather be dead thanexperience the loss of independence and quality oflife that may occur after a hip fracture.8

* Corresponding author. Tel.: +44 1733 874000;fax: +44 1733 875013.

E-mail addresses: Martyn.Parker@pbh-tr.nhs.uk,mjparker@doctors.org.uk (M.J. Parker).

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.01.003

Calcium and Vitamin D supplementation has beenadvocated as a measure to reduce the risk of furtherfractures after a hip fracture.9 Compliance withsuch therapy has not been reported. We have stu-died the effectiveness of an aggressive prescribingpolicy for calcium and Vitamin D supplementationafter a hip fracture to assess compliance and reasonsfor failure to follow recommended therapy.

Patients and methods

Between November 2002 and September 2003, 290patients were admitted to one district general hos-pital with an acute hip fracture. All the patientswere admitted to one ward specialising in hip frac-

rved.

Compliance with a pharmacological secondary fracture prevention policy 719

Figure 1 Flow diagram of participants.

Table 1 Numbers taking calcium and Vitamin D at oneyear and reasons for not taking therapy

Six weeksfollow-up

One yearfollow-up

Taking calcium and Vitamin D 111 103Taking bisphosphonate 4 8Therapy contraindicated 4 5

ture treatment, with information on all patientscollected prospectively as part of an ongoing auditand researchproject onhip fractures. Fromthese 290patients, 11wereexcludeddue to their agebeing lessthan 60 years and a further three were excludedbecause the fracture was pathological from dissemi-nated malignant tumour. A further 19 patients whodied without being discharged from hospital werealso excluded from the study. Whilst in hospital allpatients were given verbal advice regarding drugs toreduce the risk of further fractures and received aninformation booklet on hip fractures, this includedadditional advice on pharmacological methods toreduce the risk of hip fracture.

The policy of the unit was that all hip fracturepatients should be discharged home having beenprescribed calcium and Vitamin D supplements. Sixweeks after discharge, surviving patients werereviewed in a hip fracture clinic and those who didnot attend were contacted by phone to check con-tinued compliance. This attendance at clinic alwaysincluded further discussion on preventive therapy.Additional written information could also be given atthis visit. If the patient gave their consent the Gen-eral Practitioner was asked to continue the supply ofcalcium and Vitamin D and this was mentioned in theclinic letter to the General Practitioner.

One-year following the date of the hip fracture,compliance was assessed for all surviving patients byeither assessment in the hip fracture clinic or afollow-up phone call to the patient or their carers.

Gastric side effects 4 5Other side effects 2 2Refused to take 2 4Not given at hospital discharge 18 —Not renewed after discharge 25 35Lost to follow-up or unsure 7 15

Total 177 177

Results

One hundred and ninety-nine patients survived toone year from injury. One hundred and sixty-four(82.4%) were female. The average age was 80.8years. One hundred and fifty-six patients lived intheir own homes, 28 were in residential homes, 7 innursing homes and 8 patients were a hospital in-patient at the time the fracture was sustained. Onehundred and ninety-seven of the fractures weretreated operatively and two conservatively. At thetime of admission with the hip fracture 22 patients(11.1%) were already taking a bone strengtheningdrug. These medications were calcium and VitaminD (9 patients), bisphosphonate (10 patients) or hor-mone replacement therapy (3 patients). Havingdiscounted the above patients this left 177 to moni-tor their compliance over the year (Fig. 1).

Table 1 gives the number of patients taking ther-apy at the first clinic follow-up visit and at one-yearfrom injury. For the patients in whom therapy wascontraindicated at one year, two had carcinoma,two hypercalcaemia and one renal stones. Thirty-

five patients at one year had not been prescribedany therapy after discharge and a further 11declined to take therapy due to side effects. Intotal 111 out of 177 (62.7%) patients were takingtherapy to reduce the risk of further fractures.

Discussion

Calcium and Vitamin D supplement can help reducefractures in the elderly and are recommended forthose who have sustained a hip fracture.9 In arandomised trial of 3270 elderly residents of nursingand apartments homes for the elderly, Chapuy et al.reported a relative risk reduction of 43% for hipfractures and 32% for all non-vertebral fractures,

720 M. Norman, M.J. Parker

for those allocated to receive calciumandVitaminD.1

A later study of 389 participants reported a 60%reduction in all fractures after using 500 mg calciumand 700 mg of Vitamin D over a three year follow-up.2

Many elderly people have a diet which does notcontain the daily recommended daily allowance ofcalcium.11,6 More recently however the multi-centreRECORD trial has questioned the effectiveness ofcalciumandVitaminDafter a fracture in theelderly.10

Vitamin D is commonly deficient in the elderly andespecially if patients are housebound.5 As ageadvances cutaneous production of Vitamin Ddecreases along with metabolism of Vitamin D,thereby leading to a decrease in calcium absorption.Elderly patients are less likely to enjoy a diet rich inVitamin D of which only around 10—20% is actuallyabsorbed from the diet.3 Bisphosphonates are analternative therapy, but at present the evidencefor the effectiveness of these drugs in those agedover 80 years is limited.9

For patients in our study most of the patientstaking therapy were still taking therapy at one yearfrom injury. The majority were taking calcium andVitamin D, with only a small number taking bispho-sphonates. Initially at the first follow-up point, 18had not been prescribed the supplements. This maybe due to a failure at the time of discharge or incommunication if the patient was transferred toanother ward that was not aware of the prescribingpolicy. For these patients and those who requested,extra written information was provided and verbaladvice and a further letter sent to the patients’General Practitioner requesting them to continueprescribing the supplements.

Overall we felt compliance was better than wehad expected, as many of these patients were on anumber other medications. We feel that it was acombination of our aggressive prescribing policyand possible the free provision of medications forthese patients, that resulted in better compliancethan that reported in an earlier study.4 We acceptthat our information was entirely based on thepatient or their carer giving us accurate informa-

tion on their compliance and that it is inevitable afew patients may have provided incorrect informa-tion. Despite these limitations we feel that ourstudy demonstrates that an aggressive prescribingpolicy for fracture prevention therapy may beeffective.

References

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