Sang-Rim Kim, Kwang Woo Nam, Yong-Geun Park, Sung-Rak Lee*, In Im**, Yong-Chan Ha*** Department of Orthopaedic Surgery, College of Medicine, Jeju National University, Department of Orthopaedic Surgery, Halla General Hospital, Jeju *, Department of Orthopaedic Surgery, Hankook General Hospital, Jeju **, Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University *** Orthopaedic surgeon’s awareness can improve osteoporosis treatment following hip fracture. A prospective cohort study

Treatment Rate of Osteoporosis after Hip Fracture 6% Gardner MJ et al in 2002 (JBJS-A) 19.9% Judy AG et al in 2002 (Oteoporosis Int) 8.6% Ha et al in 2002 ( J Korean Orthop Assoc) Detection and management of osteoporosis in Jeju (2005) Introduction

Results of Retrospective Cohort Study in 2005 Hip fracture patients over 50 years : 174 patients Detection of osteoporosis : 35 patients (20%) Management of osteoporosis: 27 patients (15.5%) Prescription drug : Bisphosphonate 25 patients (92.5%) HRT 1 patients, SERM 1 patients Introduction

Results of Retrospective Cohort Study in 2005 Introduction 설문조사 (17 명 ) Detection of osteoporosis : 15 명 (88.2%) Management of osteoporosis: 17 명 (100%) 처방약제 Bisphosphonate 17 명 (100%) 실제관리율 Detection of osteoporosis : 35 명 (20%) Management of osteoporosis: 27 명 (15.5%) 처방약제 Bisphosphonate 25 명 (92.5%) HRT-1 명. SERM-1 명 ≠ ≠≠ ≠

The Purpose of Study To determine whether a orthopaedic surgeon education program would increase the percentage of patients receiving treatment for osteoporosis following a hip fracture To know barriers against management of osteoporosis in patients with a hip fracture

Prospective Intervention Study Materials & Methods Duration : 1st Jan, st Dec, 2007 Material : Patients over 50 years of age who lived in Jeju island and sustained a femoral neck or intertrochateric fracture Method : Reviewed hospital record. –The admitting diagnosis, mechanism of injury, detection of osteoporosis, procedures performed during hospitalization, and discharge medications –2007 population data in Jeju-Do by national statistical office

Prospective Intervention Study Materials & Methods Detection of osteoporosis : dual energy X-ray absorptiomety (DXA) Treatment : selective estrogen receptor modulator, or hormone replacement therapy, or bisphosphonate, or calcitonin therapy Follow-up: average 1 year – repeated review of the medical records at 6 months and one year after discharge

Statistical power & sample size justification 15.5 % of initiation of osteoporosis treatment in the 2005 data Significance level of 5% 80% statistical power Estimated sample size according to treatment rate after intervention Materials & Methods Expected treatment rate after intervension Size of difference Sample size 20.5%5% %10% %15% %20% %25%31  minimum 180 patients  “ 208 patients in our study ” (drop-out rate of 20%)

22 orthopedic surgeons who worked at 8 hospitals Orthopaedic surgeon education : Two times Campaign poster or Brochure for the mouse pad Intervention Materials & Methods

Patient Follow-up Materials & Methods Patients were interviewed by telephone or direct contact to evaluate their compliance to the osteoporosis treatment at six months after discharge and were followed-up for a minimum of one year

Results Patient No. : 208 cases Mean age : 79.1 years(range, years) Gender : Man - 34 cases, Woman cases Mean hospital follow-up : 8.8 months(range, 1-24 months) Neck fracture : 107 cases(51%) Intertrochanter Fx : 101cases(49%)

Coexisting medical diseasePatients Hypertension and heart problem 84(40.4%) Diabetes 35(16.8%) Depression & dementia 32(15.4%) Previous stroke 27(13%) Pneumonia & COPD 18(8.7%) Cancer 6(2.9%) Others 18(8.7%) Result

DXA Prior to hip fracture7(3.4%) After hip fracture94(45.2%) Osteoporosis(-2.5≥ T-score)93(44.7%) Osteopenia(-1> T-score>2.5)1(0.5%) Bisphosphonate medication Prior to hip fracture2(1%) After hip fracture67(32.2%) Duration of bisphosphonate medication < 6 months25(12%) ≥ 6 months42(20.2%) Mean period of medication (months)9.5(range, 1-24) Result

Before intervention (2005 data) After intervention (2007 data) Detection of osteoporosis (DXA) 20%(35/174)45.2%(94/208) Initiation of osteoporosis management 15.5%(27/174)32.2%(67/208) Comparison data before and after intervention demonstrate that detection and initiation of medication osteoporosis are increased more than two fold. Result

Mortality < 22 patients(10,6%) within 6months 30 patients(14.4%) at 12 months 38 patients at the final follow-up Result Osteoporosis medication group (7/67) Non-osteoporosis medication group Non-osteoporosis medication group (31/141)

Interview Participation in interview : 137 patients - Passed away : 38 patients - live alone the old with dementia or deafness : 8 patients - to moved and changed telephone : 25 patients Result

Question Response No(%) of patient with medication (56) No(%) of patient without medication (81) No(%) of questionnaire (137) Have you heard osteoporosis from your doctor? Yes 26(46.4)29(35.8)55(40.1) No 30(53.6)52(64.2)82(59.9) Did you examine bone mineral density at the hospital? Yes 25(44.6)24(29.6)49(60.5) No 27(48.2)50(61.7)77(56.2) Have you received anti- osteoporosis drug? Yes 40(71.4)040(29.2) No 16(28.6)73(90.1)89(65) Why don’t you start osteoporosis treatment? Don’t feel necessity to treat osteoporosis 047(58)47(34.3) Economic reason 04(4.9)4(2.9) Transport problem 04(4.9)4(2.9) Medical insurance problem 01(1.2)1(0.7) Others 014(17.3)14(10.2) Result

Discussions Intervention methods to improve osteoporosis System of the country Harrington JT et al in 2002 Arhritis Rheum Patient`s education Gardner MJ et al in 2005 JBJS-A Doctor`s awareness Gardner MJ et al in 2002 JBJS-A

Intervention for clinicians to increase treatment rates Orthopaedic surgeon ─role the first health-care providers to evaluate patients with fractures ─their improved awareness for identifying patients with osteoporosis has shown to benefit from intervention Intervention for improving osteoporosis management following hip fracture : Orthopaedic surgeon > Physician - Miki RA et al in 2008 JBJS Discussion

Barrier to initiate osteoporosis treatment ─ patients, physician, orthopaedic surgeon and medical care system - Bogoch ER et al in 2006 JBJS ─ ten kinds of barrier - Kaufman JD et al in 2003 JBJS  they insisted importance of the orthopaedic surgeon’s role to overcome of the barriers. Most common barrier according to questionaire : Patients did not feel to necessity of osteoporosis medication Discussion

Consideration for the limitation 1.Orthopaedic surgeon association society and public mess media are also enlightening the importance of osteoporosis medication following fragility fracture 2.Medical care system is quite different developed country 3.This study is performed various leveled hospital in same cohort patients could not contact with directly and indirectly method.. 5.Interventional education program was not validated Discussion

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