Le fratture di femore Il punto di vista del Bone Specialist (Fracture Liaison Services)

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Le fratture di femore

Il punto di vista del Bone Specialist (Fracture Liaison Services)

Sara Cassibba

U.O. Endocrinologia

ASST-Papa Giovanni XXIII - Bergamo

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Le fratture di femore - Il punto di vista del Bone Specialist (FLS)

OSTEOPOROSI

SILENTE

FRATTURA

DOLORE DEFORMITA’

INVALIDITA’

CENTRALITA’

DELL’EVENTO FRATTURATIVO

Clinical Consequences

Kyphosis

Loss of height Bulging abdomen

Acute and chronic pain

Breathing difficulties, reflux and other GI symptoms

Depression

REDUCED QUALITY OF LIFE

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Ø TRA LE FRATTURE DA FRAGILITA’ E’

QUELLA A MAGGIORE IMPATTO IMMEDIATO PER:

• MORTALITA’ E MORBILITA’

• QOL

• BURDEN ECONOMICO

FRATTURA DI FEMORE

Le fratture di femore - Il punto di vista del Bone Specialist (FLS

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Ø MORTALITA’:

o 5% NEL PERIOPERATORIO o 20% AD UN ANNO

Ø PERDITA DI AUTONOMIA:

o NELLA DEAMBULAZIONE 20%

o NELLE ATTIVITA’ QUOTIDIANE 40%

Ø ISTITUZIONALIZZAZIONE NEL 20% DEI CASI

FRATTURA DI FEMORE: MORTALITA’ E MORBILITA’

- Ministero della Salute. Gruppo di Lavoro: Brandi ML et al. Quaderni della Salute. Appropriatezza diagnostica e terapeutica nella prevenzione delle

fratture da fragilità da osteoporosi - 2010.

- Reumatismo (2016); 68(1):1-42 Le fratture di femore - Il punto di vista del Bone Specialist (FLS)

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Ø DISABILITA’/LIMITAZIONI FUNZIONALI à RIDUZIONE DI MOBILITA’

Ø CONSAPEVOLEZZA DELLA FRAGILITA’

à AUTOLIMITAZIONE IN ATTIVITA’ PERCEPITE COME PERICOLOSE

COMPROMISSIONE DI AUTONOMIA E SOCIALITA’

FRATTURA DI FEMORE: QOL

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Ø SPESA SANITARIA

§ COSTI DIRETTI:

ü RICOVERO E INTERVENTO

§ COSTI INDIRETTI:

ü RIABILITAZIONE

à DI DIFFICILE QUANTIFICAZIONE à ETEROGENEITA’ DEI SERVIZI

FRATTURA DI FEMORE: BURDEN ECONOMICO

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Ø PERDITA DI GIORNI DI LAVORO

o PAZIENTE IN ETA’LAVORATIVA

à 20% DEI PAZIENTI CON FRATTURA DI FEMORE DA FRAGILITA’

o CAREGIVER

FRATTURA DI FEMORE: BURDEN ECONOMICO

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FRATTURA DI FEMORE: RISCHIO IMMINENTE DI II FRATTURA

Ø Dopo la I frattura la probabilità di II frattura femorale aumenta di 7-5 vv rispetto a soggetti non fratturati di pari eta’

Ø E’ massima nel primo anno

Ø Declina ma rimane elevata (doppia) anche a sei anni dalla frattura indice

men (Table 3), except in the age group of 50e59 years. Women and men both demonstrated the same trend of increasing incidence of a second hip fracture as they aged, which plateaued at age 70e79 years and then declined.

The 1- and 5-year mortality rate was 14.1% and 42% after the first hip fracture, respectively, and 18.8% and 60.6% after the second hip fracture, respectively (Fig. 3). Women and men both showed a significantly higher mortality rate after a second hip fracture compared to the first hip fracture 1 year after the indexed fracture (p < 0.05). When comparing differences in sex, men had a higher 5- year mortality rate than women following the first or second hip fracture (p < 0.01).

Discussion

Hip fracture is a major public health issue in the elderly. Taiwan, a nation of a 23 million population with majority of ethnic Chinese people, was found to have higher incidence of hip fracture than other ethnic Chinese populations, similar to that of Western countries.^21,22 Kanis et al reported that Taiwan was among countries with highest incidence of hip fracture, second to Scandinavian countries but higher than the UK, Germany, Hong Kong, and Singapore.⁸ In light of this, the present study sheds light on the epidemiologic data and mortality of second hip fracture in order to provide information for healthcare providers and policymakers in Taiwan and other countries with similar demographic structure and hip fracture incidence. In countries where population aging is just an emerging issue but is expected to accelerate rapidly in the coming decades, like China, Brazil, and southeastern Asia, our data may underestimate the incidence and mortality of second hip fractures.^23,24

Incidence

The current study is a nationwide population-based investigation. Most of the previous studies addressing second hip fractures involved only a small number of patients thus, limiting the power of their results.^25,17,10 In a study from Denmark, Ryg et al reported a cumulative incidence of a second hip fracture between 1977 and 2001 of 9% within 1 year and 20% within 5 years.¹⁵ However, the incidence of a second hip fracture might be overestimated if death after the ﬁrst hip fracture was not taken into account.²⁶ In a Nor- wegian study, Omsland et al estimated the cumulative incidence of a second hip fracture to be 15% for women and 11% for men within 10 years of the ﬁrst hip fracture, which was higher than Taiwanese population in the current study.¹³

The lower 1- and 5-year cumulative incidence in the present study may be caused by several reasons. First, we included younger

Fig. 1. Incidence rate ratio of subsequent hip fracture in people with ﬁrst hip fracture compared to general population.

Table 1

Incidence rate ratio of second hip fractures compared to the incidence of hip fracture in Taiwan's healthy population considering selected time intervals after the ﬁrst hip fracture.

Time Incidence rate ratio 95% conﬁdence interval

3 months 7.13 7.04e7.22

6 months 6.12 6.03e6.20

1 year 5.21 5.14e5.28

2 years 4.14 4.08e4.21

3 years 3.51 3.45e3.56

4 years 2.97 2.91e3.04

5 years 2.35 2.30e2.40

6 years 2.22 2.19e2.25

Fig. 2. Cumulative incidence of second hip fracture.

Table 2

The cumulative incidence of second hip fractures after the ﬁrst hip fracture and hazard ratios (95% conﬁdence intervals) for second hip fractures in women versus men.

Time Second hip fracture ^aHR (women vs. men) p-value

Cumulative incidence (%)

Women Men

3 months 0.6 0.5 1.07 (0.94e1.12) 0.447

6 months 1.2 0.9 1.09 (0.99e1.18) 0.091

1 year 2.2 1.8 1.21 (1.12e1.29) 0.018

2 years 3.9 2.8 1.24 (1.15e1.33) 0.003

3 years 5.2 4 1.28 (1.20e1.36) <0.001

4 years 6.3 4.7 1.30 (1.21e1.39) <0.001

5 years 7.2 5.7 1.31 (1.24e1.39) <0.001

6 years 8 6.2 1.35 (1.27e1.42) <0.001

a HR, hazard ratio.

Table 3

Six-year cumulative incidence and hazard ratio (95% conﬁdence interval) for second hip fractures in women versus men according to age at ﬁrst hip fracture.

Age group (years) Women Men ^aHR (women vs. men) p-value

50e59 4 3.5 1.14 (0.98e1.29) 0.441

60e69 7.4 5.8 1.30 (1.20e1.29) <0.001

70e79 8.5 7 1.27 (1.20e1.34) <0.001

80e89 8 6.3 1.26 (1.19e1.34) <0.001

!90 6.3 4.8 1.42 (1.34e1.51) <0.001

a HR, hazard ratio.

S.-H. Lee et al. / Acta Orthopaedica et Traumatologica Turcica 50 (2016) 437e442 439

AOTT 2016; 50:437-42 Le fratture di femore - Il punto di vista del Bone Specialist (FLS)

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FRATTURA DI FEMORE: RISCHIO IMMINENTE DI NUOVA FRATTURA

Ø Incidenza cumulativa di II frattura di femorale ad un anno dalla I

(considerando il competing risk of death):

o 2,2% nelle donne o 1,8% negli uomini

Ø maggior propensione alla II frattura delle donne rispetto agli uomini

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men (Table 3), except in the age group of 50e59 years. Women and men both demonstrated the same trend of increasing incidence of a second hip fracture as they aged, which plateaued at age 70e79 years and then declined.

The 1- and 5-year mortality ratewas 14.1% and 42% afterthe first hip fracture, respectively, and 18.8% and 60.6% after the second hip fracture, respectively (Fig. 3). Women and men both showed a significantly higher mortality rate after a second hip fracture compared to the first hip fracture 1 year after the indexed fracture (p < 0.05). When comparing differences in sex, men had a higher 5- year mortality rate than women following the first or second hip fracture (p < 0.01).

Discussion

Hip fracture is a major public health issue in the elderly. Taiwan, a nation of a 23 million population with majority of ethnic Chinese people, was found to have higher incidence of hip fracture than other ethnic Chinese populations, similar to that of Western countries.

^21,22

Kanis et al reported that Taiwan was among coun- tries with highest incidence of hip fracture, second to Scandinavian countries but higher than the UK, Germany, Hong Kong, and Singapore.

⁸

In light of this, the present study sheds light on the epidemiologic data and mortality of second hip fracture in order to provide information for healthcare providers and policymakers in Taiwan and other countries with similar demographic structure and hip fracture incidence. In countries where population aging is just an emerging issue but is expected to accelerate rapidly in the coming decades, like China, Brazil, and southeastern Asia, our data may underestimate the incidence and mortality of second hip fractures.

^23,24

Incidence

The current study is a nationwide population-based investiga- tion. Most of the previous studies addressing second hip fractures involved onlya small numberof patients thus, limiting the powerof their results.

^25,17,10

In a study from Denmark, Ryg et al reported a cumulative incidence of a second hip fracture between 1977 and 2001 of 9% within 1 year and 20% within 5 years.

¹⁵

However, the incidence of a second hip fracture might be overestimated if death after the ﬁrst hip fracture was not taken into account.

²⁶

In a Nor- wegian study, Omsland et al estimated the cumulative incidence of a second hip fracture to be 15% for women and 11% for men within 10 years of the ﬁrst hip fracture, which was higher than Taiwanese population in the current study.

¹³

The lower 1- and 5-year cumulative incidence in the present study may be caused by several reasons. First, we included younger

Fig. 1. Incidence rate ratio of subsequent hip fracture in people with ﬁrst hip fracture compared to general population.

Table 1

Incidence rateratio of second hip fractures compared tothe incidence of hip fracture in Taiwan's healthy population considering selected time intervals after the ﬁrst hip fracture.

Time Incidence rate ratio 95% conﬁdence interval

3 months 7.13 7.04e7.22

6 months 6.12 6.03e6.20

1 year 5.21 5.14e5.28

2 years 4.14 4.08e4.21

3 years 3.51 3.45e3.56

4 years 2.97 2.91e3.04

5 years 2.35 2.30e2.40

6 years 2.22 2.19e2.25

Fig. 2. Cumulative incidence of second hip fracture.

Table 2

The cumulative incidence of second hip fractures after the ﬁrst hip fracture and hazard ratios (95% conﬁdence intervals) for second hip fractures in women versus men.

Time Second hip fracture ^aHR (women vs. men) p-value Cumulative incidence (%)

Women Men

3 months 0.6 0.5 1.07 (0.94e1.12) 0.447 6 months 1.2 0.9 1.09 (0.99e1.18) 0.091

1 year 2.2 1.8 1.21 (1.12e1.29) 0.018

2 years 3.9 2.8 1.24 (1.15e1.33) 0.003

3 years 5.2 4 1.28 (1.20e1.36) <0.001 4 years 6.3 4.7 1.30 (1.21e1.39) <0.001 5 years 7.2 5.7 1.31 (1.24e1.39) <0.001 6 years 8 6.2 1.35 (1.27e1.42) <0.001

a HR, hazard ratio.

Table 3

Six-year cumulative incidence and hazard ratio (95% conﬁdence interval) for second hip fractures in women versus men according to age at ﬁrst hip fracture.

Age group (years) Women Men ^aHR (women vs. men) p-value

50e59 4 3.5 1.14 (0.98e1.29) 0.441

60e69 7.4 5.8 1.30 (1.20e1.29) <0.001

70e79 8.5 7 1.27 (1.20e1.34) <0.001

80e89 8 6.3 1.26 (1.19e1.34) <0.001

!90 6.3 4.8 1.42 (1.34e1.51) <0.001

a HR, hazard ratio.

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FRATTURA DI FEMORE: RISCHIO IMMINENTE DI NUOVA FRATTURA

Ø L’incidenza cumulativa di II frattura di femore a sei anni per gruppi d’età:

o aumenta con l’età

o ha un picco tra 70 e 79 anni o declina per età pari o >80 anni

Ø HR più elevato per le donne ad ogni età dopo i 60 anni

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men(Table3),exceptintheagegroupof50e59years.Womenand menbothdemonstratedthesametrendofincreasingincidenceofa second hip fracture as they aged, which plateaued at age 70e79 yearsandthendeclined.

The1-and5-yearmortalityratewas14.1%and42%afterthefirst hipfracture,respectively,and18.8%and60.6%afterthesecondhip fracture, respectively (Fig. 3). Women and men both showed a significantly higher mortality rate after a second hip fracture comparedtothefirsthipfracture1yearaftertheindexedfracture (p<0.05).Whencomparingdifferencesinsex,menhadahigher5- year mortality rate thanwomen following the firstorsecondhip fracture(p<0.01).

Discussion

Hipfractureisamajorpublichealthissueintheelderly.Taiwan, anationofa23millionpopulationwithmajorityofethnicChinese people, was found to have higher incidence of hip fracture than other ethnic Chinese populations, similar to that of Western countries. ^21,22 Kanis et al reported that Taiwan was among coun- trieswithhighestincidenceofhipfracture,secondtoScandinavian countries but higher than the UK, Germany, Hong Kong, and Singapore. ⁸ In light of this, the present study sheds light on the epidemiologicdataandmortalityofsecondhipfractureinorderto provideinformationforhealthcareprovidersandpolicymakersin Taiwan and other countries with similar demographic structure andhipfractureincidence.Incountrieswherepopulationagingis justanemergingissuebutisexpectedtoacceleraterapidlyinthe comingdecades,likeChina,Brazil,andsoutheasternAsia,ourdata may underestimate the incidence and mortality of second hip fractures. ^23,24

Incidence

The current study is a nationwide population-based investiga- tion.Mostofthepreviousstudiesaddressingsecondhipfractures involvedonlyasmallnumberofpatientsthus,limitingthepowerof their results. ^25,17,10 In a study from Denmark, Ryget al reported a cumulative incidence of a second hip fracture between 1977 and 2001 of 9% within 1 yearand 20% within 5 years. ¹⁵ However, the incidenceofasecondhipfracturemightbeoverestimatedifdeath afterthe ﬁrsthipfracturewasnottakenintoaccount. ²⁶ In a Nor- wegianstudy,Omslandetalestimatedthecumulativeincidenceof asecondhipfracturetobe15%forwomenand11%formenwithin 10yearsoftheﬁrsthipfracture,whichwashigherthanTaiwanese populationinthecurrentstudy. ¹³

The lower 1- and 5-year cumulative incidence in the present studymaybecausedbyseveralreasons.First,weincludedyounger

Fig.1. Incidencerateratioofsubsequenthipfractureinpeoplewithﬁrsthipfracture comparedtogeneralpopulation.

Table1

Incidencerateratioofsecondhipfracturescomparedtotheincidenceofhipfracture inTaiwan'shealthypopulationconsideringselectedtimeintervalsaftertheﬁrsthip fracture.

Time Incidencerateratio 95%conﬁdenceinterval

3months 7.13 7.04e7.22

6months 6.12 6.03e6.20

1year 5.21 5.14e5.28

2years 4.14 4.08e4.21

3years 3.51 3.45e3.56

4years 2.97 2.91e3.04

5years 2.35 2.30e2.40

6years 2.22 2.19e2.25

Fig.2. Cumulativeincidenceofsecondhipfracture.

Table2

The cumulative incidence of second hip fractures after the ﬁrst hip fracture and hazardratios(95%conﬁdenceintervals)forsecondhipfracturesinwomenversus men.

Time Secondhipfracture ^a HR(womenvs.men) p-value Cumulativeincidence(%)

Women Men

3months 0.6 0.5 1.07(0.94e1.12) 0.447

6months 1.2 0.9 1.09(0.99e1.18) 0.091

1year 2.2 1.8 1.21(1.12e1.29) 0.018

2years 3.9 2.8 1.24(1.15e1.33) 0.003

3years 5.2 4 1.28(1.20e1.36) < 0.001

4years 6.3 4.7 1.30(1.21e1.39) < 0.001

5years 7.2 5.7 1.31(1.24e1.39) < 0.001

6years 8 6.2 1.35(1.27e1.42) < 0.001

a HR,hazardratio.

Table3

Six-yearcumulativeincidenceandhazardratio(95%conﬁdenceinterval)forsecond hipfracturesinwomenversusmenaccordingtoageatﬁrsthipfracture.

Agegroup(years) Women Men ^a HR(womenvs.men) p-value

50e59 4 3.5 1.14(0.98e1.29) 0.441

60e69 7.4 5.8 1.30(1.20e1.29) < 0.001

70e79 8.5 7 1.27(1.20e1.34) < 0.001

80e89 8 6.3 1.26(1.19e1.34) < 0.001

!90 6.3 4.8 1.42(1.34e1.51) < 0.001

a HR,hazardratio.

S.-H. Leeetal./ActaOrthopaedica etTraumatologicaTurcica50(2016)437e442 439

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FRATTURA DI FEMORE: MORTALITA’

A 1 E 5 ANNI: 14% E 42 % PER LA I E 18 E 60% PER LA II (p<0,05)

AOTT 2016; 50:437-42

patients aged 50e59 years who had lower risk of a second hip fracture (Table 3). Second, we have taken into account the competing risk of death in our analysis.¹³ Third, only 2.0% of the Taiwanese people aged >65 years lived in institutions according to a national survey,²⁷ which was much lower than that in France, Australia, Japan, and Canada.²⁸It has been reported that living in an institution was associated with increased risk of second hip fracture because of a higher prevalence of physical disability and mental impairments.^17,29,30 However, whether living in institutions can account for different second hip fracture incidence between countries needs further investigation, since societal factors such as government subsidies for institutionalized elderly may affect the demographic distribution of healthy or frail people. Fourth, osteoporosis is a known risk factor for hip fractures.^1,31,32The prevalence of osteoporosis in different study country is also an important factor to consider. The prevalence of osteoporosis was 40.8% for women aged more than 50 years and 17.7% among men in Denmark; whereas those are 12.5% and 5.3% for Chinese adults.^33,34 The higher osteoporosis prevalence in Nordic countries may contribute to higher incidence of second hip fractures.

In a recently published study using NHIRD in Taiwan, Shen et al analyzed cases in a 4-year period and discovered a higher one-year cumulative incidence of a second hip fracture compared to our data (4.1% and 2.7% for people aged more than 75 years and younger than 75 years, respectively).³⁵Death as a competing risk of a second hip fracture, however, was not taken into account in the study. In addition, patients with the diagnosis of a hip fracture within only 2

years before the index data were excluded in their study. This might not correctly identify true ﬁrst hip fracture, since the incidence of second hip fracture is still high at 2 years following ﬁrst hip fracture.²⁰

Incidence rate ratio

The high incidence of a subsequent hip fracture is clustered in the first few years after the first hip fracture, as described in previous studies.^20,12,15 In a study by Nymark et al,¹² the risk of a second hip fracture diminished to a level equal to or lower than the risk of a first hip fracture after 12 months. In the current study, there was a trend toward clustering of second hip fractures in the first 6 years, but not as pronounced as described by Nymark et al.

Osteoporosis prevalence in different countries may contribute to this observation, that people with more osteoporotic bones would have second hip fractures sooner.^34,33

Cumulative incidence according to sex

The cumulative incidence for men and women remained similar in the first 3 months and 6 months, but demonstrated a significant difference 1 year after the first hip fracture (HR, 1.21e1.35). Oms- land et al found that the age-adjusted risk of a second fracture during a 10-year period was 40% higher for women compared to men.¹³ The authors attributed the phenomenon to the fact that the women and men have the same risk for a second hip fracture, but in general, women live longer after prior fracture, and thus, they have a higher risk for a second fracture.

When stratified by age, we found a significantly higher cumulative incidence of second fractures in women compared to men across all age groups, except for those aged 50e59 years. In this age group, there were more non-osteoporotic hip fractures, resulting in a decreased incidence of second hip fractures, and the difference between men and women was not significant.³⁶

Mortality

The 1- and 5-year mortality rate was 14% and 42% after the first hip fracture, respectively, and 19% and 61% after the second hip fracture, respectively. The higher mortality rate after a second hip fracture may be explained by advanced age and more comorbid- ities. Many studies have reported mortality rates after first hip fractures.^13,36,3 To our knowledge, only two studies have addressed the mortality rate after a second hip fracture.^10,15The authors found the mortality rate after a second hip fracture remained higher compared to the first hip fracture of the similar baseline cohort.

This may indicate physiologic differences in recovery following the ﬁrst or second hip fracture.

When stratified by sex, the 1- and 5-year mortality rate after second hip fractures was 12.1% and 41.2% for women and 17.4% and 47.3% for men, respectively (p < 0.01). This finding was similar to previous studies.^15,10 Wehren et al³⁷ discovered a high infection rate (pneumonia/influenza and septicemia) in men after a hip fracture. This is a possible explanation for the higher mortality rate for men compared to women.

As the incidence of second hip fractures was high and the mortality rate was higher than in people with ﬁrst hip fractures, it is imperative to have some interventions after the ﬁrst hip fracture.

Brauer et al discovered the correlation of increasing use of bisphosphonate and declining incidence of hip fracture, which suggested anti-osteoporotic treatment would decrease hip fracture rate.³Similar ﬁnding has been reported by Alves et al that there was an abrupt turning point of hip fracture incidence and bisphosphonate use.³⁸ Regarding treatment of osteoporosis and incidence of

Fig. 3. Cumulative survival after second hip fracture. a, female. b, male.

patients aged 50e59 years who had lower risk of a second hip fracture (Table 3). Second, we have taken into account the competing risk of death in our analysis.¹³ Third, only 2.0% of the Taiwanese people aged >65 years lived in institutions according to a national survey,²⁷ which was much lower than that in France, Australia, Japan, and Canada.²⁸It has been reported that living in an institution was associated with increased risk of second hip fracture because of a higher prevalence of physical disability and mental impairments.^17,29,30 However, whether living in institutions can account for different second hip fracture incidence between countries needs further investigation, since societal factors such as government subsidies for institutionalized elderly may affect the demographic distribution of healthy or frail people. Fourth, osteoporosis is a known risk factor for hip fractures.^1,31,32 The prevalence of osteoporosis in different study country is also an important factor to consider. The prevalence of osteoporosis was 40.8% for women aged more than 50 years and 17.7% among men in Denmark; whereas those are 12.5% and 5.3% for Chinese adults.^33,34 The higher osteoporosis prevalence in Nordic countries may contribute to higher incidence of second hip fractures.

In a recently published study using NHIRD in Taiwan, Shen et al analyzed cases in a 4-year period and discovered a higher one-year cumulative incidence of a second hip fracture compared to our data (4.1% and 2.7% for people aged more than 75 years and younger than 75 years, respectively).³⁵Death as a competing risk of a second hip fracture, however, was not taken into account in the study. In addition, patients with the diagnosis of a hip fracture within only 2

years before the index data were excluded in their study. This might not correctly identify true ﬁrst hip fracture, since the incidence of second hip fracture is still high at 2 years following ﬁrst hip fracture.²⁰

Incidence rate ratio

The high incidence of a subsequent hip fracture is clustered in the first few years after the first hip fracture, as described in previous studies.^20,12,15 In a study by Nymark et al,¹² the risk of a second hip fracture diminished to a level equal to or lower than the risk of a first hip fracture after 12 months. In the current study, there was a trend toward clustering of second hip fractures in the first 6 years, but not as pronounced as described by Nymark et al.

Osteoporosis prevalence in different countries may contribute to this observation, that people with more osteoporotic bones would have second hip fractures sooner.^34,33

Cumulative incidence according to sex

The cumulative incidence for men and women remained similar in the first 3 months and 6 months, but demonstrated a significant difference 1 year after the first hip fracture (HR, 1.21e1.35). Oms- land et al found that the age-adjusted risk of a second fracture during a 10-year period was 40% higher for women compared to men.¹³ The authors attributed the phenomenon to the fact that the women and men have the same risk for a second hip fracture, but in general, women live longer after prior fracture, and thus, they have a higher risk for a second fracture.

When stratified by age, we found a significantly higher cumulative incidence of second fractures in women compared to men across all age groups, except for those aged 50e59 years. In this age group, there were more non-osteoporotic hip fractures, resulting in a decreased incidence of second hip fractures, and the difference between men and women was not significant.³⁶

Mortality

The 1- and 5-year mortality rate was 14% and 42% after the first hip fracture, respectively, and 19% and 61% after the second hip fracture, respectively. The higher mortality rate after a second hip fracture may be explained by advanced age and more comorbid- ities. Many studies have reported mortality rates after first hip fractures.^13,36,3 To our knowledge, only two studies have addressed the mortality rate after a second hip fracture.^10,15 The authors found the mortality rate after a second hip fracture remained higher compared to the first hip fracture of the similar baseline cohort.

This may indicate physiologic differences in recovery following the ﬁrst or second hip fracture.

When stratified by sex, the 1- and 5-year mortality rate after second hip fractures was 12.1% and 41.2% for women and 17.4% and 47.3% for men, respectively (p < 0.01). This finding was similar to previous studies.^15,10 Wehren et al³⁷ discovered a high infection rate (pneumonia/influenza and septicemia) in men after a hip fracture. This is a possible explanation for the higher mortality rate for men compared to women.

As the incidence of second hip fractures was high and the mortality rate was higher than in people with ﬁrst hip fractures, it is imperative to have some interventions after the ﬁrst hip fracture.

Brauer et al discovered the correlation of increasing use of bisphosphonate and declining incidence of hip fracture, which suggested anti-osteoporotic treatment would decrease hip fracture rate.³Similar ﬁnding has been reported by Alves et al that there was an abrupt turning point of hip fracture incidence and bisphosphonate use.³⁸ Regarding treatment of osteoporosis and incidence of

Fig. 3. Cumulative survival after second hip fracture. a, female. b, male.

Nettamente superiore nel maschio p>0,01

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RISCHIO DI II FRATTURA DOPO FRATTURA DA FRAGILITA’

95% CI 1.60–2.25] and declined after 10 years (HR 1.62, 95% CI 1.25–2.10). Prior minor fracture was a weaker risk factor (Table 4), greatest within the first year (HR 1.45, 95% CI 1.13–1.86) and no longer significant by 1 to 5 years (HR 1.07, 95% CI 0.82–1.38). Both major and minor fractures showed a time-dependent decline in importance as risk factors for incident fractures.

When compared with the risk ratio of 1.74 for osteoporotic fracture in women associated with having a history of prior fracture (BMD-adjusted), as reported in the meta-analysis by Kanis and colleagues,

⁽¹⁰⁾

CIs for major prior fractures included the reference value for all postfracture time intervals (Fig. 1). In contrast, prior minor fractures included this reference value only if the fracture occurred within the preceding year.

Discussion

This study reveals that although prior fracture is a risk factor for future fractures, its importance as a risk factor may vary with the time period since the prior fracture. The risk of a future osteoporotic fracture attributable to having a prior fracture is greatest in the first year and declines thereafter. However, prior clinical fractures of the hip, spine, forearm, and humerus conti- nued to be strong risk factors for future osteoporotic fractures even 10 years after the prior fracture, whereas a history of minor fracture may cease to be important after the first year. The results of this study have important implications for the interpretation of fracture risk for individuals with a prior fracture, especially in the context of the recent paradigm shifts in the management of osteoporosis, where risk-assessment interventions are now framed in the context of the patient’s 10-year fracture risk, as Table 3. Age at BMD Testing, Numbers of Incident Fractures, and Crude Fracture Rates According to Time Since Prior Fracture

Time since fracture n (%)

Age (years), mean (SD)

Incident fractures, n (%)

Fracture rate per 1000 person-

years (95% CI) Major fractures

None 34,812 (87.0) 63.7 (10.5) 1282 (3.7) 6.8 (5.9–7.6)

!1 year 1576 (3.9) 67.0 (10.8) 153 (9.7) 18.3 (11.7–24.9)

>1 to 5 years 1456 (3.6) 68.5 (10.8) 149 (10.2) 17.7 (10.9–24.5)

>5 to 10 years 1223 (3.1) 68.7 (10.3) 104 (8.5) 15.0 (8.2–21.8)

>10 years 924 (2.3) 69.5 (10.1) 61 (6.6) 15.0 (7.2–22.9)

Minor fractures

None 36,512 (91.3) 64.1 (10.6) 1529 (4.2) 7.7 (6.8–8.6)

!1 year 894 (2.2) 63.9 (10.7) 66 (7.4) 13.7 (6.1–21.3)

>1 to 5 years 970 (2.4) 65.6 (10.5) 59 (6.1) 10.8 (4.3–17.3)

>5 to 10 years 876 (2.2) 66.9 (10.8) 60 (6.8) 12.6 (5.2–19.9)

>10 years 739 (1.8) 67.4 (10.6) 35 (4.7) 10.8 (3.4–18.3)

Table 4. Adjusted Hazard Ratios (HRs) for Incident Fractures According to Time Since Prior Major and Minor Fractures

^a

Time since prior fracture HR (95% CI)

^b

p Value Major fractures

<1 year 1.90 (1.60–2.25) <.001

>1 to 5 years 1.75 (1.47–2.08) <.001

>5 to 10 years 1.58 (1.29–1.94) <.001

>10 years 1.62 (1.25–2.10) <.001

p-trend < .001 Minor fractures

<1 year 1.49 (1.13–1.86) .003

>1 to 5 years 1.07 (0.82–1.38) .632

>5 to 10 years 1.32 (1.02–1.71) .040

>10 years 1.09 (0.78–1.52) .633

p-trend .015

BMD¼ bone mineral density; CI ¼ confidence interval; HR ¼ hazard ratio.

aAdjusted for age, femoral neck BMD, BMI, COPD, alcohol/substance abuse, rheumatoid arthritis, systemic corticosteroid therapy, and osteoporosis therapy.

bThe reference group is women without a fracture prior to BMD testing.

Fig. 1. Hazard ratios (HR, 95% CI) for incident fractures by site and time since prior major and minor fracture. The reference line represents the BMD-adjusted risk ratio for osteoporotic fracture associated with having a prior fracture in women as reported in the meta-analysis by Kanis and colleagues.⁽¹⁰⁾

TIME SINCE FRACTURE AND FUTURE FRACTURE RISK Journal of Bone and Mineral Research

1403 95% CI 1.60–2.25] and declined after 10 years (HR 1.62, 95% CI

1.25–2.10). Prior minor fracture was a weaker risk factor (Table 4), greatest within the first year (HR 1.45, 95% CI 1.13–1.86) and no longer significant by 1 to 5 years (HR 1.07, 95% CI 0.82–1.38). Both major and minor fractures showed a time-dependent decline in importance as risk factors for incident fractures.

When compared with the risk ratio of 1.74 for osteoporotic fracture in women associated with having a history of prior fracture (BMD-adjusted), as reported in the meta-analysis by Kanis and colleagues,

⁽¹⁰⁾

CIs for major prior fractures included the reference value for all postfracture time intervals (Fig. 1). In contrast, prior minor fractures included this reference value only if the fracture occurred within the preceding year.

Discussion

This study reveals that although prior fracture is a risk factor for future fractures, its importance as a risk factor may vary with the time period since the prior fracture. The risk of a future osteoporotic fracture attributable to having a prior fracture is greatest in the first year and declines thereafter. However, prior clinical fractures of the hip, spine, forearm, and humerus conti- nued to be strong risk factors for future osteoporotic fractures even 10 years after the prior fracture, whereas a history of minor fracture may cease to be important after the first year. The results of this study have important implications for the interpretation of fracture risk for individuals with a prior fracture, especially in the context of the recent paradigm shifts in the management of osteoporosis, where risk-assessment interventions are now framed in the context of the patient’s 10-year fracture risk, as Table 3. Age at BMD Testing, Numbers of Incident Fractures, and Crude Fracture Rates According to Time Since Prior Fracture

Time since fracture n (%)

Age (years), mean (SD)

Incident fractures, n (%)

Fracture rate per 1000 person-

years (95% CI) Major fractures

None 34,812 (87.0) 63.7 (10.5) 1282 (3.7) 6.8 (5.9–7.6)

!1 year 1576 (3.9) 67.0 (10.8) 153 (9.7) 18.3 (11.7–24.9)

>1 to 5 years 1456 (3.6) 68.5 (10.8) 149 (10.2) 17.7 (10.9–24.5)

>5 to 10 years 1223 (3.1) 68.7 (10.3) 104 (8.5) 15.0 (8.2–21.8)

>10 years 924 (2.3) 69.5 (10.1) 61 (6.6) 15.0 (7.2–22.9)

Minor fractures

None 36,512 (91.3) 64.1 (10.6) 1529 (4.2) 7.7 (6.8–8.6)

!1 year 894 (2.2) 63.9 (10.7) 66 (7.4) 13.7 (6.1–21.3)

>1 to 5 years 970 (2.4) 65.6 (10.5) 59 (6.1) 10.8 (4.3–17.3)

>5 to 10 years 876 (2.2) 66.9 (10.8) 60 (6.8) 12.6 (5.2–19.9)

>10 years 739 (1.8) 67.4 (10.6) 35 (4.7) 10.8 (3.4–18.3)

Table 4. Adjusted Hazard Ratios (HRs) for Incident Fractures According to Time Since Prior Major and Minor Fractures

^a

Time since prior fracture HR (95% CI)

^b

p Value Major fractures

<1 year 1.90 (1.60–2.25) <.001

>1 to 5 years 1.75 (1.47–2.08) <.001

>5 to 10 years 1.58 (1.29–1.94) <.001

>10 years 1.62 (1.25–2.10) <.001 p-trend < .001

Minor fractures

<1 year 1.49 (1.13–1.86) .003

>1 to 5 years 1.07 (0.82–1.38) .632

>5 to 10 years 1.32 (1.02–1.71) .040

>10 years 1.09 (0.78–1.52) .633 p-trend .015

BMD¼ bone mineral density; CI ¼ confidence interval; HR ¼ hazard ratio.

aAdjusted for age, femoral neck BMD, BMI, COPD, alcohol/substance abuse, rheumatoid arthritis, systemic corticosteroid therapy, and osteoporosis therapy.

bThe reference group is women without a fracture prior to BMD testing.

Fig. 1. Hazard ratios (HR, 95% CI) for incident fractures by site and time since prior major and minor fracture. The reference line represents the BMD-adjusted risk ratio for osteoporotic fracture associated with having a prior fracture in women as reported in the meta-analysis by Kanis and colleagues.⁽¹⁰⁾

TIME SINCE FRACTURE AND FUTURE FRACTURE RISK Journal of Bone and Mineral Research

1403

JBMR 2010; 25(6,):1400–1405 Le fratture di femore - Il punto di vista del Bone Specialist (FLS)

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Ø META’ DEI PAZIENTI CON FRATTURA DI FEMORE HANNO GIA’ AVUTO UNA

FRATTURA DA FRAGILITA’

Ø I PAZIENTI CON FRATTURA DI FEMORE PRESENTANO, NEL 70% DEI CASI,

FRATTURE VERTEBRALI

FRATTURE DI FEMORE E RISCHIO DI ALTRE FRATTURE DA FRAGILITA’

Rev clin Esp; 207(9):464-8 Osteoporos Int 14:780-784

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>

FRATTURA DI FEMORE

LA DIMENSIONE DEL

PROBLEMA IN ITALIA

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Ø INCIDENZA: 80.000/ANNO

Ø DISTRIBUZIONE:

o 75% DONNE (94% >65 ANNI) o 25% UOMINI

Ø L’INCIDENZA RADDOPPIA:

o NELLE DONNE >65 ANNI o NEGLI UOMINI >75 ANNI

LE FRATTURE DI FEMORE IN ITALIA

mente evidente nelle donne. Pertanto, il numero dei soggetti fratturati è destinato ad aumentare negli anni a venire, e si rendono sempre più ne- cessari, da un lato, gli interventi preventivi e, dal- l’altro, quelli volti a migliorare la registrazione e l’elaborazione dei dati epidemiologici, che sono fondamentali per conoscere i rischi, i costi e l’impatto sociale di questo problema. Si stima che in Italia l’osteoporosi colpisca circa 5.000.000 di persone, di cui l’80% è rappresentato da donne in postmenopausa. I siti scheletrici generalmente riconosciuti come sede di fratture da fragilità sono quelli a maggiore contenuto di osso trabecolare, ossia le vertebre, il femore prossimale, il polso, l’omero prossimale e la caviglia. A oggi i dati epidemiologici raccolti in Italia su vasti campioni sono scarsi e quelli più rappresentativi sono stati estrapolati dalle Schede di Dimissione Ospedaliera (SDO), raccolte dal Ministero della Salute. Essi, tuttavia, si riferiscono solo ai soggetti in cui la frattura ha richiesto un ricovero.

In Italia ogni anno si registrano circa 80.000 frat-

ture di femore, il 75% si verifica nella popolazione femminile e, di questa percentuale, il 94% avviene nelle donne con età > 65 anni.

Il 90% delle fratture femorali è legato a una caduta e il rischio di cadute aumenta con l’età. Circa un terzo degli individui oltre i 65 anni cade almeno una volta l’anno. L’1% delle cadute, nelle donne, provoca una frattura del femore.

La mortalità per frattura di femore risulta essere del 5% nel periodo immediatamente successivo all’evento traumatico e del 15-25% a un anno dallo stesso. Nel 20% dei casi si verifica una perdita definitiva della capacità di deambulare in ma- niera autonoma e solo il 30-40% dei soggetti torna alle condizioni precedenti la frattura.

Le più alte incidenze di frattura del femore prossimale si osservano nelle donne al di sopra dei 75 anni (oltre 50.000 l’anno dal 2001 al 2005). L’incidenza raddoppia nelle donne a partire dai 65 anni di età (osteoporosi postmenopausale), mentre negli uomini questo fenomeno si osserva al di so- pra dei 75 anni (osteoporosi senile) [Figura 2.1].

Epidemiologia dell’osteoporosi e delle fratture da fragilità 2

7

Figura 2.1 Incidenza annuale delle fratture del femore prossimale dal 2000 al 2007 in Italia nella popolazione maschile (blu) e femminile (rosa) con età ≥ 45 anni (dati SDO).

45-64 65-74 2003

≥75 45-64 65-74

2002

N. fratture del femore prossimale

≥75 45-64 65-74

2005

≥75 45-64 65-74

2004

≥75 45-64 65-74

2001

≥75 60.000

40.000

30.000

0 45-64 65-74 2000

≥75 50.000

20.000

10.000

45-64 65-74 2006

≥75 45-64 65-74 2007

≥75 Quaderno 4_Quaderni 21/09/10 10.21 Pagina 7

Ministero della Salute. Gruppo di Lavoro: Brandi ML et al. Quaderni della Salute.

Appropriatezza diagnostica e terapeutica nella prevenzione delle fratture da fragilità da osteoporosi - 2010.

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Ø COSTI DIRETTI E INDIRETTI o Intervento e riabilitazione o Pensioni di invalidita’

à >1 MILIARDO DI EURO/ANNO Ø COSTI INTANGIBILI

o 364.000 giorni /anno di lavoro persi da pazienti/cargiver

à 1,7 MILIARDI DI EURO/ANNO o Altro à non quantificabile

STIMA DEI COSTI

Osteoporos Int (2007) 18:211-219 20 regions may establish their own rates, cutting off the DRGs values at the local level. Accepting a 15% average reduction for each DRG allowed us to estimate a mean value in order to overcome the differences between the regions. The costs of rehabilitation in this study may be underestimated. We chose to consider only 1 month of postoperative rehabilitation because this is the average duration provided by the law, including the rehabilitative interventions performed at the hospital (usually 10–

14 days of postoperative hospitalization days), even though not all patients comply with the rehabilitation program afterwards [37]. As suggested by the IOF [3], we considered that indirect costs due to overhead equalled 20%

of the overall direct costs, even though many authors have suggested that these costs are higher than hospitalization costs [28, 30, 33, 34]. Finally, we estimated the cost for disability financial aid paid by the state to persons who become fully disabled (recognition of disability ≥75%) after hip fracture, taking in account that some of them

(15%–25%) die within a year [2, 6, 15]. The cost estimates related to disability pensions following hip fractures are conservative: actually the entire annual sum paid as social aid may exceed 7,500 Euros per patient. We also have to consider that although the Italian law does not provide financial aid to people who have experienced AMI, its potential complications such as chronic hearth failure may result in the acknowledgment of a disability pension (but only if the disease is very severe, because of the adoption of more conservative criteria by the health authorities concerning cardiovascular diseases).

A complete analysis of the phenomenon would also require data regarding intangible costs associated with hip fractures, such as costs due to pain, lack of productivity, premature mortality, a reduction in the quality of life and social suffering. An Italian analysis reviewed by the Italian Senate Health Commission in 2002 [2] indicated that patients and their relatives lose 364,000 working days per year because of hip fractures, resulting in a high economic impact estimated as 1.7 billion Euros. Like rehabilitation costs and indirect costs, intangible costs are also difficult to measure and were not the aim of this study; therefore, they were not assessed. The increasing incidence of hip fracture is ascribed mainly to elderly women, in accordance with the higher prevalence of osteoporosis in the oldest age groups.

This study reveals the urgent necessity of adopting preventive measures to reduce the incidence and costs of osteoporosis-related hip fractures, which continue to be considered as a secondary health problem. Although our data have demonstrated similar incidences and costs between hip fractures and AMI in Italy, the overall Italian expenditures for pharmacological treatments aimed to reduce the risk of hip fractures in 2001 represented just 0.29% (almost 46 million Euros) of the national drug expenditures [2]. In the same year, total expenditures for cardiovascular drugs represented 32% of the total [2]. Other measures to prevent hip fractures could be the promotion of healthy lifestyles and physical activity and the use of hip protectors [38–44]. Further studies, including pharmaeco- nomic simulations, should determine if the adoption of proper preventive measures (not exclusively pharmacological ones) in high-risk patients (i.e., people with previous vertebral fractures and patients taking corticosteroid drugs) can decrease the incidence of hip fractures without a major impact on general costs. In Sweden, economic simulations [45] have already documented that fracture-preventive treatments are more cost-effective than common cardiovascular preventive strategies (e.g., treating hypertension for the prevention of stroke). Ethical considerations about the right of elderly people to live with an adequate quality of life make it urgent to find appropriate answers to aging- related health problems like hip fractures, which are increasing year by year in developed countries.

Table 7 Overall estimated costs for the 72,575 AMI registered in Italian elderly persons (≥65 years of age) in 2002

Patients, n Unit cost, Euros

Cost

Hospitalization costs 72,575 NA 270 million Rehabilitation

(1 month)

61,688 200 260 million

Disability pension NA NA NA

Indirect costs^b NA NA 530 million

Total 1,060

million

aAssuming 15% of patients die within 1 month after the event and thus do not begin rehabilitation;

bAssuming the hypothesis of indirect costs being up to the double of direct costs

NA, not applicable

Table 6 Overall estimated costs for the 80,804 hip fractures registered in Italian elderly persons (≥65 years of age) in 2002

Patients, n Unit cost, Euros

Cost

Hospitalization costs 80,804 NA 394 million Rehabilitation

(1 month)

76,764^a 5,375 412 million

Disability pension 18,000 6,000 108 million

Indirect costs^b NA NA 161 million

Total 1,075

million

aAssuming 5% of patients died within 1 month of surgery and thus not beginning rehabilitation;

bBased on 20% of direct costs (hospitalization and rehabilitation) NA, not applicable

Osteoporos Int (2007) 18:211–219 217

PARAGONABILI A COSTI PER IMA

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FRATTURA DI FEMORE: UN PROBLEMA SOTTOSTIMATO

« Although our data have demonstrated similar incidences and costs between hip fractures and AMI in Italy, the overall Italian expenditures for pharmacological treatments aimed to reduce the risk of hip fractures in 2001 represented just 0.29% (almost 46 million Euros) of the national drug expenditures. In the same year, total expenditures for

cardiovascular drugs represented 32% of the total »

Osteoporos Int (2007) 18:211-219

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FRATTURA DI FEMORE: IL GAP DI CURA

O

SSERVATORIO

N

AZIONALE

L’uso dei farmaci in Italia

SULL

’I

MPIEGO DEI

M

EDICINALI

gennaio-settembre 2014

Tabella 25. Monitoraggio degli indicatori di appropriatezza d’uso dei medicinali. I dati sono relativi al periodo luglio-giugno 2011-2014

Indicatore Descrizione dell'indicatore Lug2013-

giu2014

Lug2012- giu2013

Lug2011- giu2012 H-DB 1.1 Percentuale di pazienti in trattamento con farmaci antiipertensivi con comorbidità

trattati con farmaci ad azione sul sistema renina-angiotensina 79,5 82,1 83,2 H-DB 1.2 Percentuale di pazienti in trattamento con farmaci antiipertensivi antagonisti

dell’angiotensina II trattati con farmaci a brevetto scaduto (a dicembre 2013) 73,4 74,2 76,1 H-DB 1.3 Percentuale di pazienti in trattamento con farmaci antiipertensivi aderenti al

trattamento 55,2 54,7 54,3

H-DB 1.4 Percentuale di pazienti in trattamento con farmaci antiipertensivi occasionali al

trattamento 6,7 6,7 6,7

H-DB 1.5

Percentuale di pazienti avviati al trattamento con farmaci antiipertensivi in

associazione fissa con calcio-antagonista che non provengono dagli stessi principi attivi in monoterapia o dall’associazione estemporanea degli stessi principi attivi

83,3 83,5 78,9

H-DB 1.6 Percentuale di pazienti in trattamento con farmaci antiipertensivi in associazione

estemporanea con calcio-antagonista che non sono passati all'associazione fissa 97,4 96,6 96,3 H-DB 2.1 Percentuale di pazienti con pregresso evento CV o diabete in trattamento con statine 54,2 54,3 53,3 H-DB 2.2 Percentuale di pazienti in trattamento con statine senza pregresso evento CV o diabete 76,8 77,4 77,6 H-DB 2.3 Percentuale di pazienti senza pregresso evento CV o diabete in trattamento con statine

a bassa potenza 41,5 43,7 45,9

H-DB 2.4 Percentuale di pazienti con pregresso evento CV o diabete in trattamento con statine

ad alta potenza 62,9 60,9 59,0

H-DB 2.5 Percentuale di pazienti in trattamento con statine aderenti al trattamento 43,5 42,2 40,8 H-DB 2.6 Percentuale di pazienti in trattamento con statine occasionali al trattamento 8,7 9,0 9,4 H-DB 3.1 Percentuale di pazienti in trattamento con farmaci antidiabetici aderenti al

trattamento 61,7 61,4 60,1

H-DB 3.2 Percentuale di pazienti in trattamento con DPP-IV inibitori senza i criteri previsti dalle

precisazioni sulle limitazioni generali alla rimborsabilità dei DPP-IV inibitori 27,9 35,0 44,4 H-DB 3.3 Percentuale di pazienti con i criteri previsti dalle precisazioni sulle limitazioni generali

alla rimborsabilità dei DPP-IV inibitori non in trattamento con DPP-IV inibitori 59,8 67,1 74,4 H-DB 4.1 Percentuale di pazienti con ricovero per BPCO in trattamento con ICS 56,7 56,1 56,2 H-DB 4.2 Percentuale di pazienti con ricovero per BPCO in trattamento con LABA e/o LAMA 54,4 53,4 53,0 H-DB 4.3 Percentuale di pazienti in trattamento con ICS senza esacerbazioni 52,5 52,2 52,2 H-DB 4.4 Percentuale di pazienti in trattamento con farmaci per le sindromi ostruttive delle vie

respiratorie aderenti al trattamento 13,9 14,1 13,6

H-DB 4.5 Percentuale di pazienti in trattamento con farmaci per le sindromi ostruttive delle vie

respiratorie occasionali al trattamento 61,5 61,4 62,0

H-DB 5.1 Percentuale di pazienti con frattura vertebrale o di femore o in terapia con

corticosteroidi in trattamento con farmaci per l’osteoporosi 23,3 25,5 29,3

H-DB 5.2 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi senza pregressa

frattura vertebrale o di femore e senza pregressa terapia con corticosteroidi 94,1 95,0 95,0 H-DB 5.3 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi che associano

calcio o vitamina D 59,3 53,5 51,1

H-DB 5.4 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi aderenti al

trattamento 48,5 48,5 49,5

H-DB 5.5 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi occasionali al

trattamento 15,2 14,9 15,5

H-DB 6.1

Percentuale di pazienti in trattamento con farmaci antidepressivi della classe SNRI (inibitori della ricaptazione della serotonina-epinefrina) dopo secondo fallimento della classe SSRI (inibitori selettivi della ricaptazione della serotonina)

20,5 19,4 19,8

H-DB 6.2 Percentuale di pazienti in trattamento con farmaci antidepressivi aderenti al

trattamento 39,1 38,5 37,6

H-DB 6.3 Percentuale di pazienti in trattamento con farmaci antidepressivi occasionali al

trattamento 23,6 24,2 25,3

H-DB 7.1 Percentuale di pazienti in trattamento con inibitori della pompa protonica senza i

criteri di rimborsabilità previsti dalla Nota AIFA 1 o dalla Nota AIFA 48 45,3 44,4 44,3 H-DB 8.1 Percentuale di pazienti avviati ad un nuovo ciclo di terapia in trattamento epoetina alfa

biosimilare 45,6 25,1 18,9

Nota: i dati utilizzati nel calcolo degli indicatori è ottenuto su una parte delle ASL complessivamente coinvolte nel monitoraggio degli indicatori avviato nell’ambito del Rapporto OsMed 2012. Per ogni anno, è stato considerato il periodo luglio-giugno.

Abbreviazioni: CV=cardiovascolare; DPP-IV=inibitori della dipeptidil-peptidasi IV; BPCO= broncopneumopatia cronica ostruttiva; ICS= c orticosteroidi inalatori; LAMA= antagonista muscarinico a lunga durata d’azione; LABA: beta2-agonista a lunga durata d’azione.

- 57 -

O SSERVATORIO N AZIONALE L’uso dei farmaci in Italia

SULL ’I MPIEGO DEI M EDICINALI gennaio-settembre 2014

Tabella 25. Monitoraggio degli indicatori di appropriatezza d’uso dei medicinali. I dati sono relativi al periodo luglio-giugno 2011-2014

Indicatore Descrizione dell'indicatore Lug2013-

giu2014

Lug2012- giu2013

Lug2011- giu2012 H-DB 1.1 Percentuale di pazienti in trattamento con farmaci antiipertensivi con comorbidità

trattati con farmaci ad azione sul sistema renina-angiotensina 79,5 82,1 83,2

H-DB 1.2 Percentuale di pazienti in trattamento con farmaci antiipertensivi antagonisti

dell’angiotensina II trattati con farmaci a brevetto scaduto (a dicembre 2013) 73,4 74,2 76,1 H-DB 1.3 Percentuale di pazienti in trattamento con farmaci antiipertensivi aderenti al

trattamento 55,2 54,7 54,3

H-DB 1.4 Percentuale di pazienti in trattamento con farmaci antiipertensivi occasionali al

trattamento 6,7 6,7 6,7

H-DB 1.5

Percentuale di pazienti avviati al trattamento con farmaci antiipertensivi in

associazione fissa con calcio-antagonista che non provengono dagli stessi principi attivi in monoterapia o dall’associazione estemporanea degli stessi principi attivi

83,3 83,5 78,9

H-DB 1.6 Percentuale di pazienti in trattamento con farmaci antiipertensivi in associazione

estemporanea con calcio-antagonista che non sono passati all'associazione fissa 97,4 96,6 96,3 H-DB 2.1 Percentuale di pazienti con pregresso evento CV o diabete in trattamento con statine 54,2 54,3 53,3 H-DB 2.2 Percentuale di pazienti in trattamento con statine senza pregresso evento CV o diabete 76,8 77,4 77,6 H-DB 2.3 Percentuale di pazienti senza pregresso evento CV o diabete in trattamento con statine

a bassa potenza 41,5 43,7 45,9

H-DB 2.4 Percentuale di pazienti con pregresso evento CV o diabete in trattamento con statine

ad alta potenza 62,9 60,9 59,0

H-DB 2.5 Percentuale di pazienti in trattamento con statine aderenti al trattamento 43,5 42,2 40,8 H-DB 2.6 Percentuale di pazienti in trattamento con statine occasionali al trattamento 8,7 9,0 9,4 H-DB 3.1 Percentuale di pazienti in trattamento con farmaci antidiabetici aderenti al

trattamento 61,7 61,4 60,1

H-DB 3.2 Percentuale di pazienti in trattamento con DPP-IV inibitori senza i criteri previsti dalle

precisazioni sulle limitazioni generali alla rimborsabilità dei DPP-IV inibitori 27,9 35,0 44,4 H-DB 3.3 Percentuale di pazienti con i criteri previsti dalle precisazioni sulle limitazioni generali

alla rimborsabilità dei DPP-IV inibitori non in trattamento con DPP-IV inibitori 59,8 67,1 74,4 H-DB 4.1 Percentuale di pazienti con ricovero per BPCO in trattamento con ICS 56,7 56,1 56,2 H-DB 4.2 Percentuale di pazienti con ricovero per BPCO in trattamento con LABA e/o LAMA 54,4 53,4 53,0 H-DB 4.3 Percentuale di pazienti in trattamento con ICS senza esacerbazioni 52,5 52,2 52,2 H-DB 4.4 Percentuale di pazienti in trattamento con farmaci per le sindromi ostruttive delle vie

respiratorie aderenti al trattamento 13,9 14,1 13,6

H-DB 4.5 Percentuale di pazienti in trattamento con farmaci per le sindromi ostruttive delle vie

respiratorie occasionali al trattamento 61,5 61,4 62,0

H-DB 5.1 Percentuale di pazienti con frattura vertebrale o di femore o in terapia con

corticosteroidi in trattamento con farmaci per l’osteoporosi 23,3 25,5 29,3

H-DB 5.2 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi senza pregressa

frattura vertebrale o di femore e senza pregressa terapia con corticosteroidi 94,1 95,0 95,0 H-DB 5.3 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi che associano

calcio o vitamina D 59,3 53,5 51,1

H-DB 5.4 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi aderenti al

trattamento 48,5 48,5 49,5

H-DB 5.5 Percentuale di pazienti in trattamento con farmaci per l’osteoporosi occasionali al

trattamento 15,2 14,9 15,5

H-DB 6.1

Percentuale di pazienti in trattamento con farmaci antidepressivi della classe SNRI (inibitori della ricaptazione della serotonina-epinefrina) dopo secondo fallimento della classe SSRI (inibitori selettivi della ricaptazione della serotonina)

20,5 19,4 19,8

H-DB 6.2 Percentuale di pazienti in trattamento con farmaci antidepressivi aderenti al

trattamento 39,1 38,5 37,6

H-DB 6.3 Percentuale di pazienti in trattamento con farmaci antidepressivi occasionali al

trattamento 23,6 24,2 25,3

H-DB 7.1 Percentuale di pazienti in trattamento con inibitori della pompa protonica senza i

criteri di rimborsabilità previsti dalla Nota AIFA 1 o dalla Nota AIFA 48 45,3 44,4 44,3 H-DB 8.1 Percentuale di pazienti avviati ad un nuovo ciclo di terapia in trattamento epoetina alfa

biosimilare 45,6 25,1 18,9

Nota: i dati utilizzati nel calcolo degli indicatori è ottenuto su una parte delle ASL complessivamente coinvolte nel monitoraggio degli indicatori avviato nell’ambito del Rapporto OsMed 2012. Per ogni anno, è stato considerato il periodo luglio-giugno.

Abbreviazioni: CV=cardiovascolare; DPP-IV=inibitori della dipeptidil-peptidasi IV; BPCO= broncopneumopatia cronica ostruttiva; ICS= c orticosteroidi inalatori; LAMA= antagonista muscarinico a lunga durata d’azione; LABA: beta2-agonista a lunga durata d’azione.

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(OsMED). AIFA. L’uso dei farmaci in Italia. Rapporto Nazionale Anno 2015

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Ø PERCORSI DIAGNOSTICO-TERAPEUTICI

o A DIVERSA ESTENSIONE, COMPLESSITA’ E STRUTTURAZIONE

o IN CUI UN TEAM MULTIDISCIPLINARE COLLABORA ALLA PREVENZIONE

SECONDARIA DELLA FRATTURA DA FRAGILITA’

FRACTURE LIAISON SERVICE (FLS)

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Ø INDIVIDUAZIONE DEL PAZIENTE CON FRATTURA DA FRAGILITA’

Ø INQUADRAMENTO DIAGNOSTICO

Ø STRATIFICAZIONE DEL RISCHIO DI CADUTA E FRATTURA

Ø AVVIO DI TERAPIA SECONDO LINEE GUIDA Ø FOLLOW UP A BREVE E LUNGO TERMINE PER

l’OTTIMIZZAZIONE DELL’ADERENZA

FRACTURE LIAISON SERVICE (FLS): SCOPI

Osteoporos Int. 2013; 24(8):2135-52

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PUBBLICAZIONI SUI RISULTATI DI MODELLI DI FLS ESEMPLARI

à AUSTRALIA.

o Osteoporos Int. 2011;22:849–58 o Osteoporos Int. 2012;23:97– 107

à CANADA

o J Bone Joint Surg Am. 2006;88:25–34 o J Bone Joint Surg Am. 2008;90:1197–205 à UK

o Osteoporos Int.2003;14:1028–34 o Osteoporos Int.2011;22:2083–98 à USA

FRACTURE LIAISON SERVICE (FLS): RISULTATI

Curr Osteoporos Rep 2013 Mar;11(1):52-60

I RISULTATI POSITIVI DI QUESTI MODELLI IN TERMINI DI RIDUZIONE DI NUOVE FRATTURE,

RIDUZIONE DEI COSTI, AUMENTO DELL’APPROPIATEZZA DIAGNOSTICO –

TERAPEUTICA, HA PORTATO ORGANIZZAZIONI COME L’ASBMR E L’IOF A DARE AVVIO A

PROGRAMMI DI SUPPORTO ALL’

IMPLEMENTAZIONE DELLE FLS

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"Worldwide, there is a large care gap that is leaving millions of fracture patients at serious risk of future fractures. ‘Capture the Fracture’ hopes to close this gap and make secondary fracture prevention a