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Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review

Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a... Background: the complex management for patients presenting to hospital with vertebral fragility fractures provides justifi- cation for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the develop- ment of such a service. Methods: non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers. Results: a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fra- gility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more co- pathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality. Conclusion: these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted—providing access to diagnostic, therapeutic, surgical and rehabilitation interventions. Keywords: vertebral fragility fracture, hospital, osteoporosis, older people 17 T. Ong et al. those studies fulfilling the eligibility criteria or where there was Introduction uncertainty. Disagreements were resolved through discussion. In Europe, it is estimated that 3.5 million fragility fractures are sustained annually, 520,000 of them vertebral fragility frac- Data extraction tures [1]. Patients presenting to hospital with vertebral fragility The variables of interest were specified prior to the search and fractures have varying levels of pain and disability, for which comprised: hospital admission incidence; patient demographics; there are an increasing number of interventions, both medical bone health; comorbid burden; frailty; cognition; mood, activ- and surgical. The large number of such patients, their clinical ities of daily living; clinical presentation to hospital; proportion complexity and the complexity of their management may pro- of patients managed operatively; health outcomes (mortality, vide justification for the development of specific services for institutionalisation, hospital complications, changes in patient’s them, as has been done with the orthogeriatric model of care health status) and resource utilisation (length of hospital stay, for patients with hip fracture [2]. To developsuchaservicefor primary and secondary care attendance post-hospitalisation). vertebral fragility fractures, it is important to have an under- Data were extracted by two reviewers (T.O. and P.K.) using a standing of the number of patients in need of hospital admis- specified data extraction form. sion, their clinical presentation, management and outcomes. A review of existing scientific literature would provide such information. Therefore, we conducted a review of the existing Methodological quality literature to determine the incidence of hospital admission for The Newcastle-Ottawa Scale (NOS) was used to assess quality vertebral fragility fractures, their characteristics and health out- of the included studies (Appendix 2 in Supplementary data). comes with the overall intention of informing the development The scale was adapted to appraise the quality of cross-sectional of a specific service for vertebral fragility fracture management studies. Cut-off scores were used to rate quality of the studies in hospital. [4, 5]. No studies were excluded on the basis of their methodo- logical quality. Methods Synthesis of results Eligibility criteria A narrative synthesis was done under specific headings The protocol (available on request from the authors) and based on the framework by the Economic Social and reporting of this review was conducted in accordance with Research Council [6]. The synthesis process was an iterative the PRISMA statement for systematic reviews [3]. All non- one of exploring relationships within and between the randomised studies (cohort, case-control and cross-sectional reported data to see how different studies contributed to studies) of patients which reported either hospital admission the relevant headings. Where appropriate, findings from incidence, patient characteristics or outcomes associated with included studies were grouped together and reported using hospitalisation for vertebral fragility fracture were eligible for appropriate descriptive statistics. When results were pooled, inclusion. Eligibility criteria were if the majority of participants studies were weighted according to their sample size. were ≥50 years, and if the fractures were either low-trauma or due to osteoporosis. Studies were excluded if they included participants with malignancy, clinical features of a high impact Results injury (i.e. burst fracture, unstable fracture and spinal cord The search strategy identified 6,057 titles and abstracts. impingement), cervical fractures, incidental vertebral fragility After excluding duplicates, 5983 titles and abstracts were fracture and recruitment outside an inpatient setting. screened. A total of 18 studies were identified from the search for inclusion and one paper was further identified Search strategy through citation searching (Fig. 1). In total, 19 studies were The search was conducted using MEDLINE, EMBASE, included in the systematic review, of which seven studies CINAHL and AMED database from inception till November were cross-sectional and twelve were cohort studies, origin- 2015. The search strategy focussed on the core search terms of ating from eleven countries (Table 1). Overall, 12 out of the ‘vertebral fracture’ and its focus of care which is in ‘hospital’ 19 included studies were judged to be of moderate or good using the appropriate search terms, synonyms, and related quality (Supplementary data Appendix 3). terms. Citation searches were performed on the included papers and their reference lists were also scanned for relevant Incidence of hospital admission with vertebral papers. The search strategy for MEDLINE is detailed in the fracture supplementary data (Appendix 1). Seven studies reported the incidence of hospital admission with vertebral fragility fracture using large national hospital databases Study selection of Spain [8], America [9], Hungary [12], Italy [13], Sweden [17] The screening of titles and abstracts were done independently and France [20]; and Medicare, an American national insurance by two reviewers (T.O. and P.K.). Full texts were obtained for programme dataset [10]. There was geographical variation in 18 Characteristics and outcomes of hospitalised patients Figure 1. Flow diagram of study selection. the overall incidence of hospital admission from 2.8 to 19.3 per assessed as of poor quality [23], were of moderate quality 10,000/year (Table 2). The incidence rose with increasing age, [7, 8, 16, 22]. One study [8] reported data from a national peaking at 10–50 per 10,000/year in people older than 80. The registry and four used individual local hospital data [7, 16, incidence of hospitalisation for vertebral fragility fracture for 22, 23]. Gosch reported that 49% of those admitted to hos- men and women were relatively similar in the 50–60 years age pital with a vertebral fragility fractures had a known diagno- group, but a higher incidence was reported in women older sis of osteoporosis [16]. Bouza using the national Spanish than 60, with at least a ratio of 2:1. registry reported that 35% of their study population had osteoporosis coded as part of the hospital admission [8]. Both Suseki and Takahara did not describe the prevalence Patient demographics of osteoporosis but reported that the average bone mineral In total, 10 studies [7–10, 13, 14, 17, 18, 20, 25] were con- density values in among their study participants was low sidered fully representative of a hospitalised vertebral fragility enough to be considered osteoporotic [22, 23]. Gosch and fracture cohort using the NOS assessment of study quality. Bloomfield further reported that 42 and 35% of those with The pooled, weighted, proportion of women in these studies vertebral fragility fractures had sustained a low trauma frac- was 65% (range: 57–84%). Four of these studies [7, 8, 14, 25] ture previously [7, 16] (Table 3). reported patients’ ages: the pooled weighted mean age was 81 years (range: 70–82). No other demographic details were reported in the included studies. Comorbidities Four studies used the Charlson comorbidity index to report Bone health history comorbidities [8, 14, 16, 25] and two studies simply The prevalence of osteoporotic bone disease was reported reported the number of comorbidities [9, 20]. The in five studies. These studies, except one which was Charlson comorbidity index is a clinical scale of weighted 19 T. Ong et al. Table 1. Characteristics of included studies Study Country Study description VFF Age, y VFF diagnosis patients, .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. Cross-sectional Bloomfield and Sing [7] New Zealand Analysis of discharge records of patients from a large district hospital over 12 months for 154 >65 Identified using hospital discharge summaries prescription of secondary prevention for osteoporosis on discharge. Bouza et al. [8] Spain Using the 2002 National Hospital Discharge Register of patients admitted with vertebral 7,100 >30 ICD-9 (code 805, all subgroups) fragility fracture and osteoporosis over 12 months to determine the burden of vertebral fragility fracture and its impact on healthcare services. Gehlbach et al. [9] America Describe characteristics of patients with vertebral fragility fracture identified using the 1997 68,901 ≥45 ICD-9 (code 733.13, 805.2, 805.4 and 805.8) Nationwide Inpatient Sample and their resource use compared with hip fractures. Jacobsen et al. [10] America Incidence of vertebral fragility fracture hospitalisation over 4 years using the Medicare 14,091 ≥65 ICD-9 (code 805.0, 805.2, 805.4, 805.8) Provider Analysis and Review file. Papaioannou et al. [11] Canada Length of stay of patients in an acute hospital with vertebral fragility fractures identified from 3,494 ≥50 ICD-9 (code 805.2, 805.4, 733.13) the Canadian Institute for Health Information Discharge Abstract Database over 12 months. Pentek et al. [12] Hungary Hospital incidence of patients admitted with vertebral fragility fractures identified from the 8,195 ≥50 ICD-10 (code S22.0, S22.1, S32.0, M48.5) Hungarian National Health Insurance Fund Administration over 5 years. Piscitelli et al. [13] Italy National incidence of vertebral fragility fractures over 7 years based on the national 413,724 ≥40 ICD-9 (code 805, all subgroups) hospitalisation database maintained by the Italian Ministry of Health to assess hip, vertebral, humerus, wrist/forearm fragility fracture incidence. Cohort Chen et al. [14] America Compare outcomes of vertebral fragility fracture patients treated operatively (vertebroplasty 68,752 ≥65 ICD-9 (code 733.13, 805.2, 805.4) or kyphoplasty) or non-operatively identified from the Medicare 2006 database. Data collected at baseline, discharge, 6 months, 1, 2 and 3 years. Flug et al. [15] America Outcome of patients admitted with vertebral fragility fractures and treated operatively 248 Not stated ICD-9 (code 733.13, 805.2, 805.4) (vertebroplasty or kyphoplasty) over 30 months compared with those not operated. Data collected at admission and at 30 days post-discharge. Gosch et al. [16] Austria Describe outcome of patients admitted to an orthogeriatric unit with a non-hip fracture 55 ≥70 Not stated (vertebral fragility fractures, humerus, wrist, thoracic, pelvis, lower extremity and other fractures). Data collected on admission and at 1 year follow up. Johnell et al. [17] Sweden Patients identified from the Swedish Patient Register over 8 years for with either a thoracic or 17,425 ≥50 ICD-9 (no codes available) lumbar high- or low-energy fracture and followed up to assess risk of subsequent fracture. Lee and Yip [18] Hong Kong Describe characteristics and outcomes of patients admitted with low back pain and vertebral 497 ≥65 Plain lateral radiographs of thoracic and lumbar spine fragility fractures over a 6-year period. Data collected from admission, at discharge, and at with collapse of the anterior and posterior borders at the end of the study period for readmission outcomes. >15% of its normal height Levy et al. [19] America Evaluate outcomes in vertebral fragility fracture patients treated operatively and non- 250 Not stated ICD-9 (cod 805.2, 805.4) operatively over 10 years. Maravic et al. [20] France Study of hospital burden and outcomes of patients treated with vertebroplasty or non- 13,624 ≥60 ICD-10 (code M48.4, M48.5, M80.-8, M81.-8, S22.0, operatively admitted into French hospitals with vertebral fragility fractures identified from S22.1, S32.0, S32.7, T08) the 2009 French Hospital National Database. Data collected from admission till 1 year after hospitalisation. Nolla et al. [21] Spain Describe the patient characteristics presenting to a rheumatology unit with vertebral fragility 120 >30 Radiological evidence of at least 20% reduction in fracture related back pain over 10 years. Patients followed up till the end of the study vertebra height taken to indicate a fracture period. Continued Characteristics and outcomes of hospitalised patients comorbidities, where higher scores indicate a higher mortal- ity risk, but is not a comprehensive list of all possible comorbidities [26]. Two studies reporting the Charlson comorbidity index were rated as good quality [14, 25] and two [8, 16] were of moderate quality. Between 77 and 95% of those admitted with vertebral fragility fractures had a low Charlson comorbidity index score, between 0 and 2 [8, 14, 25]. Studies reporting the number of comorbidities indicated higher levels of comorbidity: Gehlbach reported that all patients had at least one co-pathology, and that 75% of men and 78% of women had more than five comorbidities [9]. Maravic reported that 53% had at least one existing ICD-10 coded medical condition:[20] this was the only study that reported on the prevalence of dementia in hospi- talised vertebral fragility fractures, which was 8% [20] (Table 3). Hospital presentation and management Between 59 and 78% of patients admitted to hospital with vertebral fragility fracture were triggered by a preceding fall or trauma [16, 22, 23]. Plain x-ray imaging was the initial radiology investigation of choice [18, 21–23]. However, each study used a different radiological x-ray definition for vertebral fractures. Two studies reported that magnetic resonance imaging of the spine showed signal changes, even though almost half of those with a fracture had no deformity detected on x-ray done at clinical presentation [22, 23]. The majority of vertebral fragility fractures in hospital were managed non-operatively which centred on bed rest, adequate analgesia, mobilise as pain allowed and osteopor- osis management [18, 22–24]. Only two studies reported on the number of patients initiated osteoporosis treatment at 33 and 30%, respectively [7, 19]. Four cohort studies reported on patients that had surgi- cal vertebral augmentation (percutaneous vertebroplasty or balloon kyphoplasty) as part of their treatment in hospital [14, 15, 20, 25]. Three of the studies [14, 20, 25] utilised data obtained from national registries and one study from a local hospital dataset [15]. Between 7 and 11% of patients with vertebral fragility fractures proceeded to vertebroplasty [14, 20]; and between 15 and 33% proceeded to balloon kyphoplasty [14, 25]. Three of these cohort studies described a younger group of patients that were managed operatively [14, 20, 25], and two of them reported that they also had fewer comorbidities [14, 20] although but this association was not demonstrated in another study [25]. Health outcomes Overall hospital mortality ranged from 0.9 to 3.5% [8, 14, 20, 25]. Among the variables analysed, increasing age [8, 14, 20], male gender [8, 14], and increasing comorbid- ities [8, 14, 20] was associated with higher mortality. No other variables associated with hospital mortality were Table 1. Continued Study Country Study description VFF Age, y VFF diagnosis patients, .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. Suseki et al. [22] Japan Identify risk factors for poor clinical outcomes for vertebral fragility fracture patients 159 Not stated Lateral plain radiographs and T1 weighted sagittal MRI admitted with back pain to hospital. Data collected on admission and at discharge from hospital. Takahara et al. [23] Japan Describe radiographic and clinical features of vertebral fragility fracture patients admitted to 78 ≥50 Spinal x-ray assessed using the Genant semi-quantitative hospital with back. Data collected from admission till discharge from hospital. criteria and MRI/bone scan. Pain persisted for >1 week Theander et al. [24] Sweden Compare changes in ADL and QoL over 1 year in patients admitted to hospital with a 42 ≥60 Not stated painful hip or vertebral fragility fracture. Follow up interviews conducted 1 week, 4 and 12 months after the index fracture. Zampini et al. [25] America Compare clinical outcomes and healthcare cost of kyphoplasty compared to those not 5,766 ≥65 ICD-9 (code 805.2, 805.4) operated in patients admitted with vertebral fragility fracture using the Nationwide Inpatient Sample. ADL, activities of daily living; QoL, quality of life; VFF, vertebral fragility fracture. T. Ong et al. Table 2. Incidence of vertebral fragility fractures admitted to hospital Study Country Data source Age Overall incidence of hospital origin inclusion, admission per 10,000/year .. ... .. ... ... .. ... .. ... .. ... .. ... ... .. ... .. ... .. ... ... .. ... .. ... .. ... .. ... ... .. ... Bouza et al. [8] Spain National Hospital Discharge Register 2002 ≥30 2.8 Pentek et al. [12] Hungary Hungarian National Health Insurance Fund Administration 1999–2003 ≥50 4.8 Maravic et al. [20] France French Hospital National Database 2009 ≥60 9.3 Jacobsen et al. [10] America Medicare Provider Analysis and Review 1986–1989 ≥65 9.4 Johnell et al. [17] Sweden National Swedish register, the patient register of the National Board of Health and ≥50 9.7 Welfare, from 1987 to 1994 Gehlbach et al. [9] America Nationwide Inpatient Sample 1997, part of the Healthcare Cost and Utilisation ≥45 16 Project sponsored by the Agency for Healthcare Research and Quality Piscitelli et al. [13] Italy National hospitalisation database maintained by the Italian Ministry of Health ≥40 19.3 2002–2008 described. One year mortality was reported between 20.0 Healthcare resource utilisation and 26.9% [14, 16, 19]. Increasing age and comorbid bur- In total, 13 studies described the length of stay of patients with den were also associated with lower 1 year survival [14, 19]. vertebral fragility fractures in hospital [8, 9, 11, 14–16, 18, 20– Three studies assessed as good on the NOS reported on 25]. These data were drawn from a combination of large the discharge destination of patients after their hospital national databases to findings from single site studies. The admission [9, 14, 25]. Overall, between 34 and 50% were median length of stay was 9.8 (IQR = 5.6–12.5; range: 5–41.7) transferred to either an institutional care facility or skilled days. Longer length of stay was associated with increasing nursing facility; between 24 and 38% were discharged to comorbidities [8, 9, 20]. Other variables such as age [21], gen- their usual residence without any formal support; and der [8, 21, 22], increasing number of fractures [21], history of 11–15% went home with formal support [9, 14, 25]. The trauma [23] and signal change on MRI of the spine [23]was studies did not report long term care home rates. None of not associated with duration of inpatient stay (Table 3). the studies reported any predictors of discharge destination. Only two cohort studies reported data on hospital- related complication [14, 25]. Pneumonia was the most Discussion prevalent complication at 3% [14, 25]. The prevalence of pressure ulcers was 1%; and hospital acquired infection was There was wide geographical variation in the incidence of 0.1% [14, 25]. Prevalence of deep vein thrombosis (DVT) patients hospitalised due to vertebral fragility fractures. varied from 0.2 [25] to 2.7% [14]. The reason for this differ- These patients were mostly older women, between the ages ence is unclear as neither study described its DVT diagnostic of 70 and 85 years, one-third of whom had a previous diag- criteria or presence of any local venous thromboembolic nosis of osteoporosis or a previous fragility fracture. Three- prevention and management. quarter of patients presented following a low trauma injury. Three different studies reported new disability and pain Most patients were managed non-operatively; and there was symptoms after hospital admission [16, 23, 24]. Theander et al. wide variability in the proportion who had either percutan- [24] reported that among patients that were independent with eous vertebroplasty or balloon kyphoplasty. Bone health personal and extended activities of daily living on admission, assessment and prescription of medication for osteoporosis only 31% at 4 months and none at 12 months was still com- occurred in only a third. Patients stayed an average 10 days pletely independent post-hospital admission. No patients in hospital. Although hospital mortality from vertebral fra- returned to their pre-admission state. This study did have a gility fracture was low (0.9–3.5%), there were longer term cohort with a high prevalence of multiple fractures (average consequences post-fracture: up to half of patients were dis- number of vertebral deformities per patient was 5) and was charged from hospital into a care facility; a considerable assessed using the NOS to be of poor quality [24]. Gosch et al. proportion of patients (depending upon the way this was [16] reported that the mean (SD) Barthel index at 1 year post- measured in different studies) were more dependent for fracture was 69/100(32), a score the authors felt to indicate sig- their activities of daily living after discharge. Age and nificant dependency for assistance with activities of daily living. comorbidities were associated with worse outcomes, such However, there was no baseline score to compare with. At 12 as hospital length of stay and mortality. months post-admission, there was a reduction in mobility as Although this review used a systematic search process, measured using the Parker Mobility Scale by 24% [16]. Suseki some of the findings were limited by the small number of et al. [22] reported that up to 35% of their cohort had new studies contributing to each aspect of patient characteristics back related disability (where pain is either more intense, longer and outcomes. Of the 19 studies included, only five studies in duration, or higher patient-reported pain score; with new were considered high quality and we have drawn our key limitation of activity not present before back pain) (Table 3). findings and conclusions from the most reliable studies. For 22 Characteristics and outcomes of hospitalised patients Table 3. Main findings of included studies Known osteoporosis Previous Comorbidities Mortality Discharge destination Disability post-hospitalisation Mean length fracture of stay, days .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... Bloomfield et al. [7] 35.1% Bouza et al. [8] 35.2% CCI score: ≤2 95.1%; 3.5% 11.4 ≥3 4.9% Gehlbach et al. [9] ≥5 diagnoses in 75.1% Institutional care: 42.0% men, 5.8 men, 78.4% women 52.3% women Usual residence with support: 11.6% men, 13.1% women Usual residence with no support: 46.4% men, 34.6% women Papaioannou et al. [11] 10.1 Chen et al. [14] CCI score: ≤2 77.0%; 1.7% 1 year mortality: Institutional care: 32.7% 7.4 ≥3 23.0% 26.9% Usual residence with support: 14.8% Usual residence with no support: 37.9% Flug et al. [15] 8.1 Gosch et al. [16] 49.1% 41.8% Mean (SD) 2.3 (1.6) 1 year mortality: 20% BI at 12 months post-hospitalisation was mean 9.0 (SD) 68.7(31.6); reduction in PMS by 24% Lee and Yip [18] 5.0 Levy [19] 1 year mortality: 25.2% .Maravic et al. et al. [20] 53% had at least one 0.9% 9.6 medical condition Nolla et al. [21] 15.9 Suseki et al. [22] Study mean BMD considered 35% had new back related disability 41.7 diagnostic of osteoporosis Takahara et al. [23] Study mean BMD considered 22.6 diagnostic of osteoporosis Theander et al. [24] Independent with personal and extended ADL: Median, 10 30.5% at 4 months; 0% at 12 months Zampini et al. [25] CCI score: ≤2 86.0%; 2.5% Institutional care: 33.5% 5.3 ≥3 14.0% Usual residence with support: 11.3% Usual residence with no support: 21% BI, Barthel index; PMS, Parker mobility scale; BMD, bone mineral density; ADL, activities of daily living; CCI, Charlson comorbidity index. T. Ong et al. example, the finding that there was wide variation in the identify those with co-pathologies in order to mitigate their incidence of hospitalisation for vertebral fragility fracture effects upon length of stay and subsequent outcomes. It is was evidenced by large national database studies and is likely that a service making use of Comprehensive Geriatric likely to be genuine. We appreciate that the results we Assessment, either as an in-patient or elsewhere, would be reviewed do not take account of incidental vertebral frac- required for this group. Given that most people will have tures encountered in patients admitted for other conditions. presented with a fall, all patients should be given access to The findings we present about the demographic features of services and interventions that reduce the risk of further patients are based on robust, representative studies, but the falls such as strength and balance training. data in them were limited. We note that we found little or The review also illustrates gaps in the research knowl- no information about levels of frailty, mood, cognition or edge that are suitable for future research. Relatively little is quality of life. The wide scope of this review requires limits known about the effect that frailty and cognitive impair- on what is found by the search and selection process, which ment has upon the management and outcome of vertebral may lead to the omission of some relevant studies. We fragility fractures. Similarly, little is known about exactly aimed to examine and mitigate against this by hand search- why there is increased disability in many patients at out- ing the reference lists of selected papers; we identified only come and hence how this might be reduced. Whilst this one of our 19 papers this way. review did not study the effectiveness of intervention or To the best of our knowledge, there have been no previ- services for vertebral fragility fractures, future research will ous reviews that have reported the characteristics and out- need to be developed for this group of patients. comes specifically for patients admitted to hospital with vertebral fragility fractures. We have identified that patients Key points with vertebral fragility fractures admitted to hospital are on average in their 80s and have a traumatic event preceding their � Older people and those with multiple comorbidities hospital admission, making them slightly different from those admitted to hospital with a vertebral fragility fracture are who are not admitted, who more commonly sustain ‘atrau- at higher mortality risk and discharge to a care facility. matic’ fractures [27]. Studies using the Charlson Comorbidity � This review highlights that there is still a gap in evidence Index showed low levels of comorbidity, but this index is a of how patient and fracture characteristics of those hospi- prognostic score rather than a comprehensive list. Studies list- talised affect their short and longer term outcomes. ing the total number of comorbidities showed comorbidity to � Further understanding of the natural history of this be common—three quarter of patients had five or more cohort will help inform the development of a specialist comorbidities. This is important because healthcare outcomes service, such as an orthogeriatric model for patients such as mortality, length of stay and discharge to a care facility admitted to hospital with a vertebral fragility fractures. are associated with increasing comorbidities. Therefore, services taking into account of comorbidities in many, but not all, patients could potentially influence their outcomes. Such a spe- Supplementary data cialised service for vertebral fragility fractures admitted to hos- pital could deliver similar benefits as those in the management Supplementary data are available at Age and Ageing online. of hip fractures where levels of comorbidity are also high [28]. Thus, this review provides a unique summary of the evi- Acknowledgements dence base upon which plans for a specific service for ver- tebral fragility fractures admitted to hospital can be based. We would like to thank Dr Veronika Van der Wardt for The review indicates considerable geographical variation in reviewing the manuscript prior to submission. admission rates, which could reflect both the geographical incidence of vertebral fragility fractures (and hence the prevalence of osteoporosis and the falls rate) and the pro- Conflict of interest portion of these patients that are admitted to hospital. None declared. Those setting up services for patients with vertebral fragility fractures may need to acquire local data in order to scope an appropriately sized service. The review also indicates Funding that such a service will need to have second-line diagnostic T.O. is a recipient of a research training fellowship from the capabilities, given that half of patients will have no changes Dunhill Medical Trust (grant number RTF49/0114). on plain X-rays. The review also shows that such a service has the potential to improve bone health and prevent future fractures through routine diagnosis and management of Declaration osteoporosis. A service would need to have a consistent approach to ensure that all who might benefit from surgery All authors declare no support from any organisation for have access to it. 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Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review

Age and Ageing , Volume 47 (1) – May 10, 2017

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© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.
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10.1093/ageing/afx079
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Abstract

Background: the complex management for patients presenting to hospital with vertebral fragility fractures provides justifi- cation for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the develop- ment of such a service. Methods: non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers. Results: a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fra- gility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more co- pathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality. Conclusion: these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted—providing access to diagnostic, therapeutic, surgical and rehabilitation interventions. Keywords: vertebral fragility fracture, hospital, osteoporosis, older people 17 T. Ong et al. those studies fulfilling the eligibility criteria or where there was Introduction uncertainty. Disagreements were resolved through discussion. In Europe, it is estimated that 3.5 million fragility fractures are sustained annually, 520,000 of them vertebral fragility frac- Data extraction tures [1]. Patients presenting to hospital with vertebral fragility The variables of interest were specified prior to the search and fractures have varying levels of pain and disability, for which comprised: hospital admission incidence; patient demographics; there are an increasing number of interventions, both medical bone health; comorbid burden; frailty; cognition; mood, activ- and surgical. The large number of such patients, their clinical ities of daily living; clinical presentation to hospital; proportion complexity and the complexity of their management may pro- of patients managed operatively; health outcomes (mortality, vide justification for the development of specific services for institutionalisation, hospital complications, changes in patient’s them, as has been done with the orthogeriatric model of care health status) and resource utilisation (length of hospital stay, for patients with hip fracture [2]. To developsuchaservicefor primary and secondary care attendance post-hospitalisation). vertebral fragility fractures, it is important to have an under- Data were extracted by two reviewers (T.O. and P.K.) using a standing of the number of patients in need of hospital admis- specified data extraction form. sion, their clinical presentation, management and outcomes. A review of existing scientific literature would provide such information. Therefore, we conducted a review of the existing Methodological quality literature to determine the incidence of hospital admission for The Newcastle-Ottawa Scale (NOS) was used to assess quality vertebral fragility fractures, their characteristics and health out- of the included studies (Appendix 2 in Supplementary data). comes with the overall intention of informing the development The scale was adapted to appraise the quality of cross-sectional of a specific service for vertebral fragility fracture management studies. Cut-off scores were used to rate quality of the studies in hospital. [4, 5]. No studies were excluded on the basis of their methodo- logical quality. Methods Synthesis of results Eligibility criteria A narrative synthesis was done under specific headings The protocol (available on request from the authors) and based on the framework by the Economic Social and reporting of this review was conducted in accordance with Research Council [6]. The synthesis process was an iterative the PRISMA statement for systematic reviews [3]. All non- one of exploring relationships within and between the randomised studies (cohort, case-control and cross-sectional reported data to see how different studies contributed to studies) of patients which reported either hospital admission the relevant headings. Where appropriate, findings from incidence, patient characteristics or outcomes associated with included studies were grouped together and reported using hospitalisation for vertebral fragility fracture were eligible for appropriate descriptive statistics. When results were pooled, inclusion. Eligibility criteria were if the majority of participants studies were weighted according to their sample size. were ≥50 years, and if the fractures were either low-trauma or due to osteoporosis. Studies were excluded if they included participants with malignancy, clinical features of a high impact Results injury (i.e. burst fracture, unstable fracture and spinal cord The search strategy identified 6,057 titles and abstracts. impingement), cervical fractures, incidental vertebral fragility After excluding duplicates, 5983 titles and abstracts were fracture and recruitment outside an inpatient setting. screened. A total of 18 studies were identified from the search for inclusion and one paper was further identified Search strategy through citation searching (Fig. 1). In total, 19 studies were The search was conducted using MEDLINE, EMBASE, included in the systematic review, of which seven studies CINAHL and AMED database from inception till November were cross-sectional and twelve were cohort studies, origin- 2015. The search strategy focussed on the core search terms of ating from eleven countries (Table 1). Overall, 12 out of the ‘vertebral fracture’ and its focus of care which is in ‘hospital’ 19 included studies were judged to be of moderate or good using the appropriate search terms, synonyms, and related quality (Supplementary data Appendix 3). terms. Citation searches were performed on the included papers and their reference lists were also scanned for relevant Incidence of hospital admission with vertebral papers. The search strategy for MEDLINE is detailed in the fracture supplementary data (Appendix 1). Seven studies reported the incidence of hospital admission with vertebral fragility fracture using large national hospital databases Study selection of Spain [8], America [9], Hungary [12], Italy [13], Sweden [17] The screening of titles and abstracts were done independently and France [20]; and Medicare, an American national insurance by two reviewers (T.O. and P.K.). Full texts were obtained for programme dataset [10]. There was geographical variation in 18 Characteristics and outcomes of hospitalised patients Figure 1. Flow diagram of study selection. the overall incidence of hospital admission from 2.8 to 19.3 per assessed as of poor quality [23], were of moderate quality 10,000/year (Table 2). The incidence rose with increasing age, [7, 8, 16, 22]. One study [8] reported data from a national peaking at 10–50 per 10,000/year in people older than 80. The registry and four used individual local hospital data [7, 16, incidence of hospitalisation for vertebral fragility fracture for 22, 23]. Gosch reported that 49% of those admitted to hos- men and women were relatively similar in the 50–60 years age pital with a vertebral fragility fractures had a known diagno- group, but a higher incidence was reported in women older sis of osteoporosis [16]. Bouza using the national Spanish than 60, with at least a ratio of 2:1. registry reported that 35% of their study population had osteoporosis coded as part of the hospital admission [8]. Both Suseki and Takahara did not describe the prevalence Patient demographics of osteoporosis but reported that the average bone mineral In total, 10 studies [7–10, 13, 14, 17, 18, 20, 25] were con- density values in among their study participants was low sidered fully representative of a hospitalised vertebral fragility enough to be considered osteoporotic [22, 23]. Gosch and fracture cohort using the NOS assessment of study quality. Bloomfield further reported that 42 and 35% of those with The pooled, weighted, proportion of women in these studies vertebral fragility fractures had sustained a low trauma frac- was 65% (range: 57–84%). Four of these studies [7, 8, 14, 25] ture previously [7, 16] (Table 3). reported patients’ ages: the pooled weighted mean age was 81 years (range: 70–82). No other demographic details were reported in the included studies. Comorbidities Four studies used the Charlson comorbidity index to report Bone health history comorbidities [8, 14, 16, 25] and two studies simply The prevalence of osteoporotic bone disease was reported reported the number of comorbidities [9, 20]. The in five studies. These studies, except one which was Charlson comorbidity index is a clinical scale of weighted 19 T. Ong et al. Table 1. Characteristics of included studies Study Country Study description VFF Age, y VFF diagnosis patients, .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. Cross-sectional Bloomfield and Sing [7] New Zealand Analysis of discharge records of patients from a large district hospital over 12 months for 154 >65 Identified using hospital discharge summaries prescription of secondary prevention for osteoporosis on discharge. Bouza et al. [8] Spain Using the 2002 National Hospital Discharge Register of patients admitted with vertebral 7,100 >30 ICD-9 (code 805, all subgroups) fragility fracture and osteoporosis over 12 months to determine the burden of vertebral fragility fracture and its impact on healthcare services. Gehlbach et al. [9] America Describe characteristics of patients with vertebral fragility fracture identified using the 1997 68,901 ≥45 ICD-9 (code 733.13, 805.2, 805.4 and 805.8) Nationwide Inpatient Sample and their resource use compared with hip fractures. Jacobsen et al. [10] America Incidence of vertebral fragility fracture hospitalisation over 4 years using the Medicare 14,091 ≥65 ICD-9 (code 805.0, 805.2, 805.4, 805.8) Provider Analysis and Review file. Papaioannou et al. [11] Canada Length of stay of patients in an acute hospital with vertebral fragility fractures identified from 3,494 ≥50 ICD-9 (code 805.2, 805.4, 733.13) the Canadian Institute for Health Information Discharge Abstract Database over 12 months. Pentek et al. [12] Hungary Hospital incidence of patients admitted with vertebral fragility fractures identified from the 8,195 ≥50 ICD-10 (code S22.0, S22.1, S32.0, M48.5) Hungarian National Health Insurance Fund Administration over 5 years. Piscitelli et al. [13] Italy National incidence of vertebral fragility fractures over 7 years based on the national 413,724 ≥40 ICD-9 (code 805, all subgroups) hospitalisation database maintained by the Italian Ministry of Health to assess hip, vertebral, humerus, wrist/forearm fragility fracture incidence. Cohort Chen et al. [14] America Compare outcomes of vertebral fragility fracture patients treated operatively (vertebroplasty 68,752 ≥65 ICD-9 (code 733.13, 805.2, 805.4) or kyphoplasty) or non-operatively identified from the Medicare 2006 database. Data collected at baseline, discharge, 6 months, 1, 2 and 3 years. Flug et al. [15] America Outcome of patients admitted with vertebral fragility fractures and treated operatively 248 Not stated ICD-9 (code 733.13, 805.2, 805.4) (vertebroplasty or kyphoplasty) over 30 months compared with those not operated. Data collected at admission and at 30 days post-discharge. Gosch et al. [16] Austria Describe outcome of patients admitted to an orthogeriatric unit with a non-hip fracture 55 ≥70 Not stated (vertebral fragility fractures, humerus, wrist, thoracic, pelvis, lower extremity and other fractures). Data collected on admission and at 1 year follow up. Johnell et al. [17] Sweden Patients identified from the Swedish Patient Register over 8 years for with either a thoracic or 17,425 ≥50 ICD-9 (no codes available) lumbar high- or low-energy fracture and followed up to assess risk of subsequent fracture. Lee and Yip [18] Hong Kong Describe characteristics and outcomes of patients admitted with low back pain and vertebral 497 ≥65 Plain lateral radiographs of thoracic and lumbar spine fragility fractures over a 6-year period. Data collected from admission, at discharge, and at with collapse of the anterior and posterior borders at the end of the study period for readmission outcomes. >15% of its normal height Levy et al. [19] America Evaluate outcomes in vertebral fragility fracture patients treated operatively and non- 250 Not stated ICD-9 (cod 805.2, 805.4) operatively over 10 years. Maravic et al. [20] France Study of hospital burden and outcomes of patients treated with vertebroplasty or non- 13,624 ≥60 ICD-10 (code M48.4, M48.5, M80.-8, M81.-8, S22.0, operatively admitted into French hospitals with vertebral fragility fractures identified from S22.1, S32.0, S32.7, T08) the 2009 French Hospital National Database. Data collected from admission till 1 year after hospitalisation. Nolla et al. [21] Spain Describe the patient characteristics presenting to a rheumatology unit with vertebral fragility 120 >30 Radiological evidence of at least 20% reduction in fracture related back pain over 10 years. Patients followed up till the end of the study vertebra height taken to indicate a fracture period. Continued Characteristics and outcomes of hospitalised patients comorbidities, where higher scores indicate a higher mortal- ity risk, but is not a comprehensive list of all possible comorbidities [26]. Two studies reporting the Charlson comorbidity index were rated as good quality [14, 25] and two [8, 16] were of moderate quality. Between 77 and 95% of those admitted with vertebral fragility fractures had a low Charlson comorbidity index score, between 0 and 2 [8, 14, 25]. Studies reporting the number of comorbidities indicated higher levels of comorbidity: Gehlbach reported that all patients had at least one co-pathology, and that 75% of men and 78% of women had more than five comorbidities [9]. Maravic reported that 53% had at least one existing ICD-10 coded medical condition:[20] this was the only study that reported on the prevalence of dementia in hospi- talised vertebral fragility fractures, which was 8% [20] (Table 3). Hospital presentation and management Between 59 and 78% of patients admitted to hospital with vertebral fragility fracture were triggered by a preceding fall or trauma [16, 22, 23]. Plain x-ray imaging was the initial radiology investigation of choice [18, 21–23]. However, each study used a different radiological x-ray definition for vertebral fractures. Two studies reported that magnetic resonance imaging of the spine showed signal changes, even though almost half of those with a fracture had no deformity detected on x-ray done at clinical presentation [22, 23]. The majority of vertebral fragility fractures in hospital were managed non-operatively which centred on bed rest, adequate analgesia, mobilise as pain allowed and osteopor- osis management [18, 22–24]. Only two studies reported on the number of patients initiated osteoporosis treatment at 33 and 30%, respectively [7, 19]. Four cohort studies reported on patients that had surgi- cal vertebral augmentation (percutaneous vertebroplasty or balloon kyphoplasty) as part of their treatment in hospital [14, 15, 20, 25]. Three of the studies [14, 20, 25] utilised data obtained from national registries and one study from a local hospital dataset [15]. Between 7 and 11% of patients with vertebral fragility fractures proceeded to vertebroplasty [14, 20]; and between 15 and 33% proceeded to balloon kyphoplasty [14, 25]. Three of these cohort studies described a younger group of patients that were managed operatively [14, 20, 25], and two of them reported that they also had fewer comorbidities [14, 20] although but this association was not demonstrated in another study [25]. Health outcomes Overall hospital mortality ranged from 0.9 to 3.5% [8, 14, 20, 25]. Among the variables analysed, increasing age [8, 14, 20], male gender [8, 14], and increasing comorbid- ities [8, 14, 20] was associated with higher mortality. No other variables associated with hospital mortality were Table 1. Continued Study Country Study description VFF Age, y VFF diagnosis patients, .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. Suseki et al. [22] Japan Identify risk factors for poor clinical outcomes for vertebral fragility fracture patients 159 Not stated Lateral plain radiographs and T1 weighted sagittal MRI admitted with back pain to hospital. Data collected on admission and at discharge from hospital. Takahara et al. [23] Japan Describe radiographic and clinical features of vertebral fragility fracture patients admitted to 78 ≥50 Spinal x-ray assessed using the Genant semi-quantitative hospital with back. Data collected from admission till discharge from hospital. criteria and MRI/bone scan. Pain persisted for >1 week Theander et al. [24] Sweden Compare changes in ADL and QoL over 1 year in patients admitted to hospital with a 42 ≥60 Not stated painful hip or vertebral fragility fracture. Follow up interviews conducted 1 week, 4 and 12 months after the index fracture. Zampini et al. [25] America Compare clinical outcomes and healthcare cost of kyphoplasty compared to those not 5,766 ≥65 ICD-9 (code 805.2, 805.4) operated in patients admitted with vertebral fragility fracture using the Nationwide Inpatient Sample. ADL, activities of daily living; QoL, quality of life; VFF, vertebral fragility fracture. T. Ong et al. Table 2. Incidence of vertebral fragility fractures admitted to hospital Study Country Data source Age Overall incidence of hospital origin inclusion, admission per 10,000/year .. ... .. ... ... .. ... .. ... .. ... .. ... ... .. ... .. ... .. ... ... .. ... .. ... .. ... .. ... ... .. ... Bouza et al. [8] Spain National Hospital Discharge Register 2002 ≥30 2.8 Pentek et al. [12] Hungary Hungarian National Health Insurance Fund Administration 1999–2003 ≥50 4.8 Maravic et al. [20] France French Hospital National Database 2009 ≥60 9.3 Jacobsen et al. [10] America Medicare Provider Analysis and Review 1986–1989 ≥65 9.4 Johnell et al. [17] Sweden National Swedish register, the patient register of the National Board of Health and ≥50 9.7 Welfare, from 1987 to 1994 Gehlbach et al. [9] America Nationwide Inpatient Sample 1997, part of the Healthcare Cost and Utilisation ≥45 16 Project sponsored by the Agency for Healthcare Research and Quality Piscitelli et al. [13] Italy National hospitalisation database maintained by the Italian Ministry of Health ≥40 19.3 2002–2008 described. One year mortality was reported between 20.0 Healthcare resource utilisation and 26.9% [14, 16, 19]. Increasing age and comorbid bur- In total, 13 studies described the length of stay of patients with den were also associated with lower 1 year survival [14, 19]. vertebral fragility fractures in hospital [8, 9, 11, 14–16, 18, 20– Three studies assessed as good on the NOS reported on 25]. These data were drawn from a combination of large the discharge destination of patients after their hospital national databases to findings from single site studies. The admission [9, 14, 25]. Overall, between 34 and 50% were median length of stay was 9.8 (IQR = 5.6–12.5; range: 5–41.7) transferred to either an institutional care facility or skilled days. Longer length of stay was associated with increasing nursing facility; between 24 and 38% were discharged to comorbidities [8, 9, 20]. Other variables such as age [21], gen- their usual residence without any formal support; and der [8, 21, 22], increasing number of fractures [21], history of 11–15% went home with formal support [9, 14, 25]. The trauma [23] and signal change on MRI of the spine [23]was studies did not report long term care home rates. None of not associated with duration of inpatient stay (Table 3). the studies reported any predictors of discharge destination. Only two cohort studies reported data on hospital- related complication [14, 25]. Pneumonia was the most Discussion prevalent complication at 3% [14, 25]. The prevalence of pressure ulcers was 1%; and hospital acquired infection was There was wide geographical variation in the incidence of 0.1% [14, 25]. Prevalence of deep vein thrombosis (DVT) patients hospitalised due to vertebral fragility fractures. varied from 0.2 [25] to 2.7% [14]. The reason for this differ- These patients were mostly older women, between the ages ence is unclear as neither study described its DVT diagnostic of 70 and 85 years, one-third of whom had a previous diag- criteria or presence of any local venous thromboembolic nosis of osteoporosis or a previous fragility fracture. Three- prevention and management. quarter of patients presented following a low trauma injury. Three different studies reported new disability and pain Most patients were managed non-operatively; and there was symptoms after hospital admission [16, 23, 24]. Theander et al. wide variability in the proportion who had either percutan- [24] reported that among patients that were independent with eous vertebroplasty or balloon kyphoplasty. Bone health personal and extended activities of daily living on admission, assessment and prescription of medication for osteoporosis only 31% at 4 months and none at 12 months was still com- occurred in only a third. Patients stayed an average 10 days pletely independent post-hospital admission. No patients in hospital. Although hospital mortality from vertebral fra- returned to their pre-admission state. This study did have a gility fracture was low (0.9–3.5%), there were longer term cohort with a high prevalence of multiple fractures (average consequences post-fracture: up to half of patients were dis- number of vertebral deformities per patient was 5) and was charged from hospital into a care facility; a considerable assessed using the NOS to be of poor quality [24]. Gosch et al. proportion of patients (depending upon the way this was [16] reported that the mean (SD) Barthel index at 1 year post- measured in different studies) were more dependent for fracture was 69/100(32), a score the authors felt to indicate sig- their activities of daily living after discharge. Age and nificant dependency for assistance with activities of daily living. comorbidities were associated with worse outcomes, such However, there was no baseline score to compare with. At 12 as hospital length of stay and mortality. months post-admission, there was a reduction in mobility as Although this review used a systematic search process, measured using the Parker Mobility Scale by 24% [16]. Suseki some of the findings were limited by the small number of et al. [22] reported that up to 35% of their cohort had new studies contributing to each aspect of patient characteristics back related disability (where pain is either more intense, longer and outcomes. Of the 19 studies included, only five studies in duration, or higher patient-reported pain score; with new were considered high quality and we have drawn our key limitation of activity not present before back pain) (Table 3). findings and conclusions from the most reliable studies. For 22 Characteristics and outcomes of hospitalised patients Table 3. Main findings of included studies Known osteoporosis Previous Comorbidities Mortality Discharge destination Disability post-hospitalisation Mean length fracture of stay, days .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... .. .. .. .. .. ... Bloomfield et al. [7] 35.1% Bouza et al. [8] 35.2% CCI score: ≤2 95.1%; 3.5% 11.4 ≥3 4.9% Gehlbach et al. [9] ≥5 diagnoses in 75.1% Institutional care: 42.0% men, 5.8 men, 78.4% women 52.3% women Usual residence with support: 11.6% men, 13.1% women Usual residence with no support: 46.4% men, 34.6% women Papaioannou et al. [11] 10.1 Chen et al. [14] CCI score: ≤2 77.0%; 1.7% 1 year mortality: Institutional care: 32.7% 7.4 ≥3 23.0% 26.9% Usual residence with support: 14.8% Usual residence with no support: 37.9% Flug et al. [15] 8.1 Gosch et al. [16] 49.1% 41.8% Mean (SD) 2.3 (1.6) 1 year mortality: 20% BI at 12 months post-hospitalisation was mean 9.0 (SD) 68.7(31.6); reduction in PMS by 24% Lee and Yip [18] 5.0 Levy [19] 1 year mortality: 25.2% .Maravic et al. et al. [20] 53% had at least one 0.9% 9.6 medical condition Nolla et al. [21] 15.9 Suseki et al. [22] Study mean BMD considered 35% had new back related disability 41.7 diagnostic of osteoporosis Takahara et al. [23] Study mean BMD considered 22.6 diagnostic of osteoporosis Theander et al. [24] Independent with personal and extended ADL: Median, 10 30.5% at 4 months; 0% at 12 months Zampini et al. [25] CCI score: ≤2 86.0%; 2.5% Institutional care: 33.5% 5.3 ≥3 14.0% Usual residence with support: 11.3% Usual residence with no support: 21% BI, Barthel index; PMS, Parker mobility scale; BMD, bone mineral density; ADL, activities of daily living; CCI, Charlson comorbidity index. T. Ong et al. example, the finding that there was wide variation in the identify those with co-pathologies in order to mitigate their incidence of hospitalisation for vertebral fragility fracture effects upon length of stay and subsequent outcomes. It is was evidenced by large national database studies and is likely that a service making use of Comprehensive Geriatric likely to be genuine. We appreciate that the results we Assessment, either as an in-patient or elsewhere, would be reviewed do not take account of incidental vertebral frac- required for this group. Given that most people will have tures encountered in patients admitted for other conditions. presented with a fall, all patients should be given access to The findings we present about the demographic features of services and interventions that reduce the risk of further patients are based on robust, representative studies, but the falls such as strength and balance training. data in them were limited. We note that we found little or The review also illustrates gaps in the research knowl- no information about levels of frailty, mood, cognition or edge that are suitable for future research. Relatively little is quality of life. The wide scope of this review requires limits known about the effect that frailty and cognitive impair- on what is found by the search and selection process, which ment has upon the management and outcome of vertebral may lead to the omission of some relevant studies. We fragility fractures. Similarly, little is known about exactly aimed to examine and mitigate against this by hand search- why there is increased disability in many patients at out- ing the reference lists of selected papers; we identified only come and hence how this might be reduced. Whilst this one of our 19 papers this way. review did not study the effectiveness of intervention or To the best of our knowledge, there have been no previ- services for vertebral fragility fractures, future research will ous reviews that have reported the characteristics and out- need to be developed for this group of patients. comes specifically for patients admitted to hospital with vertebral fragility fractures. We have identified that patients Key points with vertebral fragility fractures admitted to hospital are on average in their 80s and have a traumatic event preceding their � Older people and those with multiple comorbidities hospital admission, making them slightly different from those admitted to hospital with a vertebral fragility fracture are who are not admitted, who more commonly sustain ‘atrau- at higher mortality risk and discharge to a care facility. matic’ fractures [27]. Studies using the Charlson Comorbidity � This review highlights that there is still a gap in evidence Index showed low levels of comorbidity, but this index is a of how patient and fracture characteristics of those hospi- prognostic score rather than a comprehensive list. Studies list- talised affect their short and longer term outcomes. ing the total number of comorbidities showed comorbidity to � Further understanding of the natural history of this be common—three quarter of patients had five or more cohort will help inform the development of a specialist comorbidities. This is important because healthcare outcomes service, such as an orthogeriatric model for patients such as mortality, length of stay and discharge to a care facility admitted to hospital with a vertebral fragility fractures. are associated with increasing comorbidities. Therefore, services taking into account of comorbidities in many, but not all, patients could potentially influence their outcomes. Such a spe- Supplementary data cialised service for vertebral fragility fractures admitted to hos- pital could deliver similar benefits as those in the management Supplementary data are available at Age and Ageing online. of hip fractures where levels of comorbidity are also high [28]. Thus, this review provides a unique summary of the evi- Acknowledgements dence base upon which plans for a specific service for ver- tebral fragility fractures admitted to hospital can be based. We would like to thank Dr Veronika Van der Wardt for The review indicates considerable geographical variation in reviewing the manuscript prior to submission. admission rates, which could reflect both the geographical incidence of vertebral fragility fractures (and hence the prevalence of osteoporosis and the falls rate) and the pro- Conflict of interest portion of these patients that are admitted to hospital. None declared. Those setting up services for patients with vertebral fragility fractures may need to acquire local data in order to scope an appropriately sized service. The review also indicates Funding that such a service will need to have second-line diagnostic T.O. is a recipient of a research training fellowship from the capabilities, given that half of patients will have no changes Dunhill Medical Trust (grant number RTF49/0114). on plain X-rays. The review also shows that such a service has the potential to improve bone health and prevent future fractures through routine diagnosis and management of Declaration osteoporosis. A service would need to have a consistent approach to ensure that all who might benefit from surgery All authors declare no support from any organisation for have access to it. Furthermore, the review demonstrates the submitted work; no financial relationships with any that a vertebral fragility fractures service would need to organisations that might have an interest in the submitted 24 Characteristics and outcomes of hospitalised patients morbidity after vertebral compression fracture in the work; no other relationships or activities that could appear Medicare population. J Bone Joint Surg Am 2013; 95: to have influenced the submitted work. 1729–36. 15. Flug J, Hanford A, Ortiz O. Vertebral augmentation versus References conservative therapy for emergently admitted vertebral com- pression deformities: an economic analysis. Pain Physician 1. Hernlund E, Svedborn A, ivergard M, Compston J, Cooper C, 2013; 16: 441–5. Stenmark J et al. Osteoporosis in the European Union: medical 16. Gosch M, Druml T, Nicholas JA et al. Fragility non-hip frac- management, epidemiology and economic burden. Arch ture patients are at risk. 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Age and AgeingPubmed Central

Published: May 10, 2017

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