Osteoporotic fractures impose a significant morbidity, mortality and economic burden (1). Research within our hospital confirmed low rates of identification and secondary prevention for patients discharged from Emergency Department (ED) with a fracture (2). The Fracture Liaison Service (FLS) aimed to identify, review and then manage these patients following their discharge from the ED.
Objectives
To evaluate the performance of a FLS in a Western Australian hospital.
Methods
Patients aged >50 yrs who presented to the Emergency Department after a fracture at Sir Charles Gairdner Hospital (SCGH) were invited to the FLS. A retrospective control group from SCGH determined the historical fracture risk without an active FLS intervention. Fremantle Hospital was used as a prospective control cohort. Demographic data was collected at baseline then patients were followed up at 3 & 12 months. The follow-up survey collected information on: awareness of osteoporosis, investigations undertaken (e.g. BMD testing), had a diagnosis been made, medication usage, health care utilisation, falls & fracture information and quality of life (EQ-5D).
Results
The FLS reduced the recurrence of minimal trauma fractures over 12 months by between 9.2 to 10.2% compared to a retrospective cohort & a prospective control cohort. 167 or 69.3% of eligible patients agreed to attend the Fragile Bone Clinic. As the program becomes more main-stream the utilisation of the service is expected to increase. The FLS demonstrated a 17.1% increase in patient awareness of osteoporosis compared to other sites and by 35.6% compared to the SCGH retrospective group over 12 months (p<0.001). The FLS had better prescription rates of calcium (57.4% vs 28.8%), vitamin D (59.8% vs 33.0%), optimised calcium & vitamin D (48.4% vs 19.8%) and anti-resorptive therapy (29.9% vs 16.2%) compared to the retrospective cohort at SCGH. At 12 months the FLS had the highest number (n=82) and rate (46.9%) of patients initiated on pharmacological treatment compared to other sites 17 (41.5%) and SCGH Retrospective 12 (16.0%). The FLS incrementally improved the prescription, adherence and compliance with of osteoporosis treatment.
Conclusions
By 12 months the Fracture Liaison Service demonstrated that it reduced the recurrent fracture rate and significantly improved rates of pharmacological treatment initiation & patient awareness of osteoporosis.
References
Briggs AM et al. (2015) Hospitalisations, admission costs and re-fracture risk related to osteoporosis in Western Australia are substantial: a 10-year review. ANZ J Public Health. Inderjeeth CA et al. (2010) A multimodal intervention to improve fragility fracture management in patients presenting to Emergency Departments. MJA
I read the article by Gilligan et al 1 with interest but was very surprised initially at their lack of association of “boarding” with increased mortality. I note in the discussion that they compared their findings with those of Richardson2 and stated that they did not find a similar outcome. I would suggest that there are a number of reasons why this study did not find similar findings to Richardson2 or Sprivulis et al ,3 who found strong correlations between admission during overcrowded periods and death …
Abstract : During 1975 five oceanographic cruises were made by the US Coast Guard to the Grand Banks region. During April (IIP-1-75) a large anticyclonic eddy was observed between the Labrador Current and the North Atlantic Current. The eddy appeared to move southward and rejoin the North Atlantic Current. Six occupations of standard section A3, spaced throughout the year, revealed a relatively smooth pattern of variation for the Labrador Current with maximum southward transport and minimum water temperature in April changing to minimum transport and maximum temperature in November. However, repeated occupation of standard section A1 over a 54 hour period indicated that large variations in the Labrador Current transport do occur over short time scales. (Author)
Two modified mapping tables that convert Abbreviated Injury Scale (AIS) 98 codes to AIS 2008 codes have been separately developed by Palmer et al. (P‐map) and Tohira et al. (T‐map). The authors aimed to determine which map gives the most accurate code conversion. The authors computed the intraclass correlation coefficients for the Injury Severity Score (ISS), the New ISS (NISS) and the Maximum AIS (MAIS) of six body regions using the mapped AIS 2008 codes and the manually determined AIS 2008 codes (gold standard). The authors also applied post‐hoc severity adjustment to the mapped AIS 2008 codes. The ISS and NISS based on the two maps showed substantial agreement with the gold standard. The chest region MAIS of the P‐map and the extremities region MAIS of both maps demonstrated moderate agreement with the gold standard, while the MAISs of the other regions displayed substantial agreement. The post‐hoc severity adjustment for the P‐map significantly improved the agreement for the chest region MAIS. The injury severity scores based on the two maps displayed similar agreement with the gold standard. The post‐hoc severity adjustment provided by the P‐map might be better at adjusting for severity levels than that provided by the T‐map.
Abstract Objective: To describe revascularization practice for acute myocardial infarction in a sample of Australasian hospitals during 1999. Design: Survey for the 1999 calendar year. Setting: Hospitals with Australasian College for Emergency Medicine‐accredited emergency departments in Australia and New Zealand. Participants: Forty‐eight hospitals of 80 surveyed (60%), comprising 15 tertiary and 33 non‐tertiary hospitals. Main outcome measures: Time from arrival in emergency department to initiation of thrombolytic therapy, site of therapy, agent used, mortality and intracranial haemorrhage rates. Results: Approximately 30% of patients with acute myocardial infarction had revascularization therapy. Sixty‐two per cent of patients receiving thrombolytics were given this treatment in the emergency department, the remainder in the coronary care unit. Overall median door‐to‐needle times were 35.0 min emergency department versus 48.3 min coronary care unit. Streptokinase was used for 58.3% of thrombolysis. In‐hospital mortality of thrombolysed patients was 6.7% in the emergency department versus 4.3% in the coronary care unit with intracranial haemorrhage rates of 0.8% emergency department and 0.7% coronary care unit. Conclusions: Overall times to thrombolysis and outcome rates in this sample were within internationally reported figures. Emergency department times were shorter than in coronary care unit.
It has been an interesting month where I have been challenged with ideas about the professions and the future of medicine. Three events have contributed to these thoughts on our future - my annual Emergency College scientific meeting, the University of Western Australia sixth year Dedication Ceremony welcoming new doctors to the profession and a recent Sunday Times article.
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