1. Prescribing patterns of anti-osteoporotic medications in patients pre and post discharge from a large teaching hospital for fragility type fractures between 2005-2008. B. McGowan 1, Dr. K. Bennett 1, Dr. M Casey 2. 1.Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 2.Osteoporosis and Bone Health Clinic, Medicine for the Elderly, St. James’s Hospital, Dublin 8.

2. Background Osteoporosis is a skeletal disease characterised by low bone density with a resulting increase in bone fragility and therefore increased risk of fracture Osteoporosis is a skeletal disease characterised by low bone density with a resulting increase in bone fragility and therefore increased risk of fracture Fractures of the hip, vertebral body, pelvis and distal forearm have generally been considered as the typical osteoporotic fractures. Fractures of the hip, vertebral body, pelvis and distal forearm have generally been considered as the typical osteoporotic fractures. The risk of future fractures increases from 1.5- 9.5 fold following a fragility fracture The risk of future fractures increases from 1.5- 9.5 fold following a fragility fracture

3. Background cont’d International literature suggests that 1/3 of women and 1/5 of men over 50yrs suffer from osteoporosis. International literature suggests that 1/3 of women and 1/5 of men over 50yrs suffer from osteoporosis. If we apply these rates in Ireland to the age grp 50 and over, it is estimated that approx. 193,017 women and 107,430 men have osteoporosis (N=300,447). If we apply these rates in Ireland to the age grp 50 and over, it is estimated that approx. 193,017 women and 107,430 men have osteoporosis (N=300,447). The results of an Irish Burden of Illness Study demonstrated that fall related injuries in the elderly cost the Irish Health care system approximately €402 million each year The results of an Irish Burden of Illness Study demonstrated that fall related injuries in the elderly cost the Irish Health care system approximately €402 million each year

4. Anti-osteoporotic type medications Bisphosphonates (Alendronate, etidronate, risedronate,) raloxifene, strontium ranelate and teriparatide are all recommended by the UK’s National Institute for Clinical Excellence (NICE) and currently licensed in Ireland as possible treatments for preventing bone fractures in Bisphosphonates (Alendronate, etidronate, risedronate,) raloxifene, strontium ranelate and teriparatide are all recommended by the UK’s National Institute for Clinical Excellence (NICE) and currently licensed in Ireland as possible treatments for preventing bone fractures in  postmenopausal women who have already had a fracture with a diagnosis of osteoporosis  postmenopausal women with osteoporosis who have not had a fracture. (- raloxifene and -teriparatide) Oral bisphosphonates reduce the risk of vertebral fractures by 40-50% and in non-vertebral fractures by 20-40%. Oral bisphosphonates reduce the risk of vertebral fractures by 40-50% and in non-vertebral fractures by 20-40%.

5. The aims of this study To identify and examine the prescription of anti- osteoporotic type medications prior to and subsequent to discharge for osteoporotic type fracture in those aged 55 years and over between 2005 and 2008. To identify and examine the prescription of anti- osteoporotic type medications prior to and subsequent to discharge for osteoporotic type fracture in those aged 55 years and over between 2005 and 2008. To examine factors associated with prescribing of these therapies following discharge. To examine factors associated with prescribing of these therapies following discharge.

6. Methodology The Hospital In-patient Enquiry system (H.I.P.E. data) is the only source of morbidity data available nationally for acute hospital services in Ireland. The Hospital In-patient Enquiry system (H.I.P.E. data) is the only source of morbidity data available nationally for acute hospital services in Ireland. HIPE is a computer-based discharge abstracting system designed to collect demographic, clinical and administrative data on discharges and deaths from acute general hospitals nationally. HIPE is a computer-based discharge abstracting system designed to collect demographic, clinical and administrative data on discharges and deaths from acute general hospitals nationally. The HIPE data from one of the largest teaching hospitals in Dublin was used to identify all patients over the age of 55 years admitted with osteoporotic type fractures between 2005 and 2008. The HIPE data from one of the largest teaching hospitals in Dublin was used to identify all patients over the age of 55 years admitted with osteoporotic type fractures between 2005 and 2008.

7. Coding of HIPE data cont’d Each HIPE discharge record represents details of one admission. Each HIPE discharge record represents details of one admission. The most important aspect of this process is the coding of the diagnoses and procedures performed, using The International Classification of Diseases, tenth Revision, Clinical Modification (ICD-10-CM). The most important aspect of this process is the coding of the diagnoses and procedures performed, using The International Classification of Diseases, tenth Revision, Clinical Modification (ICD-10-CM). By identifying the specific codes for fractures we examined data on all patients who were admitted to hospital for treatment of both typical and atypical osteoporotic type fractures within the specific time period 2005 – 2008. By identifying the specific codes for fractures we examined data on all patients who were admitted to hospital for treatment of both typical and atypical osteoporotic type fractures within the specific time period 2005 – 2008.

8. Typical osteoporotic type fractures ICD-10- CM Atypical osteoporotic type fractures ICD-10- CM HipS72.0, S72.1, S72.2, S72.9 HipS72.3, S72.4, S72.7, S72.8 Distal radius and ulnaS52.5, S52.6, S52.7, S52.8 Distal radius and ulnaS52.0, S52.2, S52.3 Tibia and FibulaS82.2, S82.4, S82.5, S82.6 Tibia and FibulaS82.8, S82.9 PelvisS32.1, S32.4, S32.5 Thoracic and lumbar vertebraeS22.0, S32.0 Clavicle, Scapula, Sternum and Humerus S22.2, S42.0, S42.2, S42.3, S42.4, S42.9 Fractures of the ribsS22.3, S22.4Other atypical osteoporotic type fractures S22.8, S22.9, S42.1, S62, S92, S02, S12

9. The HSE-PCRS pharmacy database The HSE-Primary Care Reimbursement Services (HSE- PCRS; formerly GMS medical services) scheme provides free healthcare to approximately 30% of the Irish population (approximately 1.2 million). The HSE-Primary Care Reimbursement Services (HSE- PCRS; formerly GMS medical services) scheme provides free healthcare to approximately 30% of the Irish population (approximately 1.2 million). Eligibility is means tested, and all medicines are dispensed free of charge to patients registered under this scheme. The service was also made available to all those over 70 years of age from July 2001. Eligibility is means tested, and all medicines are dispensed free of charge to patients registered under this scheme. The service was also made available to all those over 70 years of age from July 2001. While the HSE-PCRS population cannot be considered representative of the entire population, as the elderly, the young and the socially disadvantaged are over- represented, it is estimated to account for approximately 70% of all medicines dispensed in primary care. While the HSE-PCRS population cannot be considered representative of the entire population, as the elderly, the young and the socially disadvantaged are over- represented, it is estimated to account for approximately 70% of all medicines dispensed in primary care.

10. The HSE-PCRS pharmacy database cont’d All prescription items are coded using the WHO Anatomical Chemical (ATC) classification system. All prescription items are coded using the WHO Anatomical Chemical (ATC) classification system. The study was carried out over a 6 year period involving prescription data for the period between January 2004 and July 2009. The study was carried out over a 6 year period involving prescription data for the period between January 2004 and July 2009. All prescriptions for medications for the prophylaxis and treatment of osteoporosis (bisphosphonates, calcitriol, strontium ranelate raloxifene, parathyroid hormone) were identified for the Eastern Regional Health board. All prescriptions for medications for the prophylaxis and treatment of osteoporosis (bisphosphonates, calcitriol, strontium ranelate raloxifene, parathyroid hormone) were identified for the Eastern Regional Health board.

11. Linking the HIPE data to the HSE-PCRS prescription data Each patient who is eligible for a medical card has a unique medical card number. This information is recorded by the hospital administration at the time of admission but at present it is not released to the National HIPE Centre. Each patient who is eligible for a medical card has a unique medical card number. This information is recorded by the hospital administration at the time of admission but at present it is not released to the National HIPE Centre. Linkage of the local HIPE data to the HSE-PCRS prescribing database was possible. Medical management before and after discharge was examined. Linkage of the local HIPE data to the HSE-PCRS prescribing database was possible. Medical management before and after discharge was examined. Since all persons ≥70 years are covered by the HSE – PCRS it was possible to link the data on 92% of this patient population and approximately 85% of those 55 years and over. Since all persons ≥70 years are covered by the HSE – PCRS it was possible to link the data on 92% of this patient population and approximately 85% of those 55 years and over.

12. Linking the HIPE data to the HSE-PCRS prescription data cont’d Once the linkage was made, all unique identifiers were removed from the merged dataset. Once the linkage was made, all unique identifiers were removed from the merged dataset. Prescribing of anti-osteoporotic therapies was considered in the 12 months pre and up to 24 months post admission. Prescribing of anti-osteoporotic therapies was considered in the 12 months pre and up to 24 months post admission. Descriptive analysis on the medications prescribed in the cohort with fractures before and after analysis are presented, in the form of percentages (and 95% CI). Descriptive analysis on the medications prescribed in the cohort with fractures before and after analysis are presented, in the form of percentages (and 95% CI). Logistic regression analysis was used to examine whether certain patients (age, gender, type of fracture,) were more or less likely to be prescribed osteoporotic medication before and/or after discharge from hospital. Logistic regression analysis was used to examine whether certain patients (age, gender, type of fracture,) were more or less likely to be prescribed osteoporotic medication before and/or after discharge from hospital.

13. Results 821 ( 70%) patients were successfully linked to the HSE-PCRS prescribing database. 821 ( 70%) patients were successfully linked to the HSE-PCRS prescribing database. 76.4% of the patients were female 76.4% of the patients were female Mean age of the study cohort was 78.14 (SD=9.53) years Mean age of the study cohort was 78.14 (SD=9.53) years 65% of the patients were > 75 years of age 65% of the patients were > 75 years of age 25% in the over 85 year age group 25% in the over 85 year age group

14. Likelihood of being prescribed anti-osteoporotic type medications post fracture Odds95% RatiosConfidenceLimits Prescribing post fracture 4.552.269.16 Genderfemale vs male2.051.273.33 Ageband60-64 vs 55-593.390.6517.78 65-69 vs 55-598.511.7541.35 70-74 vs 55-595.951.2927.51 75-79 vs 55-596.401.4129.03 80-84 vs 55-595.131.1223.61 >85 vs 55-594.911.0822.36 year of discharge2006 vs 20050.800.381.68 year of discharge2007 vs 20054.502.538.01 year of discharge2008 vs 20058.014.5514.09

16. Conclusions In summary, this study has demonstrated a dramatic increase in the prescribing of predominantly bisphosphonates to patients admitted to hospital for treatment of a fragility fracture between 2005 and 2008. In summary, this study has demonstrated a dramatic increase in the prescribing of predominantly bisphosphonates to patients admitted to hospital for treatment of a fragility fracture between 2005 and 2008. The rate of increase from 11% to 47% within the study period (2005 – 2008) is probably largely due to the introduction of an osteoporosis clinic in the hospital in 2005 and the licensing of the once weekly oral bisphosphonates in 2004. The rate of increase from 11% to 47% within the study period (2005 – 2008) is probably largely due to the introduction of an osteoporosis clinic in the hospital in 2005 and the licensing of the once weekly oral bisphosphonates in 2004.