Factors associated with initiation of bone-health medication among older adults in primary care in Ireland

Abstract Background Adults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common. Objective This study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care. Design This was a retrospective cohort study. Setting The study used data from forty-four general practices in Ireland from 2011–2017. Subjects The study included adults aged ≥ 65 years who were naïve to bone-health medication for 12 months. Methods Overall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with the Poisson distribution. Results Of 36,799 patients (51% female, mean age 75.4 (SD = 8.4)) included, 8% (n = 2,992) were observed to initiate bone-health medication during the study. One-fifth of all patients (n = 8,193) had osteoporosis or had high fracture-risk but only 21% of them (n = 1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR = 1.33 (95% CI = 1.17–1.50), P < 0.01) and all fractures (IRR = 1.30 (95% CI = 1.17–1.44), P < 0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association. Conclusions Bone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.

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Factors associated with initiation of bone-health medication among older adults in primary care in Ireland

10.1101/2020.10.05.20207233 ◽

2020 ◽

Author(s):

Mary E. Walsh ◽

Mari Nerdrum ◽

Tom Fahey ◽

Frank Moriarty

Keyword(s):

Rheumatoid Arthritis ◽

Cardiovascular Disease ◽

Primary Care ◽

High Risk ◽

Fracture Risk ◽

Bone Health ◽

Hormone Replacement ◽

List Type ◽

Inverse Association ◽

Factors Associated

ABSTRACTBackgroundAdults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however under-treatment is common.ObjectiveThis study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care.DesignRetrospective cohort study.Setting44 general practices in Ireland from 2011-2017.SubjectsAdults aged ≥65 years who were naïve to bone-health medication for 12 months.MethodsOverall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with Poisson distribution.ResultsOf 36,799 patients (51 % female, mean age 75.4 (SD=8.4)) included, 8% (n=2,992) were observed to initiate on bone-health medication during the study. One fifth of all patients (n=8,193) had osteoporosis or had high fracture-risk but only 21% of them (n=1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR=1.33 (95% CI=1.17-1.50), p<0.01) and all fractures (IRR=1.30 (95% CI=1.17-1.44), p<0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis, and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association.ConclusionsBone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.Key pointsDuring this study, 23% of women and 11% of men defined as high-risk of fracture were newly initiated on bone-health medication.Rates of potential under-treatment were highest in patients over 80 years old.Fracture history, corticosteroid use, and rheumatoid arthritis were independently associated with medication initiation.Patients with diabetes, and liver, kidney, or cardiovascular disease were less likely to be initiated on medication.Clinical guidelines should provide advice on risk-benefit decisions in osteoporosis treatment where co-morbidities are present.

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Persistence with oral bisphosphonates and denosumab among older adults in primary care in Ireland

10.1101/2020.10.05.20207290 ◽

2020 ◽

Author(s):

Mary E. Walsh ◽

Tom Fahey ◽

Frank Moriarty

Keyword(s):

Older Adults ◽

Primary Care ◽

Vitamin D ◽

Fracture Risk ◽

Bone Health ◽

Pharmacological Treatment ◽

Age Group ◽

Oral Bisphosphonates ◽

Factors Associated ◽

Increase Fracture Risk

ABSTRACTPurposeGaps in pharmacological treatment for osteoporosis can reduce effectiveness. This study aimed to estimate persistence rates for oral bisphosphonates and denosumab in older primary care patients and identify factors associated with discontinuation.MethodsOlder patients newly prescribed oral bisphosphonates or denosumab between 2012 and 2017 were identified from 44 general practices (GP) in Ireland. Persistence without a coverage gap of >90 days was calculated for both medications from therapy initiation. Factors associated with time to discontinuation were explored using Cox regression analysis. Exposures included age-group, osteoporosis diagnosis, fracture history, calcium/vitamin D prescription, number of other medications, health cover, dosing frequency (bisphosphonates) and previous bone-health medication (denosumab).ResultsOf 41,901 patients, n=1,569 newly initiated on oral bisphosphonates and n=1,615 on denosumab. Two-year persistence was 49.4% for oral bisphosphonates and 53.8% for denosumab and <10% were switched to other medication. Having state-funded health cover was associated with a lower hazard of discontinuation for both oral bisphosphonates (HR=0.49, 95%CI=0.36-0.66, p<0.01) and denosumab (HR=0.71, 95%CI=0.57-0.89, p<0.01). Older age-group, number of medications and calcium/vitamin D prescription were also associated with better bisphosphonate persistence while having osteoporosis diagnosed was associated with better denosumab persistence.ConclusionPersistence for osteoporosis medications is sub-optimal. Of concern, few patients are switched to other bone-health treatments when denosumab is stopped which could increase fracture risk. Free access to GP services and medications may have resulted in better medication persistence in this cohort. Future research should explore prescribing choices in primary-care osteoporosis management and evaluate cost-effectiveness of interventions for improving persistence.SUMMARYGaps in pharmacological treatment for osteoporosis can reduce its effectiveness. This study found approximately half of older adults in primary care newly initiated on bisphosphonates or denosumab were still taking these after 2 years. Abrupt discontinuation of denosumab without switching to an alternative is concerning due to increased fracture risk.

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Pharmacologic treatment of osteoporosis – 2011

Orvosi Hetilap ◽

10.1556/oh.2011.29111 ◽

2011 ◽

Vol 152 (33) ◽

pp. 1320-1326 ◽

Cited By ~ 2

Author(s):

Péter Lakatos

Keyword(s):

Bone Loss ◽

Fracture Risk ◽

Hormone Replacement ◽

Treatment Options ◽

Osteoporotic Fractures ◽

Cost Effective ◽

Similar Efficacy ◽

High Fracture ◽

Efficient Treatment ◽

Treatment Of Osteoporosis

Osteoporosis affects approximately 9% of the population in Hungary resulting in about 100 000 osteoporotic fractures annually. Thirty-five percent of patients with hip fractures due to osteoporosis will die within 1 year. Direct costs of osteoporosis exceed 25 billion forints per year. Apparently, cost-effective reduction of bone loss and consequent fracture risk will add up to not only financial savings but improvement in quality of life, as well. A number of pharmacological modalities are available for this purpose. The mainstay of the treatment of osteoporosis is the bisphosphonate group that includes effective anti-resorptive compounds mitigating bone loss and fragility. The recently registered denosumab exhibits similar efficacy by neutralizing RANK ligand, however, marked differences can be observed between the two drug classes. Strontium has a unique mechanism of action by rebalancing bone turnover, and thus, providing an efficient treatment option for the not fast bone losers who are at high fracture risk. The purely anabolic teriparatide is available for the extremely severe osteoporotic patients and for those who do not respond to other types of therapy. Older treatment options such as hormone replacement therapy, raloxifene, tibolone or calcitonin may also have a restricted place in the management of osteoporosis. Orv. Hetil., 2011, 152, 1320–1326.

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Factors associated with patients’ and GPs’ assessment of the burden of treatment in multimorbid patients: a cross-sectional study in primary care

BMC Family Practice ◽

10.1186/s12875-019-0974-z ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 3

Author(s):

Lilli Herzig ◽

Andreas Zeller ◽

Jérôme Pasquier ◽

Sven Streit ◽

Stefan Neuner-Jehle ◽

...

Keyword(s):

Primary Care ◽

Cross Sectional Study ◽

Sectional Study ◽

Cross Sectional ◽

Factors Associated ◽

Burden Of Treatment ◽

Multimorbid Patients

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Do GPs accurately record date of death? A UK observational analysis

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2018-001514 ◽

2018 ◽

Vol 10 (3) ◽

pp. e24-e24 ◽

Cited By ~ 4

Author(s):

Amelia Harshfield ◽

Gary A Abel ◽

Stephen Barclay ◽

Rupert A Payne

Keyword(s):

Primary Care ◽

Young Patients ◽

Practice Research ◽

Clinical Practice Research Datalink ◽

Data Sets ◽

Factors Associated ◽

National Statistics ◽

Primary Care Data ◽

National Mortality ◽

General Practices

ObjectiveTo examine the concordance between dates of death recorded in UK primary care and national mortality records.MethodsUK primary care data from the Clinical Practice Research Datalink were linked to Office for National Statistics (ONS) data, for 118 571 patients who died between September 2010 and September 2015. Logistic regression was used to examine factors associated with discrepancy in death dates between data sets.ResultsDeath dates matched in 76.8% of cases with primary care dates preceding ONS date in 2.9%, and following in 20.3% of cases; 92.2% of cases differed by <2 weeks. Primary care date was >4 weeks later than ONS in 1.5% of cases and occurred more frequently with deaths categorised as ‘external’ (15.8% vs 0.8% for cancer), and in younger patients (15.9% vs 1% for 18–29 and 80–89 years, respectively). General practices with the greatest discrepancies (97.5th percentile) had around 200 times higher odds of recording substantially discordant dates than practices with the lowest discrepancies (2.5th percentile).ConclusionDates of death in primary care records often disagree with national records and should be treated with caution. There is marked variation between practices, and studies involving young patients, unexplained deaths and where precise date of death is important are particularly vulnerable to these issues.

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Epilepsy and mortality: a retrospective cohort analysis with a nested case–control study identifying causes and risk factors from primary care and linkage-derived data

BMJ Open ◽

10.1136/bmjopen-2021-052841 ◽

2021 ◽

Vol 11 (10) ◽

pp. e052841

Author(s):

Gabriella Wojewodka ◽

Martin C Gulliford ◽

Mark Ashworth ◽

Mark P Richardson ◽

Leone Ridsdale

Keyword(s):

Risk Factors ◽

Primary Care ◽

General Population ◽

Cause Of Death ◽

Retrospective Cohort ◽

Case Control Study ◽

Case Control ◽

Factors Associated ◽

Nested Case Control ◽

Control Study

ObjectivesPeople with epilepsy (PWE) have a higher mortality rate than the general population. Epilepsy-related deaths have increased despite all-cause mortality decreasing in the general population pre-COVID-19. We hypothesised that clinical and lifestyle factors may identify people more at risk.DesignWe used a retrospective cohort study to explore cause of death and a nested case–control study to identify risk factors.SettingWe explored factors associated with mortality using primary care population data from 1 April 2004 to 31 March 2014. Data were obtained from the Clinical Practice Research Datalink which compiles anonymised patient data from primary care in the UK. Cause of death data was supplemented from the Office of National Statistics when available.ParticipantsThe analysis included 70 431 PWE, with 11 241 registered deaths.ResultsThe number of deaths within the database increased by 69% between the first and last year of the study. Epilepsy was considered as a contributing cause in approximately 45% of deaths of PWE under 35. Factors associated with increased risk of death included attendance at emergency departments and/or emergency admissions (OR 3.48, 95% CI 3.19 to 3.80), antiepileptic drug (AED) polytherapy (2 AEDs: OR 1.60, 95% CI 1.51 to 1.71; 3 AEDs: OR 2.06, 95% CI 1.86 to 2.29; 4+AEDs: OR 2.62, 95% CI 2.23 to 3.08), status epilepticus (OR 2.78, 95% CI 1.64 to 4.71), depression (OR 1.67, 95% CI 1.57 to 1.76) and injuries (OR 1.54, 95% CI 1.43 to 1.67). No seizures in the prior year (OR 0.52, 95% CI 0.41 to 0.65).ConclusionOur results add to existing evidence that deaths in epilepsy are increasing. Future studies could focus on identifying PWE at high risk and addressing them with clinical interventions or better self-management. Identifying specific risk factors for younger people should be a priority as epilepsy may be a factor in close to half of deaths of PWE under 35 years of age.

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Secondary Prevention Post Stroke in Primary Care in an Asian Setting: A Retrospective Cohort Study

10.21203/rs.3.rs-111876/v1 ◽

2020 ◽

Author(s):

Vivek Bansal ◽

Eng Sing Lee ◽

Helen Smith

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Primary Care ◽

Secondary Prevention ◽

Retrospective Cohort ◽

Care Setting ◽

Primary Care Setting ◽

Stroke Patients ◽

Factors Associated ◽

Post Stroke

Abstract Background: Stroke is one of the top contributors to burden of disability-adjusted life-years worldwide. Family physicians have key role in optimal secondary prevention post-stroke helping patients make appropriate lifestyle changes and take medication in accordance with the recommended clinical practice guidelines.Methods: Our aim was to characterize the profile of patients who were being managed in primary care setting for secondary prevention of stroke. Our specific objectives were: (i) to examine the level of overall and individual risk factors control after an index-stroke event in patients visiting the primary care setting and (ii) to describe the factors associated with the achievement of overall risk factors control in post-stroke patients.Study Design: Retrospective cohort study.We conducted a study looking retrospectively at records from our electronic chronic disease database. Our study included post-stroke patients who visited public primary care setting in Singapore between 1st January 2012 to 31st December 2016. Based on AHA Stroke guidelines, we operationalized our outcome of secondary prevention post-stroke as overall control, which comprised of patients having blood pressure, lipids, and glucose reading (for those who had diabetes) all well-controlled. We conducted descriptive analysis and performed multivariable logistic analysis to determine factors associated with overall control.Results: There were 24,240 patients in our study. Overall control was better in post-stroke patients without diabetes (49.2%) as compared to those with diabetes (28.1%).Among post-stroke patients without diabetes, factors significantly associated with overall control were sex [OR: 1.23, 95% CI: 1.10, 1.39], ethnicity [OR: 0.72, 95% CI: 0.58, 0.90], BMI [OR: 0.72, 95% CI: 0.62, 0.84) and atrial fibrillation [OR: 1.47, 95% CI: 1.21, 1.78].Among post-stroke patients with diabetes, factors significantly associated with overall control were sex [OR: 1.28, 95% CI: 1.12, 1.46], ethnicity, BMI, atrial fibrillation[OR: 1.24; 95% CI: 1.02, 1.51], chronic kidney disease and smoking status.Conclusion: We reported a sub-optimal level of overall control. Among post-stroke patients, those with diabetes had a higher proportion of sub-optimal control as compared to those without diabetes. Irrespective of diabetic status, being female, having high BMI, and of Malay ethnicity were associated with poor overall control compared to Chinese.

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Non-steroids anti-inflammatory drugs and risk of peritonsillar abscess in pharyngitis: a French longitudinal study in primary care†

Family Practice ◽

10.1093/fampra/cmy111 ◽

2018 ◽

Vol 36 (4) ◽

pp. 425-430 ◽

Cited By ~ 1

Author(s):

Cedric Piroulas ◽

Louise Devillers ◽

Cecile Souty ◽

Jonathan Sicsic ◽

Philippe Boisnault ◽

...

Keyword(s):

Primary Care ◽

Multivariate Analysis ◽

Retrospective Cohort ◽

Logistic Regression Model ◽

General Medicine ◽

Peritonsillar Abscess ◽

Factors Associated ◽

Inflammatory Drugs ◽

Anti Inflammatory ◽

Adjusted Logistic Regression

Abstract Background The safety of non-steroids anti-inflammatory drugs (NSAIDs) in the context of pharyngitis is doubtful with contradictory results in the literature. Objective To evaluate the risk of peritonsillar abscess (PTA) associated to NSAIDs consumption during a pharyngitis episode observed in primary care. Method A retrospective cohort study using Observatory of General Medicine Datalink from 1995 to 2010. All patients consulting a GP from the Datalink network for pharyngitis have been included. The occurrence of a PTA in the 15 days following the consultation for pharyngitis was matched. The association between PTA and prescriptions of NSAIDs was studied via an adjusted logistic regression model. Results During the study period, 105 802 cases of pharyngitis and 48 cases of PTA following a pharyngitis were reported, concerning respectively 67 765 and 47 patients. In the multivariate analysis, the risk of PTA was associated positively with a NSAIDs prescription (OR = 2.9, 95% CI = 1.6–5.2). Other factors associated with PTA occurrence were the prescription of corticosteroids (OR = 3.1, 95% CI = 1.3–7.6) and an age between 20 and 40 years (OR = 5.7, 95% CI = 2.5–13.0). The prescription of antibiotics was not significantly associated with PTA (P = 0.7). Conclusion Prescription of NSAIDs in pharyngitis may increase the risk of PTA. This study encourages considering cautiously the balance between benefits and harms before prescription of NSAIDs for pharyngitis.

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