Following hip fracture, hospital organizational factors associated with prescription of anti-osteoporosis medication on discharge, to address imminent refracture risk: A record-linkage study

Patients who sustain a hip fracture are known to be at imminent refracture risk. Their complex multidisciplinary rehabilitation needs to include falls prevention and anti-osteoporosis medication (AOM) to prevent such fractures. This study aimed to determine which hospital-level organisational factors predict prescription of post-hip fracture AOM, and refracture risk. A cohort of 178 757 patients aged ≥60 years who sustained a hip fracture in England and Wales (2016-19) was examined and followed for 1 year. Patient-level hospital admission datasets from 172 hospitals, the National Hip Fracture Database, and mortality data were linked to 71 metrics extracted from 18 hospital-level organisational reports. Multilevel models determined organisational factors, independent of patient case-mix, associated with (i) AOM prescription, (ii) refracture (by ICD10 coding). Patients were mean (SD) 82.7 (8.6) years old, 71% female, with 18% admitted from care homes. Overall, 101 735 (57%) were prescribed AOM during admission; while 50 354 (28%) died during 1-year follow-up, 12 240 (7%) refractured. Twelve organisational factors were associated with AOM prescription, e.g., orthogeriatrician-led care compared to traditional care models (OR 4.65 [95%CI: 2.25-9.59]); AOM was 9% (95%CI: 6%-13%) more likely to be prescribed in hospitals providing routine bone health assessment to all patients. Refracture occurred at median 126 days (IQR 59-234). Eight organisational factors were associated with refracture risk; hospitals providing orthogeriatrician assessment to all patients within 72-hours of admission had an 18% (95%CI: 2-31%) lower refracture risk, weekend physiotherapy provision an 8% (95%CI: 3-14%) lower risk, and where occupational therapists attended clinical governance meetings, a 7% (95%CI: 2-12%) lower risk. Delays initiating post-discharge community rehabilitation were associated with a 15% (95%CI: 3-29%) greater refracture risk. These novel, national findings highlight the importance of orthogeriatrician, physiotherapist and occupational therapist involvement in secondary fracture prevention post hip fracture; notably fracture risk reductions were seen within 12 months of hip fracture.