Objectives: to evaluate orthogeriatric and nurse-led fracture liaison service (FLS) models of post-hip fracture care in terms of impact on mortality (30 days and 1 year) and second hip fracture (2 years).Setting: Hospital Episode Statistics database linked to Office for National Statistics mortality records for 11 acute hospitals in a region of England.Population: patients aged over 60 years admitted for a primary hip fracture from 2003 to 2013.Methods: each hospital was analysed separately and acted as its own control in a before–after time-series design in which the appointment of an orthogeriatrician or set-up/expansion of an FLS was evaluated. Multivariable Cox regression (mortality) and competing risk survival models (second hip fracture) were used. Fixed effects meta-analysis was used to pool estimates of impact for interventions of the same type.Results: of 33,152 primary hip fracture patients, 1,288 sustained a second hip fracture within 2 years (age and sex standardised proportion of 4.2%). 3,033 primary hip fracture patients died within 30 days and 9,662 died within 1 year (age and sex standardised proportion of 9.5% and 29.8%, respectively). The estimated impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) = 0.73 (95% CI: 0.65–0.82) and HR = 0.81 (CI: 0.75–0.87), respectively. Following an FLS, these associations were as follows: HR = 0.80 (95% CI: 0.71–0.91) and HR = 0.84 (0.77–0.93). There was no significant impact on time to second hip fracture.Conclusions: the introduction and/or expansion of orthogeriatric and FLS models of post-hip fracture care has a beneficial effect on subsequent mortality. No evidence for a reduction in second hip fracture rate was found.
Interrupted time series (ITS) analysis is being increasingly used in epidemiology. Despite its growing popularity, there is a scarcity of guidance on power and sample size considerations within the ITS framework. Our aim of this study was to assess the statistical power to detect an intervention effect under various real-life ITS scenarios. ITS datasets were created using Monte Carlo simulations to generate cumulative incidence (outcome) values over time. We generated 1,000 datasets per scenario, varying the number of time points, average sample size per time point, average relative reduction post intervention, location of intervention in the time series, and reduction mediated via a 1) slope change and 2) step change. Performance measures included power and percentage bias. We found that sample size per time point had a large impact on power. Even in scenarios with 12 pre-intervention and 12 post-intervention time points with moderate intervention effect sizes, most analyses were underpowered if the sample size per time point was low. We conclude that various factors need to be collectively considered to ensure adequate power for an ITS study. We demonstrate a means of providing insight into underlying sample size requirements in ordinary least squares (OLS) ITS analysis of cumulative incidence measures, based on prespecified parameters and have developed Stata code to estimate this.
General rightsThis document is made available in accordance with publisher policies. Please cite only the published version using the reference above. Full terms of use are available: http://www.bristol.ac.uk/pure/about/ebr-terms VOLUME 4 ISSUE 28 SEPTEMBER 2016 ISSN 2050 DOI 10.3310/hsdr04280 HEALTH SERVICES AND DELIVERY RESEARCHModels of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England Andrew Judge, M Kassim Javaid, José Leal, Samuel Hawley, Sarah Drew, Sally Sheard, Daniel Prieto-Alhambra, Rachael Gooberman-Hill, Janet Lippett, Andrew Farmer, Nigel Arden, Alastair Gray, Michael Goldacre, Antonella Delmestri and Cyrus Cooper Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England Declared competing interests of authors: Daniel Prieto-Alhambra has received unrestricted research and educational grants from Amgen and Bioibérica S.A. Nigel Arden reports personal fees from Merck Sharp & Dohme (MSD), grants and personal fees from Roche, personal fees from Smith and Nephew, personal fees from Q-Med, personal fees from Nicox, personal fees from Flexion, personal fees from Bioibérica and personal fees from Servier. Cyrus Cooper has received consultancy fees, lecture fees and honoraria from Amgen, GlaxoSmithKline, Alliance for Better Bone Health, Eli Lilly, Pfizer, Novartis, MSD, Servier, Medtronic and Roche. M Kassim Javaid has in the last 5 years received honoraria for travel expenses, speaker fees and/or advisory committees from Lilly UK, Amgen, Servier, MSD, Medtronic, Internis, Consilient Health and Jarrow Formulas. He also serves on the Scientific Committee of the National Osteoporosis Society and International Osteoporosis Foundation. Andrew Judge has received consultancy fees, lecture fees and honoraria from Servier, UK Renal Registry, Oxford Craniofacial Unit, IDIAP Jordi Gol and Freshfields Bruckhaus Deringer, is a member of the Data Safety and Monitoring Board (which involved receipt of fees) from Anthera Pharmaceuticals, Inc., and received consortium research grants from Roche.Published September 2016 DOI: 10.3310/hsdr04280 This report should be referenced as follows:Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, et al. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. Health Serv Deliv Res 2016;4(28). Health Services and Delivery ResearchISSN 2050-4349 (Print) ISSN 2050-4357 (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/).Editorial contact: nihredit@southampton.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the repor...
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