Uitreiking en presentatie IWO-ASBMR “young investigators award”

1. Peter van den Berg
Verpleegkundig Specialist
Characterization of FLS Non-Attenders by Home
Visits and Questionnaires.
by Home Visits
ASBMR Poster Young Investigators Award – IWO 2019

2. 2
‘Young’ Investigators award

3. 3
Back to work: achtergrond onderzoek
NHG richtlijn: http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden.htm
CBO richtlijn: http://www.cbo.nl/thema/Richtlijnen/Overzicht-richtlijnen/Bewegingsapparaat/?p=242

4. Achtergrond van het onderzoek – strategie?
RIVM-rapport 2007. Vergrijzing en toekomstige ziektelast. Prognose chronische ziektenprevalentie 2005-2025.
Lötters Calc Tissue 2016
Mc Lellan Ost Int 2003 Ganda Ost Int 2013
- 850.000 mensen met osteoporose verwachte stijging tot 2040 is > 60%
- mannen + 50% (210.000 naar 325.000) - vrouwen + 37% (640.000 naar 880.000)
- 120.000 fracturen/ jaar > 50 jaar > 30% hiervan is osteoporose gerelateerd
- Fractuur(preventie) & Osteoporosepolikliniek = best practice / standard of care
- Komst naar Fractuur & Osteoporosepolikliniek (FLS) actuele situatie in NL 30-50% (!)

5. Studie in 4 Nederlandse ziekenhuizen met een FLS (Eekman):
2,207 patients were invited:
- 50.6 % responded.
- Not interested (38%)
- Already screened/under treatment for osteoporosis (15.7%)
- Physically unable to attend the clinic (11.5%) (death (5.2%))
- Hip fracture patients responded less frequently (29%)
- Patients with a wrist (60%) or ankle fracture (65.2%) were more likely to attend the FLS
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Wat we al weten:
Osteoporosis International 2014

6. 6
Hoe doen we het dan in NL?
Osteoporosis International 2015
Results:
90 invited hospitals
24 (27%) fully responded
24,468 consecutive patients
(25% of fracture patients in the Netherlands in the year 2012)
Response rate of invited patients only 49% on average

7. 7
FLS - Attenders versus Non-attenders
I think that my fracture risk is not increased although I had a fracture.
Yes
No/do not know
99 (18%)
432 (82%)
24 (12%)
181 (88%)
Perceived advice to attend the FLS
Perceived advice to attend=Yes
Perceived advice to attend= No
428 (80%)
109 (20%)
61 (29%)
147 (71%)
Taking interest in Bone Quality
Yes
No
Somewhat
No response
63 (12%)
236 (44%)
229 (43%)
9 (1%)
15 (7%)
118 (57%)
64 (31%)
11 (5%)
ATTENDING
n=537 (72%)
NOT-ATTENDING
n=208 (28%)

8. Measure of
Association:
OR (95%CI)
Test of Association:
Pearson’s Chi-square
p-value
FLS NON-ATTENDANCE
Demographic factors contributing to be a non-attender
Male
Living alone
Age > 70 yr.
Low income*
Low education
1.67 (1.17; 2.42)
1.98 (1.43; 2.74)
1.87 (1.35; 2.60)
3.03 (2.00; 4.55)
3.03 (2.00; 4.55)
.002
<.001
<.001
<.001
<.001
Extrinsic Motivations contributing to be a non-attender
No advice was perceived to have a DXA and to visit the FLS 9.1 (6.7; 12.5) <.001
Intrinsic Motivations contributing to be a non-attender
I am not interested in my bone strength* 2.08 (1.50; 2.94) <.001
I do not think that my fracture risk is increased after sustaining this fracture 1.72 (1.08; 2.86) .024
Frailty: Tilburg Frailty Indicator (TFI)
Frailty 2.12 (1.51; 2.98) .002
FLS ATTENDANCE
Extrinsic Motivation contributing to be an attender
Advice was perceived to have a DXA and to visit the FLS 5.9 (3.7; 9.1) <.001
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Univariate Associations
vd Berg Ost Int 2019
* Ong Injury 2015

9. 9
Multivariate analyse
Measure of Association:
OR (95%CI)
Test of Association:
Pearson’s Chi-square
p-value
FLS NON-ATTENDANCE
Demographics contributing to be a non-attender
Male
Living alone
Low education
2.08 (1.35; 3.21)
2.05 (1.48; 2.85)
1.82 (1.27; 2.63)
.002
<.001
.0014
Extrinsic Motivations contributing to be a non-attender
No advice was perceived to have a DXA and to visit the FLS 3.23 (1.96; 5.56) <.001
Intrinsic Motivations contributing to be a non-attender
I am not interested in my bone strength.
I think that my fracture risk is not increased although I had a fracture
1.85 (1.33; 2.63)
1.75 (1.08; 2.86)
<.001
.002
Frailty: Tilburg Frailty Indicator (TFI)
Frailty 1.62 (1.08; 2.45) .002
FLS ATTENDANCE
Extrinsic Motivation contributing to be an attender
Advice was perceived to have a DXA and to visit the FLS 3.32 (1.75; 6.27) <.001

10. 10
ASBMR 2019

11. 935 consecutive fracture patients >50 yr. (July 2017 - February 2018)
Exclusion: 228 (24%) patients:
- toe, finger and skull fractures (n=55, 6%)
- death (n=14, 1%)
- institutionalization (n=52, 5.5%)
- recent DXA (n=22, 2%),
- already on osteoporotic treatment (n=33, 4%)
- or living outside hospital region (n=52, 5.5%).
707 (76%) invited at the FLS after face-to-face patient information and an invitation letter.
- 510 patients attended the FLS (72%)
- 197 patients did not attend / respond
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Patiënten en Methoden

12. Eight weeks later:
197 non-responders / non-attenders were called and asked for consent to be visited at
home and to fill in a questionnaire on:
- 1/ patient characteristics and the Tilburg Frailty Index (>5 indicates frailty),
- 2/ recalled perceptions of prior face-to-face patient information and / or receipt of the
invitation letter and
- 3/ patients` personal ideas and opinions about fracture prevention.
181 patients were phoned – 97 refusers
16 patients could not be reached
50 Home Visit group
42 Questionnaire group
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Procedure

13. Home Visit
n=50 (54%)
Questionnaire
n=42 (46%)
Demographics
Age at Fracture: median (min,max)
All: no.: median (min, max)
Women: no.: median (min,max)
Men: no.: median (min,max)
81 (58,101)
n=50: 81 (58,101)
n=42: 81 (58,101)
n=8: 83 (65,89)
63 (50,93)
n=42: 63 (50,93)
n=22: 60 (51,93)
n=20: 63 (50,88)
Fracture type*
Minor fracture
Major Fracture
Hip Fracture
Vertebral Fracture
6 (12%)
30 (60%)
8 (16%)
6 (12%)
23 (55%)
17 (40%)
2 (5%)
-
Education
Primary/secondary school vs.
High school/University
47 (94%)
3 (6%)
29 (69%)
13 (31%)
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Home Visit & Questionnaire
Frailty (Tilburg Frailty Indicator scores)
TFI score > 5 (frail)
TFI score < 5 (not frail)
23 (46%)
27 (54%)
13 (31%)
29 (69%)
* Warriner – J clin Epid 2011

14. I consider my fracture risk increased after a fracture. Home Visit Questionnaire
Yes
No
Do not know
13 (26%)
18 (36%)
19 (38%)
7 (17%)
22 (52%)
13 (31%)
Perceived advice to attend the FLS
Perceived advice to attend the FLS by letter = Yes
Perceived advice to attend the FLS by letter = No
34 (68%)
16 (32%)
23 (55%)
19 (45%)
Taking interest in Bone Quality
Yes
No/Somewhat
22 (44%)
28 (56%)
14 (33%)
28 (67%)
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Results
Self-reported Level of Health
Good
Poor
25 (50%)
25 (50%)
32 (76%)
10 (24%)
Do you suffer from 2 or more chronic diseases?
Yes
No
17 (34%)
33 (66%)
12 (29%)
30 (71%)
Do you take 4 or more tablets every day?
Yes
No
25 (50%)
25 (50%)
7 (17%)
35 (83%)

15. 15
Univariate associations OR 95%CI p-value
Age ≥ 70 year 17.3 6.03;49.7 < .001
Woman 4.77 1.81;12.6 .001
Low Income 6.78 1.74;26.4 .003
Self-rated low quality of life after fracture 4.26 1.59;11.4 .003
Loss of weight after fracture 3.09 1.09;8.78 .03
Difficulty in walking 3.97 1.58;9.99 .003
Difficulty maintaining your balance 6.83 2.31;20.2 < .001
Poor hearing 7.97 2.16;29.4 < .001
Lack of strength in your hands 3.81 1.27;11.5 .013
Age ≥ 70 years and no frailty (TFI ≥ 5) 19.2 3.6;102.0 < .001
Major fractures (no hip or vertebral fractures) 2.89 1.2;6.94 0.02
All Major fractures (all major including hip and vertebral fractures) 4.27 1.88;51.59 0.04
Multivariate associations HV (n=50) and Q (n=42) OR (95%CI) p-value
Age ≥ 70 16.8 (5.0; 56.7) < .001
Women 5.3 (1.5; 19.2) .008
Major Fractures 6.1 (1.7; 22.3) .0045
Results 2

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Unmet information needs
Archives Ost 2018

17. 17
Health Literacy
Health Literacy = Gezondheidsvaardigheden:
“de vaardigheden van individuen om informatie over gezondheid te verkrijgen, te begrijpen, te
beoordelen en te gebruiken bij het nemen van gezondheids-gerelateerd beslissingen”
Nederlandse bevolking
> 18 jaar: 36.4% is beperkt gezondheidsvaardig
> 65 jaar: 46.8% is beperkt gezondheidsvaardig (!)
Implicaties:
- Moeite de weg te vinden in de gezondheidszorg
- Kunnen thuis minder goed omgaan met gezondheid en ziekte
- Zijn vaak in consult geen goede gesprekspartner met zorgprofessional
- Veel, maar niet optimale zorgconsumptie
- Vaak slechtere gezondheidsuitkomsten, overlijden eerder.
www.nivel.nl

18. Ø Met één telefoongesprek (en uitnodigingsbrief) is 1 op de 4 non-attenders bereid je
thuis te ontvangen en is als second-best 1 op de 5 bereid een enquête in te vullen
Ø Tijdens de behandeling van de fractuur is er niemand geweest die deze groep de
noodzakelijke informatie heeft gegeven
Ø Dit verdient optimale aandacht van iedere betrokken zorgprofessional
Ø De strategie rond de heupfractuur patiënt verdient meer regie / andere aanpak
Ø Optimaal resultaat in deze studie: oudere vrouwen en `major fracture`
Ø Met een efficiënte inclusie-methodiek lijkt ook nu veel aan FLS effectiviteit te kunnen
worden gewonnen.
Aanbeveling
Ø Lokale initiatieven gericht op betere zorg laten onverlet de noodzaak te komen tot
structurele verbetering van de uitvoering van osteoporose- en fractuurpreventiezorg in
Nederland waarin alle beïnvloedende factoren de noodzakelijke plaats verdienen.
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Conclusies van de studie en een aanbeveling

19. dr. Paul van Haard
prof. dr. Piet Geusens
prof. dr. Joop van den Bergh
dr. Dave Schweitzer
Grote dank aan het team!