title: Impact of guideline implementation by a fracture nurse on subsequent fractures and mortality in patients presenting with non-vertebral fractures.
abstract: BACKGROUND
  Systematic implementation of guidelines in patients presenting with a fracture increases identification of patients at high risk for subsequent fractures and contributes to a decreased fracture risk. Its effect on prevention of subsequent fractures and on mortality has not been documented. The aim of this study was to determine the impact of the implementation of specific guidelines on the risk of subsequent fractures and mortality in patients presenting with a non-vertebral fracture (NVF).
  
  
  METHODS
  Before-after impact analysis in consecutive patients older than 50 years who were admitted to the hospital with a NVF during 2 periods: pre-intervention group (n = 1,920, enrolled in 1999-2001) and intervention group (n = 1,335, enrolled in 2004-2006). The intervention consisted of a dedicated fracture nurse who systematically offered fracture risk evaluation and treatment according to available guidelines. The 2-year absolute risk (AR) and hazard ratio's (HR, with 95% confidence interval (CI)) of subsequent NVFs and mortality were analysed between both groups after adjustment for age, sex and baseline fracture location by multivariable Cox regression and by intention-to-treat.
  
  
  RESULTS
  The AR of subsequent fracture was 9.9% before and 6.7% after intervention, indicating a decrease of 35% in the risk of subsequent fracture (HR 0.65; CI: 0.51-0.84, after adjustment for age, sex and baseline fracture location) and 17.9% and 11.6%, respectively, for subsequent mortality, indicating a decrease of 33% in the risk of subsequent mortality (HR: 0.67; CI: 0.55-0.81, after adjustment for age, sex and baseline fracture location).
  
  
  CONCLUSIONS
  Systematic implementation of guidelines for fracture prevention by a dedicated fracture nurse immediately after a NVF is associated with a significant reduction of the 2-year risk of subsequent NVF and mortality.
authors.affiliation: Maastricht University Medical Centre, Department of Trauma Surgery, Maastricht, The Netherlands. k.huntjens@ah.unimaas.nl
authors.forename: Kirsten M B
authors.initials: KM
authors.lastname: Huntjens
authors.forename: Tineke C M
authors.initials: TC
authors.lastname: van Geel
authors.forename: Piet P
authors.initials: PP
authors.lastname: Geusens
authors.forename: Bjorn
authors.initials: B
authors.lastname: Winkens
authors.forename: Paul
authors.initials: P
authors.lastname: Willems
authors.forename: Joop
authors.initials: J
authors.lastname: van den Bergh
authors.forename: Peter R G
authors.initials: PR
authors.lastname: Brink
authors.forename: Svenhjalmar
authors.initials: S
authors.lastname: van Helden
mesh_terms: D015331:Cohort Studies; D005260:Female; D050723:Fractures, Bone / Q000401:mortality* / Q000451:nursing / Q000517:prevention & control; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010024:Osteoporosis / Q000453:epidemiology / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D018570:Risk Assessment; D055502:Secondary Prevention; D016019:Survival Analysis