key: cord-0973994-nsh2wzb0
authors: van den Berg, Peter; van Leerdam, Martin; Schweitzer, Dave H.
title: Covid-19 given opportunity to use peripheral pulse echo ultrasound (P-EU) in the plaster room to continue secondary fracture prevention care: A retrospective cohort study from a Fracture Liaison Service perspective
date: 2021-08-30
journal: Int J Orthop Trauma Nurs
DOI: 10.1016/j.ijotn.2021.100899
sha: a0093b3c159702f6fed214092bc7659863442ea2
doc_id: 973994
cord_uid: nsh2wzb0

INTRODUCTION: Fracture Liaison Service (FLS) managed secondary fracture prevention progression has become hampered in the COVID-19 pandemic. A challenging opportunity is to use pulse-echo ultrasound (P-EU) in the plaster room. The study has two objectives: can P-EU help our decision to justly skip DXA/VFA scans in plaster treated women (50–70 years) after fracture and whether its use nudges all plaster treated patients (>50 years) who need DXA/VFA scans. PATIENTS AND METHODS: 1307 patients (cohort: pre-COVID-19) and 1056 patients (cohort: peri-COVID-19), each of them ≥ 50 years after recent fracture, were studied. Only in women aged 50–70 years, we used a P-EU decision threshold (DI) >= 0.896 g/cm(2) to rule out for further analysis by means of DXA/VFA. All other plaster patients received P-EU as part of patient information. Peri-Covid-19, all performed DXA/VFA scans were counted until three months post-study closure. By then each patient still waiting for a DXA/VFA had received a scan. RESULTS: Peri-COVID-19, 69 out of 191 plaster-treated women aged 50–70 years were ruled out (36%), for plaster and not in-plaster treated women aged 50–70 years, it was 27%. Comparing all peri-to pre-COVID-19 plaster-treated women and men, a significant P-EU nudging effect was found (difference in proportions: 8.8%) P = .001. CONCLUSION: The combination of patient information and P-EU in the plaster room is effective to spare DXA/VFA scans and nudges extra patients to undergo DXA/VFA. After all, more than a quarter of 50–70 years old women in plaster did not need to be scanned.

women aged 50-70 years, we used a P-EU decision threshold (DI) >= 0.896 23 g/cm 2 to rule out for further analysis by means of DXA/VFA. All other plaster 24 patients received P-EU as part of patient information. all 25 performed DXA/VFA scans were counted until three months post-study closure. 26 By then each patient still waiting for a DXA/VFA had received a scan. 27 

Peri-COVID-19, 69 out of 191 plaster-treated women aged 50-70 years were 29 ruled out (36%), for plaster and not in-plaster treated women aged 50-70 years, 30 it was 27%. Comparing all peri-to pre-COVID-19 plaster-treated women and 31 men, a significant P-EU nudging effect was found (difference in proportions: 32 8.8%) P = .001. patients with an osteoporotic fracture and who finally receive active treatment to 53 prevent new fractures [2, 3, 10] . We identified lack of structural and well-54 organized patient information being one of the most critical underlying 55 problems [11, 12] . Better patient information with a focus on the intrinsic 56 neglect of skeletal health is critical to perform better [11] [12] [13] [14] i.e., you gain more 57 DXA/VFA scans and a higher FLS attendance [11] . Patient information must be 58 available shortly after the fracture, for example during fracture treatment in the 59 plaster room. By then, the use of simple equipment to estimate the risk of a 60 subsequent fracture will be very easy to plan [11] . 61 In previous Finnish studies on P-EU, a significant correlation was found 62 between a proposed threshold (Density Index (DI)) and BMD at the femoral 63 neck. The optimal DI to rule out osteoporosis at the hip was >=0. 

In this retrospective study, we analyzed two cohorts of fracture patients older As soon as possible after the fracture, each patient in need of plaster treatment 122 received information in the plaster room from one of the nurse technicians. 123 Patients with fractures who did not require in-plaster treatment did not receive 124 face-to-face patient information. Soon after discharge, these patients received an 125 invitation letter at home with the request to make an appointment for a 126 DXA/VFA scan and to go to the FLS. During COVID-19, each plaster room 127 patient received the same face-to-face patient information but also an ultrasound were therefore similarly approached in the plaster room with one exception 144 whether they underwent P-EU. 145 To analyze our hypothesis that patient information in combination with P-EU 146 would increase number of DXA/VFA scans (via a nudging effect), we compared 147 the proportion of performed DXA/VFA scans between Pre-COVID-19 (P-EU-) 148 and Peri-COVID -19 (P-EU+) groups. 149 Patient characteristics of both cohorts are shown in Table 1 for proportions and for the difference between independent proportions were 178 calculated by means of Wilson score / Newcombe's method [24, 25] . In 179 addition, calculated from the difference between proportions and its confidence 180 interval, effect size was also expressed in terms of the number needed to treat 181 (NNT), being the number of patients that need to be exposed to an intervention 182 to get one additional patient with a favorable outcome. 183 The study was carried out in accordance with Good Clinical Practice (GCP) As can be seen in Table 3 , proportion-wise more DXA/VFA scans were 228 performed peri-COVID-19 than pre-COVID-19. This nudging effect of P-EU 229 exposure in the plaster room was statistically significant, P=.002. The effect size 230 (expressed as the difference between proportions) was 5.8%, 95%CI (1.9-9.7). 231 Expressed as NNT, we found that it took 18 patients who also received P-EU in 232 the plaster room to gain one extra DXA/VFA scan, 95%CI (11-53). 233 The nudging effect was also calculated for the group of all plaster room 234 attendees only (women aged 50-70 years, women over 70 years old, and men). 235 The two cohorts were again compared for the number of DXA/VFA scans 236 performed (see Table 4 The strength of the study is that it confirms both our hypotheses: a DXA/VFA 294 sparing effect, stronger compared to the outcome of a previous study from our 295 group (set-up as a first pilot among women at low risk of having osteoporosis 296 based on age category (50-70 years)) and a nudging effect, which was 297 demonstrated for the first time. We belief that both aspects are of great 298 importance for individual patients but also from a health economic perspective. 299 The nudge effects can be explained by the early timing of P-EU, almost 300 immediately after fracture during plaster treatment. 301 This study contains two clear weaknesses: 1. its retrospective design and 2. the 302 use of fixed DI cut-off to decide to rule out for DXA/VFA in women aged 50-70 303 J o u r n a l P r e -p r o o f years. It remains to be seen whether time of P-EU is optimal in the plaster room. 304 Anxiety and pain can be confounders whereby the nudging effect is wrongly 305 attributed to the application of P-EU. A future RCT in the plaster room is 306 necessary to determine this definitively. 307 In our strive to continue secondary fracture prevention we studied P-EU in the 308 plaster room. This effort is in line with the 5-steps approach of FLSs to facilitate 309 the diagnostic process of the FLS [28] . Future research is imperative to study 310 decision thresholds not only in women aged 50-70 years, but also in elderly 311 women and in men. In these different groups we should study optimal P-EU cut-312 off points in rule-out strategies, but at the same time we should also consider 313 challenges and opportunities of the nudging effect through the same 314 intervention. 315 To conclude, we had a Covid-19 given opportunity to use P-EU in the plaster 316 room to continue secondary fracture prevention care. It generated two effects: 317 the appropriate sparing of a substantial portion of DXA/VFA scans in women 318 aged 50-70 years and nudging effect interesting more plaster patients to undergo 319 a diagnostic work-up with a DXA/VFA scan. This study therefore demonstrates 320 new possibilities to optimize access to the FLS for those who need it. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f

VFA: Vertebral Fracture Assessment; FLS: Fracture Liaison Service; P-EU: Pulse-Echo Ultrasound. Fracture code exit registration is the code use by the Finance Dept. of the Hospital. Identified eligible patients for DXA/VFA and FLS care pre-and peri-COVID-19 based on fracture code exit registration N=2363

plaster-treated patients: n=272 Ruled out for DXA/VFA (in women 50-70 yrs

DXA/VFA performed n=687 (65,1%)

DXA/VFA including waiting list (n=75) scheduled n=762 (71%)