Factors influencing the treatment of osteoporosis following fragility fracture

Osteoporosis Treatment After Osteoporotic Fractures: Data From a Single Medical Center

OBJECTIVE

Most patients do not receive osteoporosis treatment after osteoporotic fracture. This study reviewed osteoporosis treatment after osteoporotic fractures in a center without a Fracture Liaison Service.

METHODS

We identified all patients with hip, vertebral, humeral or radial fractures, evaluated in Meir Medical Center, in 2017. The exclusion criteria were not a Clalit Health Services member, high-energy fracture or 30-day postoperative mortality. The primary endpoint was osteoporosis drugs issued within 12 months of fracture. Secondary endpoints included bone densitometry and 1-year mortality.

RESULTS

Five-hundred-eighty-two patients (average age 78.6 ± 11.1 years, 75.8% women) were included. There were 321 (55.5%) hip, 84 (14.1%) humeral, 33 (5.6%) vertebral, and 144 (24.7%) radial fractures. Osteoporosis drugs were issued to 26.5% of the patients; those with humeral fractures received the least (21.4%) and vertebral, the most (30.3%; P = .51). Bone densitometry was performed in 23.2% of patients. One-year mortality after hip fracture was 12.1%, followed by humeral (3.6%; P < .05). Logistic regression showed that previous treatment (odds ratio [OR] = 7.4; 95% confidence interval [CI] 3.6-15.2), bone densitometry (OR = 4.4; 95% CI 2.6-7.4) and endocrinology visit (OR = 2.6; 95% CI, 1.4-4.6) were the most important factors associated with treatment.

CONCLUSION

Fewer than one third of patients received pharmacotherapy within 1 year after fracture. Because pharmacotherapy reduces future fractures and mortality, we recommend that medical staff who care for patients with fracture adopt practical and effective strategies to increase treatment rates among patients with osteoporotic fractures.

Persistence and compliance to osteoporosis therapy in a fracture liaison service: a prospective cohort study

Persistence and compliance to osteoporosis medications aiming to prevent fragility fractures are essential for fracture prevention, but are suboptimal in the population. A Fracture Liaison Service with a systematic follow-up led to ongoing therapy and optimal drug compliance for more than half of treated patients over 2 years.

PURPOSE

Fracture Liaison Services (FLS) have the potential to improve persistence and compliance to osteoporosis therapy. We aimed to assess patterns of drug use in a high-level intervention FLS.

METHODS

Women and men (> 40 years) with a fragility fracture were recruited in a FLS, where osteoporosis therapy was prescribed if appropriate. Based on claims data, patients who filled their prescription in the 3-month period following baseline were selected. The 1- and 2-year persistence rates were measured using survival analysis. In non-persistent subjects, 1-year treatment re-initiation was measured. The 1- and 2-year compliance levels were measured, using the proportion of days covered (PDC > 80% = compliant). Regression analyses were performed to identify predictors of non-persistence/compliance.

RESULTS

Out of 332 subjects with complete drug insurance coverage, 297 (89.5%) were prescribed osteoporosis therapy by the FLS, and 275 (92.6%) were dispensed. Two hundred sixty participants (86.9% female; mean age 65.6 years) were selected for having filled a prescription inside 3 months after baseline. The 1- and 2-year persistence rates were 66.4% and 55.6%, respectively. Treatment re-initiation was observed in 56% of non-persistent patients. PDC was > 80% in 64.2% for 1 year and 62.5% for 2 years. Older and younger age, smoking, higher spine bone mineral density, lower major FRAX risk, and missing follow-up visits were predictors of non-persistence and/or non-compliance.

CONCLUSIONS

After 2 years in a high-level intervention FLS, more than half the treated participants were persistent and compliant to treatment. Comparative effectiveness studies must be undertaken to determine whether this intervention is an improvement over usual care.

Prescription practices of anti-osteoporosis medication among Thai orthopedic surgeons (PAMOS study) in osteoporotic hip fracture

As a medication for preventing osteoporotic fracture is recommended but scarcely prescribed, this study surveyed Thai orthopedic surgeons to explore key determinants of their prescription practices. In addition to a set of well-known determinants, the patient's health insurance status could also influence the prescription practice.

PURPOSE

Although many guidelines suggest using anti-osteoporosis medications in patients who suffered from fragility hip fractures, low rate of prescription was encountered all over the world. In this study, we aimed to explore potential determinants affecting the prescription of anti-osteoporosis medications by orthopedic surgeons.

MATERIALS AND METHODS

Online questionnaire survey was conducted among randomly selected orthopedic surgeons in Thailand. We inquired the factors associated with anti-osteoporosis medication prescription (likely to prescribe, unlikely to prescribe, or not influential). The reasons for not prescribing were also inquired.

RESULTS

Two hundred and ninety-four participants responded to the questionnaires. Age, gender, previous fragility fracture, and BMD results seemed to influence the medication prescription. Interestingly, the type of reimbursement was responded as an important factor. The leading reason for not prescribing the medication was due to the high cost of the treatment.

CONCLUSIONS

Knowing the factors affecting the prescription of anti-osteoporosis medication is beneficial for strategic planning in order to increase the rate of prescription. The gap of treatment may be reduced, and the morbidity and mortality of the patients can be decreased.

Gender differences in anti-osteoporosis drug treatment after osteoporotic fractures

This study examined differences between men and women in factors affecting anti-osteoporosis drug treatment after osteoporotic fracture. Using a national claims database, we analyzed patients aged 50 years and older who experienced their first osteoporotic fracture between January 1, 2008, and December 31, 2012. We examined whether patients were prescribed anti-osteoporosis drugs within 6 months post-fracture. Factors associated with treatment status were identified using multivariate logistic regression. Among a total of 556,410 patients aged 50 and older, only 37% were prescribed anti-osteoporosis drugs within 6 months post-fracture. Female patients with fractures were more likely to receive pharmacotherapy than male patients (41.7 vs. 19.3%). Older age significantly increased the likelihood of receiving anti-osteoporosis drugs after osteoporotic fracture. For men, the adjusted odds ratio for receiving therapy was greatest in those aged 80 years and older (OR 6.4), and for women, it was largest in those aged 70-79 (OR 3.33). Both men and women were more likely to be prescribed drugs after a spine fracture, with men having significantly greater odds of receiving drug therapy (men, OR 7.1, 95% CI 6.5-7.9; women 4.79, CI 4.63-4.96). Patients with rheumatic disease or other osteoporosis-inducing comorbid disease were more likely to be prescribed anti-osteoporosis drugs. Our findings indicate that a lack of anti-osteoporosis pharmacotherapy after fracture remains a problem in Korea, especially among men, highlighting the need for effective quality improvement interventions to maximize post-fracture treatment rates.

Are we treating osteoporotic fractures of the hip adequately? A Middle Eastern cohort study

Fragility hip fractures treated in a center in the Middle East were retrospectively studied for adequacy of osteoporosis management. Of the 318 patients treated, over 70% did not have a structured investigation and about 30% did not receive any therapeutic supplements. Our series showed a preventable 8.8% secondary fracture rate.

PURPOSE

To study the adequacy of evaluation and treatment of osteoporosis after fragility fractures of the hip. The study also attempts to estimate the prevalence of secondary fractures after the original injury.

METHODS

This is a retrospective evaluation of the electronic database to search all the admissions for fractures of the hip in patients over 50 years at a tertiary care Trauma and Orthopaedic center in the Sultanate of Oman. The study period was defined as October 2010 to December 2015. Their case records, BMD reports, and laboratory data were analyzed. Pharmacological interventions and the documented compliance with such therapy were also recorded.

RESULTS

Over the study period, 318 fragility fractures of the hip were treated. Of these, 233 (73.3%) did not receive a DEXA scan and 94% did not have their vitamin D₃ (vit D) tested. About 29.9% percent cases did not receive any nutritional supplement or therapeutic intervention though diagnosed as fragility fracture. Twenty-eight patients (8.8%) reported for secondary fractures of the hip. Of these, 86% was initiated on supplement after their index fracture though 78.6% had not had a BMD study.

CONCLUSIONS

Less than 27% patients receive BMD test following fragility fracture of the hip and only 6% a vit D3 assay. Secondary fractures of the hip tend to occur in approximately 9% of the cases in Oman; this seems to occur equally in patients who have had as well as not had any calcium and vit D supplements after the index injury.

Factors Affecting Bone Mineral Density Measurement after Fracture in South Korea

Background

Prior osteoporotic fractures are strongly associated with the subsequent fractures. To prevent this, the diagnosis of osteoporosis following an osteoporotic fracture is important. The measurement of bone mineral density (BMD) is the first step for the diagnosis and management of osteoporosis. Therefore, the purposes of this study are 1) to evaluate the rate of BMD measurement after osteoporotic fracture in Korean population; and 2) determine the associated factors with BMD measurement after fractures among Korean patients.

Methods

From database of Health Insurance Review & Assessment Service, we identified patients with osteoporotic fractures happened in 2010. The BMD examinations were evaluated by using procedure codes. We evaluated the rate of BMD measurement within 6 months after fracture according to gender, age group (10-year incremental), type of insurance, residency area (rural vs. urban), type of medical institute, department, history of depression, rheumatoid arthritis, medical history suggestive of secondary osteoporosis, osteoporosis-induced drug, and number of family members.

Results

During study period, about a half (53.9%) of patients with osteoporotic fractures had BMD measurement. Men, younger age, urban residency, and depression history were associated with low rate of BMD measurement. However, increasing age, use of glucocorticoid use, osteoporosis-inducing comorbid disease including rheumatologic disease, and osteoporosis-induced drug user were associated with higher likelihood of BMD measurement.

Conclusions

Our results showed that about a half of patients with osteoporotic fractures had BMD measurement in South Korea, and provided the basic information to encourage management after fracture by educating not only patient but also physician about post-fracture management.

Disparities in osteoporosis treatments

Osteoporosis treatment rates within 2 years following an index event (fragility fracture, osteoporotic bone mineral density (BMD) T-score, or osteoporosis ICD-9 codes) were determined from 2005 to 2011. Most patients were not treated. Fracture patients had the lowest treatment rate. Low treatment rates also occurred in patients that were male, black, or had non-commercial insurance.

INTRODUCTION

Clinical recognition of osteoporosis (osteoporotic BMD, assignment of an ICD-9 code, or the occurrence of fragility fractures) provides opportunities to treat patients at risk for future fracture.

METHODS

A cohort of 36,965 patients was identified from 2005 to 2011 in the Indiana Health Information Exchange, with index events after age 50 of either non-traumatic fractures, an osteoporosis ICD-9 code, or a BMD T-score ≤ -2.5. Patients with osteoporosis treatment in the preceding year were excluded. Medication records during the ensuing 2 years were extracted to identify osteoporosis treatments, demographics, comorbidities, and co-medications. Predictors of treatment were evaluated in a multivariable logistic regression model.

RESULTS

The cohort was 78 % female, 11 % black, 91 % urban-dwelling, and 53 % commercially insured. The index events were as follows: osteoporosis diagnosis (47 % of patients), fragility fracture (44 %), and osteoporotic T-scores (9 %). Within 2 years after the index event, 23.3 % received osteoporosis medications (of which, 82.2 % were oral bisphosphonates). Treatment rates were higher after osteoporosis diagnosis codes (29.3 %) or osteoporotic T-score (53.9 %) than after fracture index events (10.5 %) (p < 0.001). Age had an inverted U-shaped effect for women with highest odds around 60-65 years. Women (OR 1.86) and non-black patients (OR 1.52) were more likely to be treated (p < 0.001). Patients with public (versus commercial) insurance (OR 0.86, p < 0.001) or chronic comorbidities (ORs about 0.7-0.9, p < 0.001) were less likely to be treated.

CONCLUSION

Most osteoporosis treatment candidates remained untreated. Men, black patients, and patients with fracture or chronic comorbidities were less likely to receive treatment, representing disparity in the recognition and treatment of osteoporosis.

The NYU Osteoporosis Model of Care Experience

INTRODUCTION

Participants who sustain a fragility fracture are at increased risk for subsequent fractures. Despite the consequences of recurrent fractures, bone mineral density (BMD) testing and treatment rates for osteoporosis after a fracture remain low. The New York University (NYU) Langone Osteoporosis Model of Care was developed to identify women at increased risk for recurrent fractures and to reduce the rates of subsequent fracture through patient and physician education.

METHODS

Women aged 50 years and older who had a fracture and received their care at NYU affiliated hospitals were contacted via mail after discharge. Participants were provided educational materials explaining decreased bone strength and its possible relationship to their fracture and were asked to complete a questionnaire. One year postfracture, participants were sent follow-up questionnaires requesting their most recent fracture treatment and BMD information. Educational material was also provided to the treating orthopedic surgeons.

RESULTS

Overall, 524 patients were contacted and 210 (40%) enrolled. By the end of 24 months, 92 participants completed their 1-year questionnaire (44% of the enrollees). Forty-two (46%) participants had undergone new BMD testing and 37 (40%) were receiving antiresorptive medications, including 6 (6%) who had not been prescribed these medications before enrolling in the program.

CONCLUSIONS

The Osteoporosis Model of Care is a simple and cost-effective educational program, which improved comprehensive fracture care in an actual clinical setting. Patient enrollment remains a challenge in implementing the program. Our program highlights difficulties in providing community-dwelling participants with appropriate postfracture care. With increasing concern among the public regarding the use of bone strengthening medications and continued low postfracture treatment rates, educating patients with high fracture risk is critical to reducing the rate of subsequent fracture. Our Model of Care Program demonstrates both the success and limitations of a postfracture educational approach using discharge diagnosis data to identify patients with fracture.

A survey of outcomes and management of patients post fragility fractures in China

We found that the fragility hip and vertebral fractures caused excess mortality rates in this Chinese female population, which was unexpectedly lower than those in western countries and other Asian countries. This was the first nationwide survey relating to post-fracture outcomes conducted among Chinese population in Mainland China.

INTRODUCTION

This study aimed to investigate the mortality, self-care ability, diagnosis, and medication treatment of osteoporosis following fragility hip and vertebral fractures through a nationwide survey among female patients aged over 50 in Mainland China.

METHODS

This was a multicenter, retrospective cohort study based on medical chart review and patient questionnaire. Female patients aged 50 or older admitted for low-trauma hip or vertebral fractures and discharged from Jan 1, 2008 to Dec 31, 2012 were followed.

RESULTS

Total of 1151 subjects of hip fracture and 842 subjects of vertebral fracture were included. The mean age was 73.4 ± 10.0, and the median of duration from index fracture to interview was 2.6 years. The overall 1-year, 2-year, 3-year, 4-year, and 5-year cumulative mortality rates were 3.5, 7.0, 11.2, 13.1, and 16.9 %, respectively. The first year mortality rates in hip (3.8 %, 95% CI 3.3-4.4 %) and vertebral fracture (3.1 %, 95% CI 2.5-3.7 %) were significantly higher than that in the general population (1.6 %). Impaired self-care ability was observed in 33.2, 40.6, and 23.8 % of overall, hip fracture, and vertebral fracture group, respectively. The overall diagnosis rate of osteoporosis was 56.8 %, and bone mineral density (BMD) measurement had never been conducted in 42.0 % among these women. After the index fracture, 69.6 % of them received supplements and/or anti-osteoporotic medications, among which 39.6 % only received calcium with/without vitamin D supplementation.

CONCLUSIONS

The osteoporotic hip and vertebral fractures caused excess mortality rates in this population of Mainland China. The current diagnosis and medical treatment following the fragility fractures is still insufficient in Mainland China.

Anti-osteoporosis drug prescribing after hip fracture in the UK: 2000-2010

The probability of initiating with anti-osteoporosis therapy increased from 7 % in 2000 to 46 % in 2010. This improvement was greater for patients over the age of 75 years. Men, those overweight, having dementia or exposed to antipsychotics, sedatives/hypnotics or opioid analgesics were significantly less likely to receive anti-osteoporosis drugs.

INTRODUCTION

The objective of this study was to examine trends and determinants of anti-osteoporosis drug prescribing after hip fracture in the UK between 2000 and 2010.

METHODS

Data were extracted from the UK Clinical Practice Research Datalink for patients ≥50 years who had a first hip fracture between 2000 and 2010 and who did not currently (≤6 months prior) receive anti-osteoporosis drugs (bisphosphonates, strontium ranelate, parathyroid hormone, calcitonin and raloxifene) (n = 27,542). The cumulative incidence probability of being prescribed anti-osteoporosis drugs within 1 year after hip fracture was estimated by Kaplan-Meier life-table analyses. Determinants for treatment initiation were estimated by Cox proportional hazards models.

RESULTS

The probability of being prescribed any anti-osteoporosis drug after hip fracture increased from 7 % in 2000 to 46 % in 2010. This trend was more marked in patients ≥75 years. The increase in prescribing of anti-osteoporosis drugs was complemented by a similar increase in vitamin D/calcium provision. Cumulative incidence of receiving anti-osteoporosis therapy was greater at any given point in time in women (8 % in 2000, 51 % in 2010) compared to men (4 % in 2000, 34 % in 2010). In addition to male gender, multivariable Cox regression identified reduced likelihood of receiving anti-osteoporosis drugs for those being overweight, having dementia and exposed to psychotropic drugs (antipsychotics, sedatives/hypnotics) or opioid analgesics.

CONCLUSION

Although the prescribing of anti-osteoporosis drugs after hip fracture has increased substantially since 2000, the overall rate remained inadequate, particularly in men. With the continuing increase in the absolute number of hip fractures, further research should be made into the barriers to optimise osteoporosis management.

Rates of non-vertebral osteoporotic fractures in rheumatoid arthritis and postfracture osteoporosis care in a period of evolving clinical practice guidelines

In 2002, guidelines for the management of osteoporosis were published by Osteoporosis Canada and widely disseminated. We aimed to assess if those guidelines had any impact on clinical practice and ultimately on fracture rates in rheumatoid arthritis (RA). This was an observational study using the Quebec healthcare databases. To quantify the use of osteoporosis drugs, hormone replacement therapy (HRT), bone mineral density (BMD) testing, and fracture rates, quarterly age-standardized rates between 1998 and 2008 were calculated. A time series approach was used to predict fracture rates from 2003 onward, based on the earlier data. The provision of postfracture osteoporosis care, as defined by the initiation of osteoporosis drugs, HRT, or BMD testing, was examined; and logistic regressions identified factors associated with care. The study population in each quarter was mainly composed of older women. The use of osteoporosis drugs and BMD testing increased over the study period. The actual fracture rates from 2003 onward fell within the projected rates and their 95 % CI indicating no reduction. A total of 1,279 subjects were included in the postfracture care analysis. Over time, the likelihood of receiving osteoporosis care increased by 64 % (OR = 1.64, 95 % CI 1.27-2.11), and the two strongest predictors of care were female gender and corticosteroid use. Over our study period, fracture rates remained stable in this RA population. However, the use of osteoporosis drugs, BMD testing, and provision of postfracture osteoporosis care improved, which may result from gradual adoption of guidelines.

Patterns of anti-osteoporosis medication use among women at high risk of fracture: findings from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

Objective

To assess patterns of anti-osteoporosis medication (AOM) use over 3 years among women at high risk of major fracture.

Methods

The GLOW registry follows a cohort of more than 40,000 women aged ≥55 from 615 primary care practices in 10 countries. Self-administered surveys (baseline, 12, 24, and 36 months) collected data on patient characteristics, perception of fracture risk, and AOM use. FRAX scores were calculated from the baseline surveys and women classified as high risk if their FRAX 10-year probability of major fracture was ≥20%.

Results

A total of 5774 women were classified as at high risk and had complete data over 3 years. At baseline, 2271 (39%) reported receiving AOM, 739 (13%) reported prior but not current use, and 2764 (48%) said they had never used AOM. Over 3 years, 85% of baseline non-users continued as non-users and 15% initiated AOM; among baseline users, 49% continued the same medication class, 29% stopped AOM, and 12% switched. Women who stopped AOM were less likely to self-report osteoporosis (HR 0.56, 95% CI 0.42–0.75) than women who continued AOM. Compared with non-users who did not begin treatment, women initiating AOM were more likely to report a diagnosis of osteoporosis (HR 11.3, 95% CI 8.2–15.5) or osteopenia (HR 4.1, 95% CI 2.9–5.7) and be very concerned about osteoporosis (HR 1.9, 95% CI 1.3–2.8).

Conclusions

Less than 40% of women at high risk of fracture reported taking AOM. Women who stopped AOM were less likely to believe they have osteoporosis. Women who initiated treatment appeared motivated primarily by a diagnosis of osteoporosis or osteopenia and concern about the condition.

Characteristics associated with anti-osteoporosis medication use: data from the Global Longitudinal Study of Osteoporosis in Women (GLOW) USA cohort

INTRODUCTION

Many women at risk of fracture do not receive anti-osteoporosis medication (AOM), while others may be receiving unnecessary treatment.

PURPOSE

To examine the characteristics associated with AOM use among women at low and high risks of fracture.

METHODS

The Global Longitudinal Study of Osteoporosis in Women (GLOW) is a prospective cohort study in which data were collected, via self-administered questionnaires, from 60,393 non-institutionalized women aged ≥ 55 years in 10 countries between October 1, 2006 and April 30, 2008. This is a cross-sectional analysis of baseline USA data, in which women were classified as having low fracture risk (<65 years; no FRAX risk factors) or high fracture risk (≥65 years; prior fracture or ≥ 2 other FRAX risk factors).

RESULTS

Of 27,957 women, 3013 were at low risk of fracture and 3699 were at high risk. Only 35.7% of high-risk women reported AOM treatment, rising to 39.5% for those with self-reported osteopenia and 65.4% for those with self-reported osteoporosis. Conversely, 13.4% of low-risk women reported AOM, rising to 28.7% for osteopenia and 62.4% for osteoporosis. Characteristics associated with significantly higher AOM treatment rates among low- and high-risk women were: osteoporosis (odds ratios 75.3 and 18.1, respectively), osteopenia (17.9 and 6.3), concern about osteoporosis (2.0 and 1.8), higher perceived risk of fracture (2.3 and 1.6), and higher vitality score (1.7 and 1.6).

CONCLUSION

Use of AOM is frequently inconsistent with published guidelines in both high- and low-risk women. Characteristics other than FRAX fracture risk appear to influence this use, particularly the presence of self-reported osteoporosis.

A fracture does not adversely affect bone mineral density responses after teriparatide treatment

BACKGROUND

Fracture leads to local and systemic catabolic physiologic changes. As teriparatide is an agent used to treat osteoporosis in patients with fragility fractures, it is unclear whether teriparatide treatment alters bone mineral density (BMD) and bone markers when given to patients with fractures.

QUESTIONS/PURPOSES

We asked whether BMD and bone marker responses would be blunted in patients with fractures placed on teriparatide after fracture compared with patients without fractures on teriparatide.

PATIENTS AND METHODS

We retrospectively collected data from 141 patients treated with teriparatide for osteoporosis. Seventy-seven patients received teriparatide after fractures (fracture group), whereas 64 were treated for other indications (nonfracture group). We determined BMD at the lumbar spine and at the proximal femur before and 12 and 24 months posttreatment. Bone markers (urine N-telopeptide [urine NTX], bone-specific alkaline phosphatase [BALP]) were measured at baseline and 3, 12, and 24 months posttreatment.

RESULTS

Mean lumbar spine and hip BMDs at last followup increased from baseline with no differences between groups to approximately 9% and 4% at 24 months, respectively. Both bone markers increased from baseline in the nonfracture group, peaking at 12 months. For the fracture group, only urine NTX increased at 3 and 12 months posttreatment. Although the peak levels of both bone markers in the nonfracture group were greater, there was no difference between the two groups.

CONCLUSIONS

Fracture does not have a negative effect on the BMD and bone marker responses to teriparatide treatment. Clinicians should anticipate comparable BMD responses when treating patients with teriparatide for osteoporotic fractures and for other indications.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.