Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture

Digital wrist tomosynthesis (DWT)-based finite element analysis of ultra-distal radius differentiates patients with and without a history of osteoporotic fracture

Despite effective therapies for those at risk of osteoporotic fracture, low adherence to screening guidelines and limited accuracy of bone mineral density (BMD) in predicting fracture risk preclude identification of those at risk. Because of high adherence to routine mammography, bone health screening at the time of mammography using a digital breast tomosynthesis (DBT) scanner has been suggested as a potential solution. BMD and bone microstructure can be measured from the wrist using a DBT scanner. However, the extent to which biomechanical variables can be derived from digital wrist tomosynthesis (DWT) has not been explored. Accordingly, we measured stiffness from a DWT based finite element (DWT-FE) model of the ultra-distal (UD) radius and ulna, and correlate these to reference microcomputed tomography image based FE (μCT-FE) from five cadaveric forearms. Further, this method is implemented to determine in vivo reproducibility of FE derived stiffness of UD radius and demonstrate the in vivo utility of DWT-FE in bone quality assessment by comparing two groups of postmenopausal women with and without a history of an osteoporotic fracture (Fx; n = 15, NFx; n = 51). Stiffness obtained from DWT and μCT had a strong correlation (R2 = 0.87, p < 0.001). In vivo repeatability error was <5 %. The NFx and Fx groups were not significantly different in DXA derived minimum T-scores (p > 0.3), but stiffness of the UD radius was lower for the Fx group (p < 0.007). Logistic regression models of fracture status with stiffness of the nondominant arm as the predictor were significant (p < 0.01). In conclusion this study demonstrates the feasibility of fracture risk assessment in mammography settings using DWT imaging and FE modeling in vivo. Using this approach, bone and breast screening can be performed in a single visit, with the potential to improve both the prevalence of bone health screening and the accuracy of fracture risk assessment.

The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years

Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline.

PURPOSE

After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines.

METHODS

PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance.

RESULTS

Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures.

CONCLUSIONS

Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Modeling Large Sparse Data for Feature Selection: Hospital Admission Predictions of the Dementia Patients Using Primary Care Electronic Health Records

A growing elderly population suffering from incurable, chronic conditions such as dementia present a continual strain on medical services due to mental impairment paired with high comorbidity resulting in increased hospitalization risk. The identification of at risk individuals allows for preventative measures to alleviate said strain. Electronic health records provide opportunity for big data analysis to address such applications. Such data however, provides a challenging problem space for traditional statistics and machine learning due to high dimensionality and sparse data elements. This article proposes a novel machine learning methodology: entropy regularization with ensemble deep neural networks (ECNN), which simultaneously provides high predictive performance of hospitalization of patients with dementia whilst enabling an interpretable heuristic analysis of the model architecture, able to identify individual features of importance within a large feature domain space. Experimental results on health records containing 54,647 features were able to identify 10 event indicators within a patient timeline: a collection of diagnostic events, medication prescriptions and procedural events, the highest ranked being essential hypertension. The resulting subset was still able to provide a highly competitive hospitalization prediction (Accuracy: 0.759) as compared to the full feature domain (Accuracy: 0.755) or traditional feature selection techniques (Accuracy: 0.737), a significant reduction in feature size. The discovery and heuristic evidence of correlation provide evidence for further clinical study of said medical events as potential novel indicators. There also remains great potential for adaption of ECNN within other medical big data domains as a data mining tool for novel risk factor identification.

Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality

CONTEXT

Geriatric hip fractures are increasingly common and confer substantial morbidity and mortality. Fragmentation in geriatric hip fracture care remains a barrier to improved outcomes.

OBJECTIVE

To evaluate the impact of a comprehensive geriatric hip fracture program on long-term mortality.

DESIGN

We conducted a retrospective cohort study of patients aged 65 years and older admitted to our academic medical center between January 1, 2012, and March 31, 2016 with an acute fragility hip fracture. Mortality data were obtained for in-state residents from the state public health department.

MAIN OUTCOME MEASURES

Mortality within 1 year of index admission and overall survival based on available follow-up data.

RESULTS

We identified 243 index admissions during the study period, including 135 before and 108 after program implementation in October 2014. The postintervention cohort trended toward a lower unadjusted 1-year mortality rate compared with the preintervention cohort (15.7% vs 24.4%, p = 0.111), as well as lower adjusted mortality at 1 year (relative risk = 0.73, 95% confidence interval = 0.46-1.16, p = 0.18), although the differences were not statistically significant. The postintervention cohort had significantly higher overall survival than did the preintervention cohort (hazard ratio for death = 0.43, 95% confidence interval = 0.25-0.74, p = 0.002).

CONCLUSION

Fixing fragmentation in geriatric hip fracture care such as through an orthogeriatric model is essential to improving overall survival for this patient population.

Does Simultaneous Computed Tomography and Quantitative Computed Tomography Show Better Prescription Rate than Dual-energy X-ray Absorptiometry for Osteoporotic Hip Fracture?

Purpose

This study aimed to evaluate the efficacy of simultaneous computed tomography (CT) and quantitative CT (QCT) in patients with osteoporotic hip fracture (OHF) by analyzing the osteoporosis detection rate and physician prescription rate in comparison with those of conventional dual-energy X-ray absorptiometry (DXA).

Materials and Methods

This study included consecutive patients older than 65 years who underwent internal fixation or hip arthroplasty for OHF between February and May 2015. The patients were assigned to either the QCT (47 patients) or DXA group (51 patients). The patients in the QCT group underwent QCT with hip CT, whereas those in the DXA group underwent DXA after surgery, before discharge, or in the outpatient clinic. In both groups, the patients received osteoporosis medication according to their QCT or DXA results. The osteoporosis evaluation rate and prescription rate were determined at discharge, postoperative (PO) day 2, PO day 6, and PO week 12 during an outpatient clinic visit.

Results

The osteoporosis evaluation rate at PO week 12 was 70.6% (36 of 51 patients) in the DXA group and 100% in the QCT group (P<0.01). The prescription rates of osteoporosis medication at discharge were 70.2% and 29.4% (P<0.001) and the cumulative prescription rates at PO week 12 were 87.2% and 60.8% (P=0.003) in the QCT and DXA groups, respectively.

Conclusion

Simultaneous CT and QCT significantly increased the evaluation and prescription rates in patients with OHF and may enable appropriate and consistent prescription of osteoporosis medication, which may eventually lead to patients' medication compliance.

The Effectiveness of a Private Orthopaedic Practice-Based Osteoporosis Management Service to Reduce the Risk of Subsequent Fractures

BACKGROUND

Osteoporosis is prevalent in the United States, with an increasing need for management. In this study, we evaluated the effectiveness of a private orthopaedic practice-based osteoporosis management service (OP MS) in reducing subsequent fracture risk and improving other aspects of osteoporosis management of patients who had sustained fractures.

METHODS

This was a retrospective cohort study using the 100% Medicare data set for Michigan residents with any vertebral; hip, pelvic or femoral; or other nonvertebral fracture during the period of April 1, 2010 to September 30, 2014. Patients who received OP MS care with a follow-up visit within 90 days of the first fracture, and those who did not seek OP MS care but had a physician visit within 90 days of the first fracture, were considered as exposed and unexposed, respectively (first follow-up visit = index date). Eligible patients with continuous enrollment in Medicare Parts A and B for the 90-day pre-index period were followed until the earliest of death, health-plan disenrollment, or study end (December 31, 2014) to evaluate rates of subsequent fracture, osteoporosis medication prescriptions filled, and bone mineral density (BMD) assessments. Health-care costs were evaluated among patients with 12 months of post-index continuous enrollment. Propensity-score matching was used to balance differences in baseline characteristics. Each exposed patient was matched to an unexposed patient within ± 0.01 units of the propensity score. After propensity-score matching, Cox regression examined the hazard ratio (HR) of clinical and economic outcomes in the exposed and unexposed cohorts.

RESULTS

Two well-matched cohorts of 1,304 patients each were produced. The exposed cohort had a longer median time to subsequent fracture (998 compared with 743 days; log-rank p = 0.001), a lower risk of subsequent fracture (HR = 0.8; 95% confidence interval [CI] = 0.7 to 0.9), and a higher likelihood of having osteoporosis medication prescriptions filled (HR = 1.7; 95% CI = 1.4 to 2.0) and BMD assessments (HR = 4.3; 95% CI = 3.7 to 5.0). The total 12-month costs ($25,306 compared with $22,896 [USD]; p = 0.082) did not differ significantly between the cohorts.

CONCLUSIONS

A private orthopaedic practice-based OP MS effectively reduced subsequent fracture risk, likely through coordinated and ongoing comprehensive patient care, without a significant overall higher cost.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Identifying characteristics of an effective fracture liaison service: systematic literature review

Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.

Internal Medicine Hospitalists' Perceived Barriers and Recommendations for Optimizing Secondary Prevention of Osteoporotic Hip Fractures

OBJECTIVES

Osteoporosis is a major public health concern affecting an estimated 10 million people in the United States. To the best of our knowledge, no qualitative study has explored barriers perceived by medicine hospitalists to secondary prevention of osteoporotic hip fractures. We aimed to describe these perceived barriers and recommendations regarding how to optimize secondary prevention of osteoporotic hip fracture.

METHODS

In-depth, semistructured interviews were performed with 15 internal medicine hospitalists in a tertiary-care referral medical center. The interviews were analyzed with directed content analysis.

RESULTS

Internal medicine hospitalists consider secondary osteoporotic hip fracture prevention as the responsibility of outpatient physicians. Identified barriers were stratified based on themes including physicians' perception, patients' characteristics, risks and benefits of osteoporosis treatment, healthcare delivery system, and patient care transition from the inpatient to the outpatient setting. Some of the recommendations include building an integrated system that involves a multidisciplinary team such as the fracture liaison service, initiating a change to the hospital policy to facilitate inpatient care and management of osteoporosis, and creating a smooth patient care transition to the outpatient setting.

CONCLUSIONS

Our study highlighted how internal medicine hospitalists perceive their role in the secondary prevention of osteoporotic hip fractures and what they perceive as barriers to initiating preventive measures in the hospital. Inconsistency in patient care transition and the fragmented nature of the existing healthcare system were identified as major barriers. A fracture liaison service could remove some of these barriers.

Osteoporosis in the Women's Health Initiative: Another Treatment Gap?

BACKGROUND

Osteoporotic fractures are associated with high morbidity, mortality, and cost.

METHODS

We performed a post hoc analysis of the Women's Health Initiative (WHI) clinical trials data to assess osteoporosis treatment and identify participant characteristics associated with utilization of osteoporosis medication(s) after new diagnoses of osteoporosis or fracture. Information from visits prior to and immediately subsequent to the first fracture event or osteoporosis diagnosis were evaluated for medication use. A full logistic regression model was used to identify factors predictive of osteoporosis medication use after a fracture or a diagnosis of osteoporosis.

RESULTS

The median length of follow-up from enrollment to the last WHI clinic visit for the study cohort was 13.9 years. Among the 13,990 women who reported new diagnoses of osteoporosis or fracture between enrollment and their final WHI visit, and also had medication data available, 21.6% reported taking an osteoporosis medication other than estrogen. Higher daily calcium intake, diagnosis of osteoporosis alone or both osteoporosis and fracture (compared with diagnosis of fracture alone), Asian or Pacific Islander race/ethnicity (compared with White/Caucasian), higher income, and hormone therapy use (past or present) were associated with significantly higher likelihood of osteoporosis pharmacotherapy. Women with Black/African American race/ethnicity (compared with White/Caucasian), body mass index ≥30 (compared with body mass index of 18.5-24.9), current tobacco use (compared with past use or lifetime nonusers), and history of arthritis were less likely to use osteoporosis treatment.

CONCLUSION

Despite well-established treatment guidelines in postmenopausal women with osteoporosis or history of fractures, pharmacotherapy use was suboptimal in this study. Initiation of osteoporosis treatment after fragility fracture may represent an opportunity to improve later outcomes in these high-risk women. Specific attention needs to be paid to increasing treatment among women with fragility fractures, obesity, current tobacco use, history of arthritis, or of Black race/ethnicity.

Spine fracture prevalence in a nationally representative sample of US women and men aged ≥40 years: results from the National Health and Nutrition Examination Survey (NHANES) 2013-2014

Spine fracture prevalence is similar in men and women, increasing from <5 % in those <60 to 11 % in those 70-79 and 18 % in those ≥80 years. Prevalence was higher with age, lower bone mineral density (BMD), and in those meeting criteria for spine imaging. Most subjects with spine fractures were unaware of them.

INTRODUCTION

Spine fractures have substantial medical significance but are seldom recognized. This study collected contemporary nationally representative spine fracture prevalence data.

METHODS

Cross-sectional analysis of 3330 US adults aged ≥40 years participating in NHANES 2013-2014 with evaluable Vertebral Fracture Assessment (VFA). VFA was graded by semiquantitative measurement. BMD and an osteoporosis questionnaire were collected.

RESULTS

Overall spine fracture prevalence was 5.4 % and similar in men and women. Prevalence increased with age from <5 % in those <60 to 11 % in those 70-79 and 18 % in those ≥80 years. Fractures were more common in non-Hispanic whites and in people with lower body mass index and BMD. Among subjects with spine fracture, 26 % met BMD criteria for osteoporosis. Prevalence was higher in subjects who met National Osteoporosis Foundation (NOF) criteria for spine imaging (14 vs 4.7 %, P < 0.001). Only 8 % of people with a spine fracture diagnosed by VFA had a self-reported fracture, and among those who self-reported a spine fracture, only 21 % were diagnosed with fracture by VFA.

CONCLUSION

Spine fracture prevalence is similar in women and men and increases with age and lower BMD, although most subjects with spine fracture do not meet BMD criteria for osteoporosis. Since most (>90 %) individuals were unaware of their spine fractures, lateral spine imaging is needed to identify these women and men. Spine fracture prevalence was threefold higher in individuals meeting NOF criteria for spine imaging (∼1 in 7 undergoing VFA). Identifying spine fractures as part of comprehensive risk assessment may improve clinical decision making.

A pilot randomized controlled trial of a decision aid with tailored fracture risk tool delivered via a patient portal

We tested the feasibility of a fracture prevention decision aid in an online patient portal. The decision aid was acceptable for patients and successfully decreased decisional conflict. This study suggests the possible utility of leveraging the patient portal to enhance patient education and decision making in osteoporosis care.

INTRODUCTION

Although interventions have improved osteoporosis screening and/or treatment for certain populations of high-risk patients, recent national studies suggest that large-scale uptake of these interventions has been limited. We aimed to determine the feasibility and potential efficacy of a patient portal-based osteoporosis decision aid (DA).

METHODS

We conducted a pilot randomized controlled trial of primary care patients aged ≥55 who were enrolled in a patient portal and had a T-score of <-1. Intervention subjects were provided a link to a patient DA. The DA contained a 10-year fracture risk calculator, summary of medication risks and benefits (prescription and nonprescription), and an elicitation of values. Subjects completed questionnaires assessing the primary outcomes of decisional conflict and preparation for decision making and secondary outcomes related to feasibility and planning for a larger trial. Charts were reviewed for physician-subject interactions and medication uptake.

RESULTS

The DA was acceptable to subjects, but 17 % of the patients in the decision aid arm incorrectly entered their T-scores into FRAX-based risk calculator. Decisional conflict was lower post-intervention for those who were randomized to the decision aid arm compared to controls (17.8 vs. 47.1, p < .001), and there was a significant difference in the percentage of patients who made a treatment decision at 3 months. No significant differences were observed in medication uptake.

CONCLUSIONS

A portal-based osteoporosis DA was acceptable and improved several measures of decision quality. Given its effect on improving the quality of patients' decisions, future studies should examine whether it improves physician guideline adherence or medication adherence uptake among treated patients.

Fracture liaison services: improving outcomes for patients with osteoporosis

Fragility fractures are sentinels of osteoporosis, and as such all patients with low-trauma fractures should be considered for further investigation for osteoporosis and, if confirmed, started on osteoporosis medication. Fracture liaison services (FLSs) with varying models of care are in place to take responsibility for this investigative and treatment process. This review aims to describe outcomes for patients with osteoporotic fragility fractures as part of FLSs. The most intensive service that includes identification, assessment and treatment of patients appears to deliver the best outcomes. This FLS model is associated with reduction in re-fracture risk (hazard ratio [HR] 0.18–0.67 over 2–4 years), reduced mortality (HR 0.65 over 2 years), increased assessment of bone mineral density (relative risk [RR] 2–3), increased treatment initiation (RR 1.5–4.25) and adherence to treatment (65%–88% at 1 year) and is cost-effective. In response to this evidence, key organizations and stakeholders have published guidance and framework to ensure that best practice in FLSs is delivered.

Geriatric Hip Fracture Care: Fixing a Fragmented System

CONTEXT

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners.

OBJECTIVE

To describe a stepwise approach to systems redesign for this patient population.

DESIGN

We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning.

MAIN OUTCOME MEASURES

Hospital length of stay.

RESULTS

We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved.

CONCLUSION

Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.

Pop-up messages in order communication systems can increase awareness of osteoporosis among physicians and improve osteoporosis treatment

RATIONALE, AIMS AND OBJECTIVES

The purpose of this study was to verify the effect of pop-up messages (regarding a history of dual-energy X-ray absorptiometry [DXA]) on the identification and management of osteoporosis after osteoporotic hip or spine fractures. We hypothesized that these pop-up messages would increase the awareness and management of osteoporosis among clinicians and patients.

METHODS

We introduced pop-up messages regarding a history of DXA in our Order Communication System (March 2012) and evaluated the records of 404 patients who were treated between January 2011 and December 2012. The patients were categorized as being treated without the pop-up messages (Group I, before March 2012) or with the pop-up messages (Group II, after March 2012). We compared their rates of DXA prescription, osteoporosis medication, exercise, mortality and subsequent refractures during a 2-year follow-up.

RESULTS

After introducing the pop-up messages, the DXA prescription rate increased from 35.1 to 57.1% (P < 0.001), the osteoporosis medication rate increased from 21.1 to 25.2% (P = 0.05) and the exercise rate increased from 35.6 to 40.5% (P = 0.018). During the 2-year follow-up, the mortality rates were 4.64% in Group I and 6.67% in Group II (P = 0.4). Subsequent refractures were found in 12.9% of Group I patients and 9.52% of Group II patients (P = 0.87).

CONCLUSION

The pop-up messages positively affected the behaviours of orthopaedic surgeons and were associated with increased rates of prescription of DXA, osteoporosis medication, and might affect the behaviour of patient, increased exercise rate. Therefore, we recommend using this simple and effective method to improve physicians' awareness of osteoporosis.

Unmet needs and current and future approaches for osteoporotic patients at high risk of hip fracture

This review provides a critical analysis of currently available approaches to increase bone mass, structure and strength through drug therapy and of possible direct intra-osseous interventions for the management of patients at imminent risk of hip fracture.

PURPOSE

Osteoporotic hip fractures represent a particularly high burden in morbidity-, mortality- and health care-related costs. There are challenges and unmet needs in the early prevention of hip fractures, opening the perspective of new developments for the management of osteoporotic patients at imminent and/or at very high risk of hip fracture. Amongst them, preventive surgical intervention needs to be considered.

METHODS

A European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)/International Osteoporosis Foundation (IOF) working group reviewed the presently available intervention modalities including preventive surgical options for hip fragility. This paper represents a summary of the discussions.

RESULTS

Prevention of hip fracture is currently based on regular physical activity; prevention of falls; correction of nutritional deficiencies, including vitamin D repletion; and pharmacological intervention. However, efficacy of these various measures to reduce hip fractures is at most 50% and may need months or years before becoming effective. To face the challenges of early prevention of hip fractures for osteoporotic patients at imminent and/or at very high risk of hip fracture, preventive surgical intervention needs further investigation.

CONCLUSION

Preventive surgical intervention needs to be appraised for osteoporotic patients at imminent and/or at very high risk of hip fracture.

[Prevalence and management of osteoporosis in trauma surgery. Implementation of national guidelines during inpatient fracture treatment]

BACKGROUND

Osteoporosis-associated fractures represent a risk factor for developing further fragility fractures. Therefore, guideline-oriented osteoporosis intervention is of utmost importance during inpatient fracture treatment.

PATIENTS AND METHODS

Women >50 years and men >60 years with fractures of the lumbar or thoracic spine, proximal femur, proximal humerus and distal radius were included in a prospective study. We analyzed the initiation of diagnosis and treatment of osteoporosis during the inpatient stay.

RESULTS

A total of 455 patients were included and bone mineral density measurement (DXA) was carried out in 65.9 %. Women underwent DXA in 69.5 % and men significantly less frequently in 52.1 %. Osteoporosis was diagnosed in 56.6 %, where women were affected in 56.2 % and men in 59 % of cases. In 83.8 % osteoporosis had been previously unknown. Treatment according to the guidelines of the Organisation of German Scientific Osteology-related Societies (DVO) was initiated in 86.7 % and 77.1 % of women >70 years and men >80 years required anti-resorptive treatment after DXA.

CONCLUSIONS

The majority of elderly patients with fractures also suffer from osteoporosis, independent of gender. Even nowadays, osteoporosis is predominantly not diagnosed until the incidence of a fracture. Therefore, the trauma surgeon is in a key position to initiate diagnosis and treatment of osteoporosis.

Is raloxifene associated with lower risk of mortality in postmenopausal women with vertebral fractures after vertebroplasty?: a hospital-based analysis

Background

Osteoporotic fractures are associated with mortality in postmenopausal woman. Whether raloxifen treatment after vertebroplasty can reduce mortality is unclear in this group. To compare the effect of raloxifene and no osteoporosis treatment on the risk of mortality after vertebroplasty, we designed this study.

Methods

This was a retrospective study (January 2001 to December 2007). Follow-up for each participant was calculated as the time from inclusion in the study to the time of death, or to December 31^st, 2013, whichever occurred first. All of the patients underwent baseline bone density studies, and age and body mass index (kg/m²) were recorded. All associated medical diseases such as diabetes, hypertension, and liver and renal disease were recorded.

Results

One hundred and forty-nine patients with vertebral fractures were enrolled, of whom 51 used raloxifene and 98 patients did not receive any anti-osteoporotic therapy. At the end of the follow-up period, 62 patients had died and 87 were still alive. The treated patients had a lower mortality rate than those who did not receive treatment (P = 0.001, HR = 3.845, 95 % CI 1.884-7.845). The most common cause of mortality was sepsis, and those who received raloxifene had a lower rate of sepsis compared to those who did not receive treatment (P < 0.001).

Conclusions

Effective treatment with raloxifene may had a lower mortality rate in patients with postmenopausal osteoporosis-related vertebral fractures after vertebroplasty.

Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework

BACKGROUND

Behavioural theory can be used to better understand the effects of behaviour change interventions targeting healthcare professional behaviour to improve quality of care. However, the explicit use of theory is rarely reported despite interventions inevitably involving at least an implicit idea of what factors to target to implement change. There is a quality of care gap in the post-fracture investigation (bone mineral density (BMD) scanning) and management (bisphosphonate prescription) of patients at risk of osteoporosis. We aimed to use the Theoretical Domains Framework (TDF) within a systematic review of interventions to improve quality of care in post-fracture investigation. Our objectives were to explore which theoretical factors the interventions in the review may have been targeting and how this might be related to the size of the effect on rates of BMD scanning and osteoporosis treatment with bisphosphonate medication.

METHODS

A behavioural scientist and a clinician independently coded TDF domains in intervention and control groups. Quantitative analyses explored the relationship between intervention effect size and total number of domains targeted, and as number of different domains targeted.

RESULTS

Nine randomised controlled trials (RCTs) (10 interventions) were analysed. The five theoretical domains most frequently coded as being targeted by the interventions in the review included "memory, attention and decision processes", "knowledge", "environmental context and resources", "social influences" and "beliefs about consequences". Each intervention targeted a combination of at least four of these five domains. Analyses identified an inverse relationship between both number of times and number of different domains coded and the effect size for BMD scanning but not for bisphosphonate prescription, suggesting that the more domains the intervention targeted, the lower the observed effect size.

CONCLUSIONS

When explicit use of theory to inform interventions is absent, it is possible to retrospectively identify the likely targeted factors using theoretical frameworks such as the TDF. In osteoporosis management, this suggested that several likely determinants of healthcare professional behaviour appear not yet to have been considered in implementation interventions. This approach may serve as a useful basis for using theory-based frameworks such as the TDF to retrospectively identify targeted factors within systematic reviews of implementation interventions in other implementation contexts.

Established Osteoporosis and Gaps in the Management: Review from a Teaching hospital

Background:

International osteoporosis foundation described severe or established osteoporosis as an osteoporotic individual with a fragility fracture. Orthopaedic surgeons frequently manage fractures, but we believe that large gaps are prevalent in the medical management of osteoporosis after fractures are fixed.

Aim:

The aim of this analysis is to assess the investigations and gaps in the management of osteoporosis in patients admitted with a fragility fracture of femur at King Fahd Hospital of the University, AlKhobar, Saudi Arabia.

Materials and Methods:

A retrospective analysis of all admission and discharge; medical and pharmacy records database of patients over ≥ 50 years with fragility fracture between January 2001 and December 2011. The outcome measures assessed were investigations such as serum calcium, phosphorous, alkaline phosphatase, parathormone, 25 hydroxy vitamin D (25OHD) levels and a dual energy X-ray absorptiometry (DEXA). Secondly once the fracture was fixed what medications were prescribed, calcium and vitamin D, antiresorptives and anabolic agents.

Results:

There were 207 patients admitted during the study period with an average age of 69.2 (12.1) years and 118 were females. In 169 (81.6%) patients, the fracture site was proximal femur. Vitamin D (25OHD) was requested in 31/207 (14.9%). DEXA scan was ordered in 49/207 (24.1%). A total of 78/207 (37.6%) patients received calcium and vitamin D3 and 94/207 (45.4%) either got calcium or vitamin D3. Bisphosphonates was used in 35, miacalcic nasal spray in 25 and anabolic agent teriparatide was prescribed in 21 patients. Post-fixation 126/207 (60.8%) patients did not receive any anti-osteoporotic medication. In untreated group, there were 87 males and 39 females.

Conclusions:

The study found that in patients, who sustained a fragility fracture, confirmation of osteoporosis by DEXA was very low and ideal treatment for severe osteoporosis was given out to few patients. More efforts are needed to fill this large gap in the correct management of osteoporosis related fractures by orthopaedic surgeons.

Clinical efficacy of a fragility care program in distal radius fracture patients

PURPOSE

To assess the quality of an initiative to improve the diagnosis and management of osteoporosis in patients over 50 years of age with distal radius fractures (DRF).

METHODS

A retrospective review was conducted to determine the baseline percentage of individuals undergoing osteoporosis screening after DRF. Thereafter, a study was implemented in which DRF patients who were not being treated for osteoporosis or had not recently undergone screening were offered a dual-energy x-ray absorptiometry scan and referral to endocrinology at the initial hand surgery clinic visit. Patients who declined participation were contacted by a patient educator to discuss the benefits of screening and address their concerns. Those who then wanted to receive an osteoporosis evaluation were scheduled for bone scanning and endocrinology consultation.

RESULTS

During the baseline period, 7 patients (15%) were screened, and 41 (85%) were not screened. During the active phase of the initiative, 82 patients over 50 years of age were treated for a DRF at our institution. A total of 44 patients were identified for potential osteoporosis screening, and 35 patients met inclusion criteria. Of these, 19 (54%) agreed to screening after the initial orthopedic evaluation, and 16 declined. After speaking to a patient educator, 9 of these 16 patients agreed to screening. Of the remaining 7 patients, 4 again declined screening and 3 were unavailable by telephone. Overall, 80% of patients who were identified in the initiative agreed to osteoporosis screening after the combination of recommendation during hand surgery clinic visit and patient education by telephone, and 64% were diagnosed with osteoporosis/osteopenia as a result of completing screening.

CONCLUSIONS

An integrated model of care among orthopedic surgeons, patient educators, and endocrinologists substantially increased screening for osteoporosis after DRF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Estimation of 10-year probability bone fracture in a selected sample of Palestinian people using fracture risk assessment tool

BACKGROUND

The Fracture Risk Assessment (FRAX) tool has been developed by the World Health Organization (WHO) to calculate 10-year probability hip fracture (HP) or major osteoporotic fracture (MOF). The objective of this study was to assess the 10-year probability of MOF and HF among a selected sample of Palestinian people.

METHODS

A sample of 100 subjects was studied. Dual energy X-ray absorpitometry was performed to measure bone mineral density (BMD) which was then inserted into FRAX Palestine online WHO tool to calculate the 10-year probability of MOF and HF.

RESULTS

The median age of participants was 61.5 years and the majority (79%) were females. The median (interquartile range) of femoral hip BMD was 0.82 (0.76-0.92) g/cm². The mean vertebral and hip T scores were -1.41 ± 0.13 SDs and -0.91 ± 0.10 SDs respectively. About one fifth of the sample (21%) had vertebral osteoporosis and 5% had hip osteoporosis. The median (interquartile range) 10-year probability of MOF and HF based on BMD were 3.7 (2.43-6.18)%, and 0.30 (0.10-0.68)% respectively.

CONCLUSION

Osteoporosis is common among Palestinian people above 50 years old. Bone fracture prevention strategies and research should be a priority in Palestine. Using FRAX might be a helpful screening tool in primary healthcare centres in Palestine.

Prevention and clinical management of hip fractures in patients with dementia

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Frax score calculations in postmenopausal women with subclinical hypothyroidism

OBJECTIVE

The aim of our study was to evaluate the relationship between the elevated TSH and fracture risk in postmenopausal women with subclinical hypothyroidism for evaluation of individuals with a high risk for osteoporotic fractures.

DESIGN

FRAX score calculation (10-year estimated risk for bone fracture) and measurement of bone markers (osteocalcin and beta cross-laps) were performed in 82 postmenopausal women with newly discovered subclinical hypothyroidism (mean age 59.17±7.07, mean BMI 27.89±3.46kg/m2, menopause onset in 48.05±4.09 years of age) and 51 matched controls (mean age 59.69±5.72, mean BMI 27.68±4.66kg/m2, menopause onset in 48.53±4.58 years of age) with normal thyroid function.

RESULTS

The main FRAX score was significantly higher in the group with subclinical hypothyroidism than in the controls (6.50±4.58 vs. 4.35±1.56; p=0.001). Hip FRAX score was significantly higher in the group with subclinical hypothyroidism (1.11±1.94 vs. 0.50±0.46; p=0.030). There was no significant difference in bone markers: osteocalcin (23.99±12.63 vs. 21.79±5.34 ng/mL; p=0.484) and beta cross-laps (365.76±184.84 vs. 306.88±110.73 pg/mL; p=0.21) between the two groups.

CONCLUSIONS

Postmenopausal patients with subclinical hypothyroidism, in particular of autoimmune origin, have higher FRAX scores and a thus greater risk for low-trauma hip fracture than euthyroid postmenopausal women. Our results point to the need to monitor postmenopausal patients with subclinical hypothyroidism for avoidance of fractures.

Diagnosis and treatment of osteoporosis in high-risk patients prior to hip fracture

PURPOSE

Hip fractures in older adults are common and serious events. Patients who sustain fragility hip fractures are defined as having osteoporosis. Patients with dementia or a history of a prior fragility fracture are at increased risk of a future fracture. This study assesses prefracture osteoporosis diagnosis and treatment in high-risk groups.

METHODS

A case-control analysis of a database of all patients age ≥60 years admitted for surgical repair of nonpathological, low-impact femur fracture between May 2005 and October 2010 was performed.

RESULTS

Of 1070 patients, 511 (47.8%) had dementia and 435 (40.7%) had been diagnosed with osteoporosis prior to admission. Patients with dementia were more likely to have a diagnosis of osteoporosis prior to their fracture than those without dementia (43.8% vs 37.7%, P < .05). Twenty-five percent of the total study population had been treated with calcium and vitamin D (Cal+D) prior to admission, and 12% with other osteoporosis medications. There was a trend toward patients with dementia being more likely to have been on Cal+D prior to admission (27.6% vs 22.5%, P = .06), but no difference in treatment with other agents (10.8% vs 13.1%, P = .25). Patients with prior fragility fractures were more likely to be on Cal+D (32.3% vs 25.0%, P < .02); however, there was no difference in the use of other osteoporosis medications (12.3% vs 12%, P = .90).

CONCLUSION

Fewer than half of patients that presented with hip fractures were diagnosed with osteoporosis prior to fracture and primary preventative treatment rates were low. Although patients with dementia are more likely to be diagnosed with osteoporosis, they were not more likely to be treated, despite having a greater risk. Additionally, those with prior fragility fractures are often not on preventative treatment. This may represent a missed opportunity for prevention and room for improvement in order to reduce osteoporotic hip fractures.

Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial

Osteoporosis management post fragility fracture has traditionally been deficient with up to 60-90 % of patients remaining untreated for osteoporosis in some studies. Efforts have been made to address this deficiency with some successes reported.

INTRODUCTION

The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting.

METHODS

A prospective randomised clinical trial was conducted to assess the DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic compared with the "usual care" of assessment initiation by the participant's general practitioner.

RESULTS

Sixty-six patients were enrolled in the study. Thirty-three patients each were in the control and intervention groups. The assessment rate (DXA scan rate) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner (68 vs 36 %, respectively; p < 0.05). For patients who were assessed for osteoporosis, treatment rates were similar in both the control and intervention groups (100 vs 88 %, p > 0.05).

CONCLUSION

This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care. Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting.

Treat-to-target for osteoporosis: is now the time?

OBJECTIVES

Current clinical practice guidelines identify patients at high risk for fracture who are likely to benefit from pharmacological therapy and suggest ways to monitor for effectiveness of therapy. However, there is no clear guidance on when fracture risk has been reduced to an acceptably low level. As a consequence, some patients at low risk for fracture may be treated for longer than necessary, whereas others at high risk for fracture may have treatment stopped when they might benefit from continuation of the same treatment or a change to a more potent therapeutic agent. The objective of this statement is to describe the potential clinical utility of developing a "treat-to-target" strategy for the management of patients with osteoporosis.

PARTICIPANTS

We recommend that a task force of clinicians, clinical investigators, and other stakeholders in the care of osteoporosis explore the options, review the evidence, and identify additional areas for investigation to establish osteoporosis treatment targets.

EVIDENCE

Data from large, prospective, randomized, placebo-controlled registration trials for currently available osteoporosis therapies should be analyzed for commonalities of correlations between easily measured endpoints and fracture risk.

CONSENSUS PROCESS

Osteoporosis experts, professional organizations, and patient care advocates should be involved in the process of developing consensus on easily measurable osteoporosis treatment targets that are supported by the best available evidence and likely to be accepted by clinicians and patients in the care of osteoporosis.

CONCLUSIONS

A treat-to-target strategy for osteoporosis offers the potential of improving osteoporosis care by reducing the burden of osteoporotic fractures and limiting adverse effects of therapy.

Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study

Background

A vast amount of literature describes the incidence of fracture as a risk for recurrent osteoporotic fractures in western and Asian countries. Osteoporosis evaluation and treatment after a low-trauma fracture, however, has not been well characterized in postmenopausal women in Asia. The purpose of this study was to characterize patient and health system characteristics associated with the diagnosis and management of osteoporosis among postmenopausal women hospitalized with a fragility fracture in Asia.

Methods

Patient surveys and medical charts of postmenopausal women (N=1,122) discharged after a fragility hip fracture from treatment centers in mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand between July 1, 2006 and June 30, 2007 were reviewed for bone mineral density (BMD) measurement, osteoporosis diagnosis, and osteoporosis treatment.

Results

The mean (SD) age was 72.9 (11.5) years. A BMD measurement was reported by 28.2% of patients, 51.5% were informed that they had osteoporosis, and 33.0% received prescription medications for osteoporosis in the 6 months after discharge. Using multivariate logistic regression analyses, prior history of fracture decreased the odds of a BMD measurement (OR 0.63, 95% CI 0.45-0.88). Having a BMD measurement increased the odds of osteoporosis diagnosis (OR 10.1, 95% CI 6.36-16.0), as did having health insurance (OR 4.95, 95% CI 1.51-16.21 for private insurance with partial self-payment relative to 100% self-payment). A history of fracture was not independently associated with an osteoporosis diagnosis (OR 0.80, 95% CI 0.56-1.15). Younger age reduced the odds of receiving medication for osteoporosis (OR 0.59, 95% CI 0.36-0.96 relative to age ≥65), while having a BMD measurement increased the odds (OR 1.79, 95% CI 1.23-2.61).

Conclusions

Osteoporosis diagnosis and treatment in Asian countries were driven by BMD measurement but not by fracture history. Future efforts should emphasize education of general practitioners and patients about the importance of fracture.

Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis

Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures, despite the availability of effective treatments. We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures. We searched eight medical literature databases to identify reports published between 1996 and 2011, describing models of care for secondary fracture prevention. Information extracted from each publication included study design, patient characteristics, identification strategies, assessment and treatment initiation strategies, as well as outcome measures (rates of bone mineral density (BMD) testing, osteoporosis treatment initiation, adherence, re-fractures and cost-effectiveness). Meta-analyses of studies with valid control groups were conducted for two outcome measures: BMD testing and osteoporosis treatment initiation. Out of 574 references, 42 articles were identified as analysable. These studies were grouped into four general models of care-type A: identification, assessment and treatment of patients as part of the service; type B: similar to A, without treatment initiation; type C: alerting patients plus primary care physicians; and type D: patient education only. Meta-regressions revealed a trend towards increased BMD testing (p = 0.06) and treatment initiation (p = 0.03) with increasing intensity of intervention. One type A service with a valid control group showed a significant decrease in re-fractures. Types A and B services were cost-effective, although definition of cost-effectiveness varied between studies. Fully coordinated, intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and/or education only.

Do the hospitalized patients with osteoporotic fractures require endocrinologists' help?

AIM

Osteoporotic fractures are a crucial cause of morbidity and mortality in patients with fragility fractures and impose huge economic burden on health care services. Orthopedic surgeons are often the only clinicians seen by the patients with osteoporotic fractures. The improvement in osteoporosis management is an urgent require; therefore, the aim of this study was to determine the efficacy of consultation with an endocrinologist in osteoporosis management of patients with a fragility fracture.

METHODS

This survey was undertaken in three phases that focused on patients with osteoporotic fractures who were admitted to five tertiary care, level-I, trauma hospital. Patients were evaluated through a questionnaire which was designed to determine whether physicians manage underlying osteoporosis.

RESULTS

The number of patients who underwent a bone mineral density test increased from a rate of 3.6% to 91% after the intervention, as calcium and vitamin D supplementation from 18% to 92%, bisphosphonate prescription from 0.5% to 83%. Also, the overall medication usage increased from 9% to 87%. A small number of patients (3%) were followed up in contrast to a rate of 73% in the third phase.

CONCLUSION

Orthopedic surgeons are not completely engaged in osteoporosis care for patients with a fragility fracture; therefore, a consultation with an endocrinologist is required to enable orhopedic surgeons to provide an effective osteoporosis care for their patients with an osteoporotic fracture.

Prevalence of vertebral fracture in oldest old nursing home residents

We evaluated vertebral fracture prevalence using DXA-based vertebral fracture assessment and its influence on the Fracture Risk Assessment (FRAX) tool-determined 10-year fracture probability in a cohort of oldest old nursing home residents. More than one third of the subjects had prevalent vertebral fracture and 50% osteoporosis. Probably in relation with the prevailing influence of age and medical history of fracture, adding these information into FRAX did not markedly modify fracture probability.

INTRODUCTION

Oldest old nursing home residents are at very high risk of fracture. The prevalence of vertebral fracture in this specific population and its influence on fracture probability using the FRAX tool are not known.

METHODS

Using a mobile DXA osteodensitometer, we studied the prevalence of vertebral fracture, as assessed by vertebral fracture assessment program, of osteoporosis and of sarcopenia in 151 nursing home residents. Ten-year fracture probability was calculated using appropriately calibrated FRAX tool.

RESULTS

Vertebral fractures were detected in 36% of oldest old nursing home residents (mean age, 85.9 ± 0.6 years). The prevalence of osteoporosis and sarcopenia was 52% and 22%, respectively. Ten-year fracture probability as assessed by FRAX tool was 27% and 15% for major fracture and hip fracture, respectively. Adding BMD or VFA values did not significantly modify it.

CONCLUSION

In oldest old nursing home residents, osteoporosis and vertebral fracture were frequently detected. Ten-year fracture probability appeared to be mainly determined by age and clinical risk factors obtained by medical history, rather than by BMD or vertebral fracture.

Development of an electronic medical record based intervention to improve medical care of osteoporosis

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. An EMR-based intervention (osteoporosis order set) was developed with physician and patient input. There was a trend toward greater calcium supplementation from July 2008 to April 2009 (s = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

INTRODUCTION

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. The study population consisted of patients over 50 years of age.

METHODS

Northwestern Memorial Hospital is a tertiary care academic hospital in Chicago. This study was conducted from September 1, 2007 through June 30, 2009.

RESULTS

Physicians reported that barriers to care comprised nonacute nature of osteoporosis, belief that osteoporosis should be addressed by the PCP, low awareness of recurrent fractures, and radiographs with terms such as "compression deformity", "wedge deformity", or "vertebral height loss" which in their opinion were not clearly indicative of vertebral fractures. An EMR-based intervention was developed with physician and patient input. Over the evaluation period, 295 fracture cases in individuals over the age of 50 years in the medicine floors were analyzed. Mean age was 72 ± 11 years; 74% were female. Sites of fracture included hip n = 78 (27%), vertebral n = 87 (30%), lower extremity n = 61 (21%), upper extremity n = 43 (15%) and pelvis n = 26 (9%). There was no increase in documentation of osteoporosis in the medical record from pre- to post-EMR implementation (p = 0.89). There was a trend toward greater calcium supplementation from July 2008 to April 2009 (p = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

CONCLUSION

An electronic medical record intervention without electronic reminders created with physician input achieves an increase in calcium supplementation but fails to increase diagnosis or treatment for osteoporosis at the time of hospitalization for a fragility fracture.

Participation in high-impact sports predicts bone mineral density in senior olympic athletes

Background:

Loss of bone mineral density (BMD) and resultant fractures increase with age in both sexes. Participation in resistance or high-impact sports is a known contributor to bone health in young athletes; however, little is known about the effect of participation in impact sports on bone density as people age.

Hypothesis:

To test the hypothesis that high-impact sport participation will predict BMD in senior athletes, this study evaluated 560 athletes during the 2005 National Senior Games (the Senior Olympics).

Study Design:

Cross-sectional methods. The athletes completed a detailed health history questionnaire and underwent calcaneal quantitative ultrasound to measure BMD. Athletes were classified as participating in high impact sports (basketball, road race [running], track and field, triathalon, and volleyball) or non-high-impact sports. Stepwise linear regression was used to determine the influence of high-impact sports on BMD.

Results:

On average, participants were 65.9 years old (range, 50 to 93). There were 298 women (53.2%) and 289 men (51.6%) who participated in high-impact sports. Average body mass index was 25.6 ± 3.9. The quantitative ultrasound-generated T scores, a quantitative measure of BMD, averaged 0.4 ± 1.3 and −0.1 ± 1.4 for the high-impact and non-high-impact groups, respectively. After age, sex, obesity, and use of osteoporosis medication were controlled, participation in high-impact sports was a significant predictor of BMD (R² change 3.2%, P < .001).

Conclusions:

This study represents the largest sample of BMD data in senior athletes to date. Senior participation in high-impact sports positively influenced bone health, even in the oldest athletes.

Clinical Relevance:

These data imply that high-impact exercise is a vital tool to maintain healthy BMD with active aging.

Secondary fracture prevention

Osteoporosis causes no symptoms until there is a fracture. Although screening for osteoporosis is recommended for some populations, patients may present with a fragility fracture. Such patients are at high risk for subsequent fractures. Despite this high risk and the presence of generally safe and effective osteoporosis therapy, only a minority of low trauma fracture patients have evaluation and treatment of underlying osteoporosis. A brief summary of the evaluation and medical treatment of the post-fracture patient is provided. Several institutions, integrated health systems, and countries have instituted programs to identify, evaluate, and treat fragility fracture patients. Such programs have had variable success. This article describes some of the programs that work, their cost-effectiveness, and the applicability to the generally non-integrated US health care system. It is clear that better management of the post-fracture patient (and other high-risk patients) will lead to fewer fractures, decreased morbidity and mortality, and long-term cost savings.

Treatment for older men with fractures

Less than 10% of men receive osteoporosis treatment, even after a fracture. A study of 17,683 men revealed that older men, those with spinal fractures, and those taking steroids or antidepressants are more likely to receive treatment after a fracture. Seeing a primary care physician also increases osteoporosis treatment rates.

INTRODUCTION

In 2000, the FDA approved bisphosphonates for the treatment of osteoporosis in men. The purpose of this study is to estimate the frequency of bisphosphonate therapy within 12 months following a fracture and describe patient/physician factors associated with treatment.

METHODS

Health insurance claims for 17,683 men ≥ 65 years of age, who had a claim for an incident fracture from 2000 to 2005, were followed for at least 6 months post-fracture for the initiation of treatment with a bisphosphonate. Patient characteristics, diagnostic procedures, therapies, co-morbidities, and provider characteristics were compared for men who received treatment with those who did not.

RESULTS

Eight percent of men (n = 1,434) received bisphosphonate therapy. Overall treatment increased from 7% in 2001 to 9% in 2005 (p < 0.001). Treatment for hip fractures remained at 7% (p = 0.747). Treatment increased with age: 6% in men aged 65-69 compared to 11.6% in men aged 85-89 (p < 0.001). Factors associated with treatment included: diagnosis of osteoporosis (OR = 8.8; 95% CI, 7.7, 10.4), glucocorticoid therapy (OR = 3.2; 95% CI, 2.4, 4.3), bone mineral density measurement (OR = 3.4; 95% CI, 2.9, 4.0), and antidepressant therapy with tricyclics (OR = 2.0; 95% CI, 1.2, 3.5) or selective serotonin reuptake inhibitors (OR = 1.7; 95% CI, 1.3, 2.4). Men with vertebral fractures (OR = 2.2; 95% CI, 1.8, 2.6) and men seen by primary physicians (OR = 2.6; 95% CI, 2.3, 3.1) were more likely to receive treatment.

CONCLUSIONS

Less than 10% of men received bisphosphonate therapy following a low-impact fracture. Men with a primary physician were more likely to receive bisphosphonate therapy; however, <25% of men were seen by a primary physician.

Predictors of treatment with osteoporosis medications after recent fragility fractures in a multinational cohort of postmenopausal women

OBJECTIVES

To determine the proportion of untreated women who reported receiving treatment after incident fracture and to identify factors that predict treatment across an international spectrum of individuals.

DESIGN

Prospective observational study. Self-administered questionnaires were mailed at baseline and 1 year.

SETTING

Multinational cohort of noninstitutionalized women recruited from 723 primary physician practices in 10 countries.

PARTICIPANTS

Sixty thousand three hundred ninety-three postmenopausal women aged 55 and older were recruited with a 2:1 oversampling of women aged 65 and older.

MEASUREMENTS

Data collected included participant demographics, medical history, fracture occurrence, medications, and risk factors for fracture. Anti-osteoporosis medications (AOMs) included estrogen, selective estrogen receptor modulators, bisphosphonates, calcitonin, parathyroid hormone, and strontium.

RESULTS

After the first year of follow-up, 1,075 women reported an incident fracture. Of these, 17% had started AOM, including 15% of those with a single fracture and 35% with multiple fractures. Predictors of treatment included baseline calcium use (P = .01), baseline diagnosis of osteoporosis (P < .001), and fracture type (P < .001). In multivariable analysis, women taking calcium supplements at baseline (odds ratio (OR) = 1.67) and with a baseline diagnosis of osteoporosis (OR = 2.55) were more likely to be taking AOM. Hip fracture (OR = 2.61), spine fracture (OR = 6.61), and multiple fractures (OR = 3.79) were associated with AOM treatment. Age, global region, and use of high-risk medications were not associated with treatment.

CONCLUSION

More than 80% of older women with new fractures were not treated, despite the availability of AOM. Important factors associated with treatment in this international cohort included diagnosis of osteoporosis before the incident fracture, spine fracture, and to a lesser degree, hip fracture.

Rapid Onset and Sustained Efficacy (ROSE) study: results of a randomised, multicentre trial comparing the effect of zoledronic acid or alendronate on bone metabolism in postmenopausal women with low bone mass

SUMMARY

The ROSE study compared a once-yearly intravenous dose of zoledronic acid with a once-weekly oral dose of alendronate in postmenopausal women. Once-yearly zoledronic acid showed a greater and faster reduction in the levels of two markers of bone turnover and may be an effective option for the treatment of osteoporosis.

INTRODUCTION

The open-label Rapid Onset and Sustained Efficacy (ROSE) study was designed to compare a once-yearly intravenous (iv) dose of zoledronic acid with a once-weekly oral dose of alendronate with respect to markers of bone turnover in approximately 600 postmenopausal women in Germany.

METHODS

Levels of N-telopeptide of collagen type I (NTx) and procollagen 1 C terminal extension peptide (P1NP) were assessed during the study. The primary objective was to assess if zoledronic acid was superior to alendronate in reducing serum NTx levels after 12 months' treatment.

RESULTS

A significantly greater reduction in NTx levels from baseline to month 12 (as determined by the area under the curve) was observed in patients treated with zoledronic acid (n = 408) versus those receiving alendronate (n = 196; 0.282 ng/mL vs. 0.270 ng/mL; P = 0.012). The reduction in levels of P1NP after 1 year was also significantly greater in patients treated with zoledronic acid compared with those receiving alendronate (28.21 vs. 25.53 ng/mL; P = 0.0024). The overall incidence of adverse events was similar between groups; both treatments were generally well tolerated. Although post-dose symptoms, including the incidence of influenza-like symptoms, were higher with zoledronic acid than alendronate initially, the incidence was similar between groups from days 4-360. Gastrointestinal symptoms were more frequent with alendronate than zoledronic acid throughout the study.

CONCLUSION

In this study, once-yearly iv zoledronic acid provided a greater and faster reduction in the levels of NTx and P1NP versus once-weekly oral alendronate.

Testing and treatment for osteoporosis following hip fracture in an integrated U.S. healthcare delivery system

Older veterans with acute hip fracture do not receive adequate evaluation and treatment for osteoporosis, irrespective of their age and underlying health status.

INTRODUCTION

Hip fractures are a serious complication of osteoporosis, leading to high mortality and morbidity. Prior studies have found significant undertreatment of osteoporosis in women with hip fracture. We examined the rate of bone density (BMD) testing and osteoporosis treatment among a predominantly male population hospitalized with hip fractures.

METHODS

We conducted a retrospective cohort study of patients age 65 years and older hospitalized in U.S. Department of Veterans Affairs (VA) hospitals with hip fracture (N = 3,347) between 1 October, 2004 and 30 September, 2006. The primary outcome was receipt of BMD testing or initiation of pharmacotherapy within 12 months of fracture.

RESULTS

The mean age of the study population was 79.0 years (SD = 6.7), 96.5% were male, and 83.3% were white. Only 1.2% of hip fracture patients underwent BMD testing and 14.5% received osteoporosis therapy within 12 months of fracture. Among fracture patients with minimal comorbid illness (N = 756) only 1.6% underwent BMD testing and 13.0% received pharmacotherapy. In logistic regression models, treatment rates were higher for women compared to men (odds ratio, 3.30; 95% CI, 2.16-5.04) and lower for blacks compared to whites (odds ratio, 0.67; 95% CI, 0.45-0.99).

CONCLUSIONS

Evaluation and treatment of osteoporosis among patients with fractures is suboptimal even in an integrated healthcare delivery system with generous pharmaceutical coverage. This study suggests that the undertreatment of osteoporosis demonstrated in the private sector is also present within the VA.

Orthopedic surgeon's awareness can improve osteoporosis treatment following hip fracture: a prospective cohort study

Through retrospective Jeju-cohort study at 2005, we found low rates of detection of osteoporosis (20.1%) and medication for osteoporosis (15.5%) in those who experienced hip fracture. This study was to determine the orthopedic surgeons' awareness could increase the osteoporosis treatment rate after a hip fracture and the patient barriers to osteoporosis management. We prospectively followed 208 patients older than 50 yr who were enrolled for hip fractures during 2007 in Jeju-cohort. Thirty four fractures in men and 174 in women were treated at the eight hospitals. During the study period, orthopedic surgeons who worked at these hospitals attended two education sessions and were provided with posters and brochures. Patients were interviewed 6 months after discharge using an evaluation questionnaire regarding their perceptions of barriers to osteoporosis treatment. The patients were followed for a minimum of one year. Ninety-four patients (45.2%) underwent detection of osteoporosis by dual energy x-ray absorptiometry and 67 (32.2%) were prescribed medication for osteoporosis at the time of discharge. According to the questionnaire, the most common barrier to treatment for osteoporosis after a hip fracture was patients reluctance. The detection and medication rate for osteoporosis after hip fracture increased twofold after orthopedic surgeons had attended the intervention program. Nevertheless, the osteoporosis treatment rate remains inadequate.

Male and non-English-speaking patients with fracture have poorer knowledge of osteoporosis

BACKGROUND

Prior fracture is a strong independent risk factor for subsequent fracture. To date, few studies have examined the level of osteoporosis knowledge specifically in the population of patients who have sustained a fracture. This study was designed to assess the knowledge of osteoporosis among patients who sustained a fracture and who were forty years of age or older, as well as to identify what social factors and health and fracture characteristics determine the level of osteoporosis knowledge in this population.

METHODS

Patients who had sustained a fracture and were attending fracture clinics at two Toronto hospitals were identified and invited to fill out a questionnaire during their visit. This questionnaire included questions that could be answered by checking "true," "false," or "don't know" and that were designed to assess the patient's knowledge of osteoporosis. The questionnaire also included questions about the respondent's background.

RESULTS

Of 259 patients identified as eligible for the study, 204 (78.8%) agreed to participate. The mean number of correct responses was 16.5 (55%) out of thirty responses. Variables significantly associated with greater numbers of correct responses were female sex, English as a first language, being currently employed, exercising regularly, and having received information from a health-care provider or from a newspaper or magazine.

CONCLUSIONS

The level of osteoporosis knowledge was fairly low among the surveyed patients, indicating that more education is needed. This study also highlighted certain characteristics (i.e., male sex, English as a second language, being unemployed, and not exercising) that are associated with a lower level of knowledge. Our results can help target certain groups for osteoporosis educational initiatives, especially ethnic groups whose first language is not English, so as to appropriately reduce the risk of future fractures in this high-risk population.

Non-simultaneous bilateral hip fracture: epidemiologic study of 241 hip fractures

INTRODUCTION

Hip fractures are an important public health problem given their growing incidence as well as their functional and vital repercussions. With longer survival, patients with a contralateral fracture are increasingly numerous. The objective of this study was to investigate the bilateralization of hip fractures in terms of anatomic location and time to the second fracture.

HYPOTHESIS

Contralateral fractures are of the same anatomical type as the primary fractures.

PATIENTS AND METHODS

This was a retrospective epidemiological study on all patients managed for hip fractures between January 2007 and May 2008. Each case of bilateralization was studied.

RESULTS

We included 241 patients in the study. The mean age at occurrence of the primary fracture was 83.3 years (range, 60-99 years). The distribution showed 45.6% true femoral neck fractures and 54.4% trochanteric fractures. Twenty-six of the 241 patients had already suffered from a hip fracture (10.8%). This fracture was the same type as the recent fracture in 80.8% of the cases. The mean time between the two fractures was 5.6 years (range, 1-277 months).

DISCUSSION

The contralateral fractures were the same anatomical type as the primary fracture in eight out of ten patients and the symmetry remains intact in 64-83% depending on the series. The fracture occurred on average within 5 years of the first hip fracture. In cases of asymmetry, the second fracture was more often a trochanteric fracture. The causes explaining this symmetry are several and are poorly known. The risk factors are numerous and their prevention is essential (acting on the patient's environment to prevent falls, rehabilitation to reestablish autonomy after the first fracture, and preventive treatment of osteoporosis), although these notions are often ignored by surgeons.

LEVEL OF EVIDENCE

IV, retrospective study.

Monitoring pharmacological therapy for osteoporosis

Osteoporosis is a common disease characterized by low bone strength that increases the risk of fractures. The consequences of fractures include increases in morbidity, mortality, and healthcare costs. Randomized clinical trials have shown that pharmacological therapy can reduce the risk of fractures. In clinical practice, however, failure to achieve optimal therapeutic benefit is common for reasons that include taking medication incorrectly, stopping it prematurely, malabsorption, and the presence of unrecognized diseases or conditions with adverse skeletal effects. Monitoring for anti-fracture effectiveness in individual patients is limited by the absence of clinical tools to directly measure bone strength. It is therefore necessary to monitor therapy with biomarkers such as bone mineral density and bone turnover markers. This is a review of the utility of these tools in the care of individual patients.

Overcoming barriers to secondary prevention in hip fracture patients: An electronic referral and management system for osteoporosis

BACKGROUND

Numerous studies have shown that osteoporosis is both under diagnosed and under treated in patients with fragility fractures. We describe the use of an electronic automated referral system to enable multidisciplinary assessment and treatment of osteoporosis in patients admitted with fragility fracture of the hip.

METHODS

An electronic referral system was developed from the hospital's trauma software database. This automatically refers patients admitted with fragility fracture of the hip to osteoporosis services. Data were collected prospectively from May to July 2007, when referral was dependent on members of the orthopaedic team and from August to October 2007, after the implementation of the electronic referral system. Primary outcomes were presence of a referral to osteoporosis services, organisation of bone density scan and follow up appointment in patients less than 75 years, and treatment with osteoporosis medication in patients greater than 75 years of age.

RESULTS

There were a total of 90 patients, 47 in the non-intervention group and 43 in the intervention group. In the non-intervention group 8/47 patients (17%) were referred to osteoporosis services whilst 43/43 (100%) were referred in the intervention group. Of patients greater than 75 years, 10/32 (31.3%) were started on a bisphosphonate in the non-intervention group compared to 28/34 (82.4%) in the intervention group. Of patients less than 75 years, 1/15 (7%) in the non-intervention group had a DEXA scan booked and appropriate follow up arranged, compared to 7/9 (78%) in the intervention group. There was significant difference between both groups in all outcomes (p<0.0001).

CONCLUSION

We present an electronic system which facilitates delivery of osteoporosis services and significantly improves management of osteoporosis in patients admitted with fragility fracture. We recommend the use of such programmes to facilitate multidisciplinary assessment and treatment of osteoporosis in orthopaedic trauma patients.