Secondary screening for osteoporosis in patients admitted with minimal-trauma fracture to a major teaching hospital

Patients discharged from a fracture liaison service still require follow-up and bone health advice

Fracture liaison services (FLSs) were established to address the well-recognised gap in bone health management after a fragility fracture. However, it is unclear what happens to patients after discharge from an FLS. Our study suggests FLSs should include a patient bone health education session and a follow-up telephone call 12-18 months post-discharge to optimise management, in particular, to assess therapy adherence and to reinforce bone health advice.

PURPOSE

While fracture liaison services (FLSs) have improved bone health management following fragility fracture, it is unclear what happens to patients following discharge from these services. We sought to determine patient self-reported medication adherence and the need for bone-specific health advice ≥ 12 months following discharge from one of the first FLSs in Australia.

METHODS

Patients were contacted by telephone ≥ 12 months following discharge from the Coffs Fracture Prevention Clinic (CFPC)/FLS to determine if the patient was still taking prescribed bone protective therapy (BPT). Bone health advice was provided, if appropriate, during the telephone interview.

RESULTS

Of the 516 consecutive patients seen in CFPC from July 2012-December 2018, 326 (63.2%) were assessed and discharged from the clinic. One hundred and two patients (19.8%) were lost to follow-up/uncontactable. Of 190 patients commenced on BPT at CFPC and who were discharged ≥ 12 months prior, 141 (74.2%) self-reported adherence with BPT. Bone health advice was required during the telephone call in 60/190 (31.6%) of these patients. Of the 141 adherent patients, 40 (28.4%) had attended a bone health education session, compared to 4/49 (8.2%) patients in the non-adherent group (p = 0.004).

CONCLUSION

At 19 months following discharge from our FLS, self-reported adherence with treatment was 74%. One bone health education session at baseline was associated with increased treatment adherence. At time of telephone contact, one third of patients required further advice to optimise bone health.

Building for better bones: evaluation of a clinical pathway in the secondary prevention of osteoporotic fractures

Objective

Osteoporosis is a common disease that is underdiagnosed and undertreated. A multidisciplinary intervention may improve the identification and treatment of osteoporosis and may consequently prevent secondary fractures.

Method

Retrospective, single-centre study comparing attitude to screening and treatment of patients admitted to the orthopaedic unit of the general hospital AZ Sint-Jan Brugge-Oostende AV (Belgium) before and after the implementation of a clinical pathway.

Results

A total of 172 patients (86 before and 86 after) were included in this study. The implementation of the pathway resulted in an increase in bone mineral density tests performed, an increment in the number of referrals to a specialist in the field of osteoporosis, and an increase in prevention and treatment of osteoporosis.

Conclusion

The implementation of a clinical pathway coordinated and evaluated by a clinical pharmacist improved the identification, referral and treatment of osteoporosis in patients hospitalised due to low-impact fractures.

Osteoporosis and low bone mineral density (osteopenia) in rural and remote Queensland

OBJECTIVE

To report that prevalence rates of osteoporosis and osteopenia differ according to different levels of remoteness in Queensland, Australia.

DESIGN

Retrospective analysis of bone mineral density scans undertaken between April 2015 and April 2016.

SETTING

Mobile laboratory housing a dual energy X-ray absorptiometry in rural and remote Queensland.

PARTICIPANTS

Four-thousand-four-hundred-and-twenty-seven referred individuals 70 years of age or older.

MAIN OUTCOME MEASURES

Bone mineral density (g cm^-2 ) at two sites was used to measure the level of bone health as per the World Health Organization criteria for osteoporosis.

RESULTS

A slightly higher percentage of women was screened and the percentage screened in both men and women decreased as levels of remoteness increased. Women in outer regional areas had significantly higher odds of having osteopenia over normal bone mineral density, compared to women in an urban setting.

CONCLUSION

As the level of remoteness increased, there was a decrease in the percentage of men and women being screened to determine their risk of osteoporosis. Furthermore, the current data suggest that women in more remote areas have significantly lower bone density, compared to an urban female population. Finally, men and women have similar levels of osteopenia across Queensland, Australia.

Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review

The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.

Hip fractures in young adults: a retrospective cross-sectional study of characteristics, injury mechanism, risk factors, complications and follow-up

This study characterises risk factors, complications and follow-up of minimal trauma hip fractures in young adults, adding to limited information examining the management framework. This group have severe systemic disease and significant risk of post-operative complications and subsequent fractures. Improved medical referral pathways enable management of osteoporosis and comorbid diseases.

AIMS

There is a paucity of literature examining minimal trauma hip fractures in young adults, despite extensive management guidelines for older patients. This study aims to characterise risk factors, complications and follow-up of hip fractures to guide management pathways.

METHODS

This is a retrospective study of patients presenting with hip fracture to a single institution from 2009 to 2015. Hip fractures were identified using ICD-10 codes and clinical information documented from medical records. Patients were categorised into minimal trauma (MTF) and high-energy fracture (HEF) groups based on mechanism of injury.

RESULTS

Of 2512 patients admitted with hip fracture, 2.5% (n = 62) were aged 15-49 years. Two patients were excluded with pathological fractures, and seven were excluded with no recorded mechanism of injury. MTF occurred in 43 patients and 10 sustained HEF. These groups had similar demographics, fracture locations and treatments. The MTF group had higher American Society of Anaesthesiologists scores (MTF 2.44 ± 0.9; HEF 1.43 ± 0.5; p = 0.025) and higher rates of chronic endocrine disease (MTF 34.9%; HEF 0%; p = 0.046). Rates of post-operative surgical (MTF 24.0%; HEF 12.5%) and medical complications (MTF 27.8%; HEF 12.5%) were high in MTF patients. Subsequent fractures occurred in five (13.9%) MTF patients during the study period compared with none in the HEF group. Only 16 (44.4%) of the MTF patients were referred to endocrine care.

CONCLUSION

Young adults with MTF of the hip have more severe systemic disease and are at risk of post-operative complications and subsequent fractures. Referral of patients to endocrine care is recommended to manage osteoporosis and comorbid diseases.

Secondary osteoporosis and metabolic bone disease in patients 50 years and older with osteoporosis or with a recent clinical fracture: a clinical perspective

PURPOSE OF REVIEW

The purpose of this review is to provide guidance to clinicians about which laboratory tests should be performed in patients with osteoporosis or with a recent fracture.

RECENT FINDINGS

Newly diagnosed secondary osteoporosis and other metabolic bone diseases (SECOB) have been found in 5-48% of patients with osteoporosis. In patients with a recent fracture, new SECOB is found in 10-47% of patients with osteoporosis, and in 26-51% if all patients with a fracture regardless of bone mineral density (BMD) are screened. More than one SECOB can be found in the same patient, even when they have already known SECOB. In primary hyperparathyroidism, hyperthyroidism, hypercortisolism, and multiple myeloma, both SECOB and its treatment have an impact on BMD and fractures. For other SECOBs, no treatment is available, or there are no data about the effect of treatment of the SECOB on BMD and fractures.

SUMMARY

We recommend performing the following tests in all patients with osteoporosis or a recent clinical fracture: calcium, phosphate, creatinine, albumin, erythrocyte sedimentation rate in all patients, 24 h urine calcium in men and serum testosterone in men less than 70 years. On indication, additional tests can be performed.

Testosterone levels increase in association with recovery from acute fracture in men

In this longitudinal case-control study, acute fracture was associated with low serum testosterone, which was transient in 43% of men. While assessment of gonadal status is part of the assessment of bone fragility, measurement of testosterone in the early period after fracture may overestimate the prevalence of androgen deficiency.

INTRODUCTION

Measurement of circulating testosterone is recommended in the evaluation of bone fragility in men. Since acute illness can transiently decrease circulating testosterone, we quantified the association of acute fracture and serum testosterone levels.

METHODS

A case-control study was conducted involving 240 men with a radiologically confirmed minimal trauma fracture presenting to a tertiary referral hospital and 89 age-matched men without a history of minimal trauma fracture serving as controls. Follow-up testosterone levels 6 months after baseline were available for 98 cases and 27 controls. Results were expressed as the median and interquartile (IQR) range.

RESULTS

Compared to controls, cases had lower total testosterone [TT, 7.2 (3.5, 10.8) vs 13.6 (10.9, 17.1) nmol/L, p < 0.001]. The 143 cases treated as inpatients had lower testosterone levels than the 97 cases treated as outpatients [TT 4.7 (2.3, 8.1) vs 10.3 (7.5, 12.7) nmol/L, p < 0.001]. Group differences in calculated free testosterone (cFT) were comparable to the group differences in TT. At follow-up, in 98 cases, median TT increased from 6.5 nmol/L (3.2, 8.5) to 9.6 nmol/L (6.9, 12.0) p < 0.0001, and SHBG remained unchanged. Of cases with low testosterone, 43% with TT <10 nmol/L and/or cFT <230 pmol/L at presentation were reclassified as androgen sufficient at follow-up. TT was unchanged in the controls.

CONCLUSIONS

Low testosterone levels in men presenting with an acute fracture may, at least in part, be due to an acute, fracture-associated, stress response. To avoid over diagnosis, evaluation for testosterone deficiency should be deferred until recovery from the acute event.

Sensitivity of osteoporosis screening guidelines for eventual hip fracture in older male veterans

This study sought to determine whether guideline-recommended clinical criteria to select men for osteoporosis screening provide significantly better sensitivity than the osteoporotic screening tool (OST) among men who later went on to have a hip fracture, and whether the sensitivity differs by race. This retrospective observational study uses data from the Department of Veterans Affairs Austin Automation Center. We identified 825 male veterans with hip fractures from 2007 to 2009. Clinical risk factors used as screening selection criteria were abstracted from five accepted guidelines. Outpatient encounters were examined for each subject to determine whether they would have met screening selection criteria for each guideline in the 5 years before their hip fracture event. Sensitivities for each guideline were compared with the OST, using McNemar's exact test. Sensitivities of Veterans Affairs Health Service Research and Development Services (VA HSR&D) and National Osteoporosis Foundation (NOF) guidelines were 77% and 82%, respectively, and were significantly better than the OST sensitivity of 72% (P<0.05). Sensitivities of American College of Physicians (ACP; 68%), VA Secretary's Letters (45%) and Center for Medicare and Medicaid Services (13%) were significantly worse than the OST sensitivity (P<0.001). The sensitivities of the VA HSR&D, ACP and NOF were significantly higher in Whites compared with non-Whites (76% vs 65%, P<0.01; 70% vs 58%, P<0.01; and 84% vs 70%, P<0.001, respectively). Only VA HSR&D and NOF clinical screening criteria are more sensitive than OST in identifying veterans who subsequently experience hip fractures, and these sensitivities vary by race.

Prevalence of undisclosed osteoporosis in patients with minimal trauma fractures: a prospective cohort study

Despite epidemiologic evidence for the presence of osteoporosis in patients with minimal trauma fractures, screening programs have not been routinely established in Australian ambulatory care clinics. Our study assessed the prevalence of osteoporosis and osteopenia in patients at a tertiary care hospital to gather local data to support policy change that favors bone mineral density screening. Our prospective observational study enrolled 115 patients, aged > 40 years, who had experienced a minimal trauma fracture. Inclusion criteria required that the patient had no history of testing for osteoporosis or metabolic bone disease/major pathology. The patients were recruited over a 6-month period. Eleven participants were excluded and 7 participants withdrew from the study, with a total of 97 patients completing the study. Participants were assessed for osteoporosis risk via bone mineral density measurement by dual-energy x-ray absorptiometry and blood screening for bone mineral levels, 25-hydroxyvitamin D, and parathyroid hormone levels. In our study patients, the prevalence of previously undiagnosed osteoporosis was 19%, undiagnosed osteopenia, 50%, and the standard bone mineral density was 32%. The most common risk factors for osteoporosis/osteopenia were smoking (22%), alcohol intake (16%), and corticosteroid use (9%). In 67% of patients, 25-hydroxyvitamin D level was in the low clinical range in 51% of patients, magnesium levels were in the high range and 18% of patients had elevated serum parathyroid levels. At month 12 of our study, 80 participants were available for follow-up: 2 patients had sustained a second fracture (1 was minimal trauma); 6 patients had required further surgery (3 fracture fixations, 3 for removal of internal fixation devices); 26 patients continued treatment regimens with calcium and 25-hydroxyvitamin D supplementation; and 28 patients had been prescribed bisphosphonates, with 22 patients complying with the prescription. The high prevalence of previously undiagnosed low bone mass in our study patient population, each of whom had experienced minimal trauma falls, provides impetus for the provision of osteoporosis screening programs and corresponding treatment as needed.

Prevalence, awareness, and treatment of osteoporosis among Korean women: The Fourth Korea National Health and Nutrition Examination Survey

PURPOSE

This study aimed to assess the factors associated with the prevalence, awareness, and treatment of osteoporosis in a representative sample of Korean women.

METHODS

Data were obtained from dual energy X-ray absorptiometry measurement of the lumbar vertebrae and femoral neck, and from a standardized questionnaire in 2870 Korean women aged 50years and older who participated in the Fourth Korea National Health and Nutrition Examination Survey 2008-2009. Osteoporosis was defined by World Health Organization T-score criteria, and awareness and treatment were defined by self-report of an osteoporosis diagnosis and self-report of current anti-osteoporotic medication use, respectively. We assessed the relationship between multiple risk factors and prevalence, awareness, and treatment.

RESULTS

Osteoporosis was reported in 39.1% of Korean women. Among those with osteoporosis, only 37.5% were aware of their diagnosis and 23.5% received pharmacological treatment. Despite higher prevalence among respondents who were older, of lower body weight, calcium intake, physical activity, and education levels, the awareness and treatment rates of these groups were similar or lower than that of the low-risk controls in multivariate logistic regression models. Moreover, easily identifiable risk factors (e.g., history of fracture, falls, height loss, familial osteoporosis) were not associated with awareness and treatment. Participants who had undergone health screening in the previous 2years exhibited increased awareness and treatment rates independently of other demographic factors.

CONCLUSIONS

Osteoporosis was highly prevalent in this Korean study but was underdiagnosed and undertreated. Routine health screenings could be an effective strategy to increase osteoporosis awareness and treatment.

A team approach: implementing a model of care for preventing osteoporosis related fractures

The implementation of a multidisciplinary team-based model of care has led to significant increases in identification of patients with osteoporosis who are at risk of refracture, together with improved treatment uptake and ongoing management.

INTRODUCTION

Osteoporosis-related fractures and consequent hospital admissions are largely preventable; however, little attention has been paid to how to achieve this, in particular, through improved models of care. Presentation to emergency departments (ED) with minimal trauma fracture (MTF) provides opportunity for patients at risk to be identified, referred and managed through a systematic process ensuring prompt intervention and continuing follow-up. This study is aimed to design and implement a care model for people over 50 years of age, presenting to ED with an MTF.

METHOD

Established a multidisciplinary fracture prevention team to identify and capture at-risk patients for referral and management. Clinical data revealed the extent of lost opportunities. An electronic flagging system and data acquisition tool were developed and piloted. Established a referral pathway to detect, manage and follow-up patients, coordinated by a fracture prevention nurse.

RESULTS

Increased awareness of osteoporosis as a cause of MTF, better identification of at-risk patients across departments and services and development of a flagging and referral protocol has resulted in 100% capture of at-risk patients presented to ED. As a result there has been a significant increase in patients attending the fracture prevention clinic (FPC) (p < 0.001) from 11% in 2007 to 29% in 2008 and a significantly reduced time between fracture and when patients are seen in the FPC (p < 0.001).

CONCLUSION

A multipronged systematic team approach to identifying and capturing patients with a high risk of refracture and a dedicated nurse coordinator role has created efficiencies in the detection and management of osteoporosis.

A novel primary care clinical prediction rule for early detection of osteoporosis

The effects of osteoporosis (OP) can be significantly slowed if disease is detected early. We report on a clinical risk prediction rule developed from patient histories taken in an orthopaedic outpatient clinic, before confirmatory testing for OP. Data were extracted from routine audits of consecutive records of patients with recent wrist fracture, comprising demographic details, medications, past and current disease, and fracture details. Clinical prediction rule elements were tested against clinical suspicion of OP. The clinical prediction elements comprised sex and age risk, medications that predispose patients to OP and/or falls, previous fractures and disease/medical conditions that are known OP risks. The best cut point (6.5) demonstrated 100% sensitivity with clinical suspicion of OP. Patient history information is often available before OP is clinically suspected or a definitive diagnosis is made. Our clinical prediction rule will be useful in primary care settings where objective measures of bone health are not readily available. It will raise OP awareness amongst health care providers and patients, particularly those not previously suspected of having OP. It will assist in identifying at-risk patients early and commencing them on appropriate management, without waiting for definitive bone health tests.

Osteoporosis risk in a home care setting

AIM

To investigate the osteoporosis risk profile of older home care clients and the prevalence of fracture and treatment within this group.

METHODS

A total of 1500 home care clients were randomly selected and mailed a survey. Overall, 874 (58%) of those surveyed completed and returned the survey.

RESULTS

A third (37%, n = 318) reported at least one fracture and 871(99.7%) reported at least one risk factor for osteoporosis. Despite this only 28% reported a diagnosis of osteoporosis, which was more likely if they had sustained a fracture. Bone mineral density tests were reported by 37.4% of respondents and 51.9% of those who had fractured. Only 34.5% who had fractured had been referred for an osteoporosis assessment following their fracture.

CONCLUSIONS

The home care clients surveyed have many of the risk factors associated with osteoporosis and fracture. A large number reported that they had already sustained fractures that can be attributed to osteoporosis. Despite this, a minority have been assessed or treated for osteoporosis.

Prevalence of vitamin D inadequacy in European postmenopausal women

OBJECTIVE

Inadequate vitamin D level is associated with secondary hyperparathyroidism and increased bone turnover and bone loss, which in turn increases fracture risk. The objective of this study is to assess the prevalence of inadequate serum vitamin D levels in postmenopausal European women. There are no clear international agreements on what constitutes a level of vitamin D inadequacy, but recent publications suggest that the circulating level of vitamin D should be over 80 nmol/L or at least between 50 and 80 nmol/L.

MATERIAL AND METHODS

Assessment of 25-hydroxyvitamin D [25(OH)D] was performed in 8532 European postmenopausal women with osteoporosis or osteopenia. European countries included France, Belgium, Denmark, Italy, Poland, Hungary, United Kingdom, Spain and Germany. Two cut-offs of 25(OH)D inadequacy were fixed : < 80 nmol/L and < 50 nmol/L.

RESULTS

Mean (SD) age of the patients was 74.2 (7.1) years, body mass index was 25.7 (4.1) kg/m(2). Level of 25(OH)D was 61.0 (27.2) nmol/L. There was a highly significant difference of 25(OH)D level across European countries (p < 0.0001). The lowest level of 25(OH)D was found in France [51.5 (26.1) nmol/L] and the highest in Spain [85.2 (33.3) nmol/L]. In the whole study population, the prevalence of 25(OH)D inadequacy was 79.6% and 32.1% when considering cut-offs of 80 and 50 nmol/L, respectively and when considering patients aged less than 65 years, the prevalence reached 86% (cut-off of 80 nmol/L) and 45% (cut-off of 50 nmol/L).

CONCLUSION

This study indicates a high prevalence of vitamin D [25(OH)D] inadequacy in European postmenopausal women. The prevalence could be even higher in some particular countries. A greater awareness of the importance of vitamin D inadequacy is needed to address this public health problem.

Fracture prevention strategies in patients presenting to Australian hospitals with minimal-trauma fractures: a major treatment gap

BACKGROUND

The aim of this study was to examine current fracture prevention strategies through the recognition, investigation and treatment of osteoporosis in patients presenting to acute hospitals with minimal-trauma fracture.

METHODS

A retrospective audit using a standardized database was conducted in 16 Australian hospitals. This involved 1829 cases of minimal-trauma fracture initially presenting to hospital emergency departments during 2003-2005. Cases of minimal-trauma fracture were retrospectively identified using diagnosis-related group fracture codes and case record review at each site. Relevant data were entered into a standardized database and analysed centrally and independently. Risk factors for osteoporosis, investigations, interventions and discharge follow up were recorded.

RESULTS

The percentage of minimal-trauma fracture patients who underwent investigation or initiated therapy designed to prevent subsequent minimal-trauma fracture was obtained. Less than 13% of patients presenting to hospital with minimal-trauma fractures had risk factors for fracture identified. Ten per cent were appropriately investigated, 12% were commenced on calcium and 12% on vitamin D. Eight per cent started bisphosphonates and 1% selective oestrogens receptor modulators in the acute setting.

CONCLUSION

Most patients presenting to Australian hospitals with minimal-trauma fracture are neither investigated nor treated for osteoporosis. As this group is at high risk of subsequent fracture, this is a missed opportunity to reduce fracture burden.

Improving diagnosis and treatment of osteoporosis: evaluation of a clinical pathway for low trauma fractures

Summary

Diagnosis and treatment of osteoporosis in hospitals is poor. We compared patient outcomes before and after implementation of a clinical protocol for low-trauma fractures. Patients in the pathway were more likely to receive information about osteoporosis or osteoporosis medications. Therefore our clinical pathway is effective in improving osteoporosis information and treatment.

Introduction

Effective therapies for reducing fracture risk are available, yet under-utilised in hospital settings. We aimed to increase rates of initiation of osteoporosis investigations, pharmacological treatment, treatment continuation, and follow-up general practitioner (GP) visits.

Methods

Comparison of patient outcomes before and after implementation of a clinical pathway in patients admitted for low-trauma fractures to the Department of Orthopaedics and Trauma at The Queen Elizabeth Hospital, Adelaide.

Results

Patients enrolled in the osteoporosis clinical pathway (n = 28) were more likely than patients receiving usual care (n = 28) to have received information about (54% vs. 29%; p < 0.05), or a prescription for osteoporosis medication (53% vs. 25%, p < 0.05). Differences in proportions of patients visiting their GP post fracture and in osteoporosis investigations suggested or undertaken were not significant. At the later audit, the high proportion of patients receiving information about osteoporosis medication had been maintained (51%). Prescription of osteoporosis medications increased to 83% (p < 0.01), and more patients saw their GP post fracture (87%; p < 0.01). High rates of medication adherence were reported in patients in all groups receiving prescriptions.

Conclusion

A clinical pathway for improving hospital management of osteoporosis is effective in improving education about, prescription for, and uptake of osteoporosis medications.

Low bone density in patients receiving methadone maintenance treatment

AIM

To examine the frequency and severity of low bone mineral density (BMD) among patients enrolled in a methadone maintenance treatment (MMT) program and to ascertain risk factors for low BMD in this population.

DESIGN

Cross-sectional.

MEASUREMENTS

Data derived from standardized survey, medical record review, and dual energy X-ray densitometry (DXA).

RESULTS

DXA results were below normal in 83% (76/92) of the study sample with T-scores < -2.5 (osteoporosis range) in 35% [32/92] and between -1.0 and -2.5 (osteopenia range) in 48% [44/92]. Risk factors for low BMD were common: tobacco use, 91%; heavy alcohol use, 52%; and HIV infection, 28%. Only 17% (16/92) were on medications that lower the risk of osteoporosis: estrogen (n = 5), testosterone (n = 4), calcium (n = 4), and Vitamin D (n = 2). None of the participants reported a known diagnosis of osteoporosis. In bivariate analyses, significant predictors of low BMD were: male gender (p < 0.001), lower weight (p = 0.009), and heavy alcohol use (p = 0.02).

CONCLUSION

More than three quarters of this sample of patients in a MMT program had low BMD. Treatable conditions associated with low BMD were commonplace. Efforts to increase awareness of low BMD in MMT patients should be considered so that effective treatment may be employed to lower future fracture risk.

[Secondary screening for osteoporosis in patients admitted for hip fracture to a rehabilitation center. Results of a survey]

GOALS

To determine prevalence, risk factors and treatment of osteoporosis in patients with hip fracture observed in a rehabilitation ward.

BACKGROUND

Hip fractures are associated with up to 20% excess mortality in the first year after fracture and cause functional disability in most survivors. Despite available risk indices and physician information, osteoporosis is still underdiagnosed and undertreated.

METHOD

We obtained history, clinical and biological data, and bone density (BD) data in 41 patients admitted with hip fracture to a rehabilitation care centre.

RESULTS

Only 3 patients had known osteoporosis. Although 50% had at least 1 clinical risk factor, all patients showed osteopenic BD scores and 68% had osteoporotic scores; only one was correctly treated.

DISCUSSION

As with international studies, our study shows that osteoporosis is underdiagnosed. Risk assessment tools allow for routine screening and preventive measures incorporated into standard care practice. The prevention of osteoporotic fracture can be promoted in rehabilitation centres.

A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures

INTRODUCTION

Despite the high risk for subsequent fracture following an initial osteoporotic fracture, the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis. The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis. A secondary aim was to define participant- and doctor-related barriers to osteoporosis management.

METHODS

Consecutive fracture patients (n=254) from the outpatient fracture clinic at St Vincent's Hospital, Sydney were interviewed over a 15-month period (February 2002-July 2003). Fracture risk factors, prior investigation and treatment for osteoporosis were collected at baseline. Participants were initially contacted after 3 months to ascertain follow-up management. All those not investigated or treated by their primary care physician were then randomized to either a personalized letter or the same letter plus an offer of a free bone mineral density (BMD) test. Participants were contacted after 9 months to record further investigations or treatment for osteoporosis.

RESULTS

Less than 20% of the participants had a primary care physician follow-up 3 months after the fracture, leaving 159 who were randomized to a personalized letter (n=79) and a personalized letter plus the offer of a free BMD test (n=80). There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [38% (letter + BMD) vs. 7% (letter only); p=0.001). A high proportion of those tested had low BMD (49% osteopenia and 17% osteoporosis). However, the rates of treatment in both groups were very low (6%). Furthermore, even among the few individuals (23%) who contacted their primary care physician, only 25% were recommended treatment. The belief that the fracture was osteoporotic was an independent predictor of having a BMD test, a primary care physician follow-up and treatment. Other independent predictors were age over 50 years for a primary care physician follow-up, female sex for having a BMD test and having had a BMD test for treatment.

CONCLUSION

This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis; however. there was no significant effect on treatment rates. The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone (odds ratio: 8.5; 95% confidence interval: 3.1-24.5), but this investigation did not affect treatment rate. The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management.

The effect of a fracture protocol on hospital prescriptions after minimal trauma fractured neck of the femur: a retrospective audit

Effective therapies for the treatment of osteoporosis and fracture have been available for a number of years. Despite this, there are numerous reports indicating very low uptake rates in those admitted to hospital with fracture. The aim of this retrospective audit was to assess the impact of a fracture protocol on inpatient prescriptions of osteoporosis therapy. A fracture protocol was arrived at by consensus and was based on recommendations from the Australian Fracture Prevention Summit, which included specific advice on the commencement in hospital of calcium, vitamin D, synthetic estrogen receptor modulators (SERMs) and bisphosphonates. We studied subjects who were treated for fractured neck of the femur at Royal Hobart Hospital from March 2002 to March 2004 and included 161 prior to the start of the protocol and 93 after. As compared to the baseline period, subjects after the introduction of the protocol had higher rates of in-hospital prescription for any treatment (58 vs. 36%, P <0.01), calcium (51 vs. 26%, P <0.01), vitamin D (48 vs. 29%, P <0.01) and oral bisphosphonates (24 vs. 5%, P <0.01), but not SERMs as expected (1 vs. 1%, P =0.70). Additional factors affecting the decision to start any treatment included in-hospital death (OR 0.16, 95% CI 0.05-0.49), dementia (OR 0.39, 95% CI 0.21-0.74), a trend for female sex (OR 1.79, 95%CI 0.96-3.36), but not age. In conclusion, a structural approach to changing hospital policy from the top down is effective at substantially increasing the usage of effective therapy after fractured neck of the femur.

Prevalence of vitamin D inadequacy in Scottish adults with non-vertebral fragility fractures

BACKGROUND

It is well established that vitamin D levels are sub-optimal in the elderly and that adults with fragility fracture are more likely to have serum vitamin D levels either lower than those of control patients of similar age, or below the normal range.

OBJECTIVES

To investigate the prevalence of vitamin D inadequacy in an elderly population presenting to the South Glasgow Fracture Liaison Service with non-vertebral fragility fractures in order to assess the extent of the problem.

RESEARCH DESIGN AND METHODS

The retrospective arm of this study used data from an established database to identify patients aged over 50 years admitted to South Glasgow University Hospitals over the previous 4 years with hip fracture. The prospective arm identified the first 50 patients aged over 50 presenting with a clinical non-vertebral fragility fracture with osteoporosis as measured by axial spine and/or hip DEXA (T-score < -2.5) after November 2004.

RESULTS

In the retrospective arm, 626 patients were identified from the database: mean age 80.5 years; 94% were aged over 60 and 74% were aged over 75. Data analysis was limited to 548 patients aged over 60 years with vitamin D recordings and not receiving supplementation with calcium and vitamin D. The mean vitamin D level was 24.7 nmol/L (9.9 ng/ml) SD = 17, however, it is likely that the true mean is lower since in approximately 25% of cases vitamin D levels were reported as < 15 nmol/L (effectively unrecordable). These were transcribed as 15 nmol/L in order to permit a numerical value to be calculated. In the absence of an agreement on what should constitute a diagnostic serum level of vitamin D inadequacy, a number of thresholds were considered--97.8% had vitamin D levels below 70 nmol/L and 91.6% had vitamin D levels below 50 nmol/L. There were no significant differences by patient sex, age or season of presentation. The mean age of patients in the prospective arm was 65.8 years (range 50.6-83.8), 72% were aged over 60 and 16% were aged over 75. The mean vitamin D level was 44.1 nmol/L (18.4 ng/ml) SD = 25.3; 82% had vitamin D levels below 70 nmol/L and 72% had vitamin D levels below 50 nmol/L. Although numbers were too small to justify extensive subgroup analyses, the mean vitamin D level in the 13 patients with hip fracture (34.5 nmol/L) was lower than in the 37 with non-hip fractures (48.2 nmol/L).

CONCLUSIONS

This study confirms almost universal vitamin D inadequacy among 548 elderly patients admitted to hospital with hip fracture, regardless of whether a threshold of 50 nmol/L or 70 nmol/L was used. However, among a prospective subset of 50 patients with clinical fragility fractures, especially those with non-hip fractures, the prevalence of inadequacy was substantially lower. It may be that vitamin D represents a correctable risk factor for fragility fracture in the elderly, possibly specifically for the hip.

Barriers to effective management of osteoporosis in moderate and minimal trauma fractures: a prospective study

Osteoporosis management is suboptimal even for high-risk people with a history of prior fracture. There is also evidence that individuals with moderate trauma fracture have a lower bone density and are at higher risk of subsequent fracture. This study aimed to define factors influencing the management of individuals at risk for osteoporosis and to examine the risk profiles of individuals with minimal and moderate trauma fractures. Consecutive fracture patients (n =218) treated in the outpatient fracture clinic in St Vincent's Hospital, Sydney, over a 15-month period (February 2002-July 2003) were interviewed. Fracture risk factors, prior investigation and treatment for osteoporosis were collected and participants were contacted after 3 months to ascertain follow-up. Risk factors for osteoporosis including family history, low dietary calcium and conditions associated with bone loss were similar between low- and moderate-trauma groups and between sexes. Even though half of participants had had a prior fracture, only 34% had a bone density scan and 16% were on anti-resorptive treatment. There was a minimal (6%) increase in the rates of investigation and treatment at the 3-month follow-up, and less in the moderate trauma group and males. Independent predictors for being investigated for osteoporosis were: age over 50, prior fracture and female gender, while predictors for treatment were: age over 50 and having been investigated. This study has confirmed low rates of investigation and treatment even in individuals who have already suffered a prior fracture, and especially in those <50 and in males. People with moderate and minimal trauma fractures had similar risk factors for osteoporosis, including a similarly high proportion of prior fractures. These findings support the concept that people with moderate trauma fractures are at higher subsequent fracture risk, yet are neither investigated nor treated. This study highlights the need for further exploration of barriers to osteoporosis management.

Effects of lifestyle and risk factors on bone mineral density in a cohort of Italian women: suggestion for a new decision rule

In this study the authors analyzed the role of risk factors in postmenopausal osteoporosis in a cohort of Italian women and evaluated predictive values of decision rules for early identification of osteoporotic women. Furthermore, the authors investigated the prevalence of secondary osteoporosis in this population. Women who underwent bone densitometry were asked to answer a questionnaire about the common risk factors for osteoporosis. Patients were classified as nonosteoporotic, nonosteopenic, and osteoporotic. Risk factors were compared among the groups by use of analysis of variance (ANOVA). National Osteoporosis Foundation (NOF) recommendation, Osteoporosis Risk Assessment Instruments (ORAIs), Osteoporosis Self-Assessment Tools (OST) score, and weight criterion were applied to this population. The authors proposed a new decision rule based on a new score. A total of 525 women received the questionnaire: 47.4% women were osteoporotic, 32.2% were osteopenic, and 20.4% nonosteoporotic. Risk factors that differed significantly between these groups were: age, age at menarche, postmenopausal period, and body mass index (BMI); the aforementioned risk factors appear to be significant predictors of bone density (BMD) in linear regression model. The incidence of secondary osteoporosis was 13%. In conclusion, the authors (1) confirmed the role played by nonmodifiable risk factors in determining BMD; (2) showed that the use of NOF guidelines, ORAI, OST score, and weight criterion is not satisfactory in our cohort; (3) suggested a new score, based upon the features that were significantly different between patients and controls; and (4) demonstrated the relatively high prevalence of secondary osteoporosis and suggest a primary screening for secondary osteoporosis in all patients with low BMD.