Rates of Osteoporosis Management and Secondary Preventative Treatment After Primary Fragility Fractures

Osteoporosis management in patients presenting to the emergency department with fragility fractures: A retrospective observational study

Objectives

This study aimed to determine the rate of anti-osteoporotic treatment (AOT) within one year in patients presenting to the emergency department with fragility fractures and to investigate the effects of physiatrist visit, secondary cause of osteoporosis, and previous fracture history on the rate of AOT.

Methods

This study included patients aged 50 years and older who presented to the emergency department between January 1, 2019, and June 1, 2023, with fragility fractures. Demographic characteristics of the patients, a history of fragility fractures, causes of secondary osteoporosis, and clinical features of AOT within one year were recorded using the hospital information system. The effects of physiatrist visit, secondary cause of osteoporosis and previous fracture history on the rate of AOT were examined by chi-square analysis.

Results

The study included a total of 357 patients, with a mean age of 73.5 + 10.1 (range: 51-100) years. The rate of patients receiving AOT was 8.4%. It was observed that 63.3% of the patients receiving AOT had a physiatrist visit, and 70% had secondary osteoporosis. Physiatrist visit and the presence of secondary osteoporosis cause affected the AOT rate statistically significantly (p = .000, p = .003, respectively), while the previous fracture history did not affect the treatment rate (p = .147).

Conclusions

Patients presenting to the emergency department with fragility fractures had a low rate of receiving AOT within one year. Physiatrist visits and finding a secondary cause of osteoporosis increase the detection rate of fragility fractures.

Impact of social determinants on osteoporosis treatment and secondary fracture risk after primary fragility fractures

This study examined the impact of social determinants of health (SDOH) on osteoporosis management and secondary fractures after primary fragility fractures. Despite similar osteoporosis treatment rates between patients with and without adverse SDOH, patients with adverse SDOH experienced significantly higher secondary fracture rates, highlighting the need for targeted interventions to improve post-fracture care in socioeconomically disadvantaged populations.

PURPOSE

Osteoporosis is a global health concern affecting over 500 million people. Fragility fractures are often the first indication of osteoporosis and are associated with significant morbidity and mortality. While low socioeconomic status is associated with increased risk of fragility fractures, the impact of social determinants of health (SDOH) on osteoporosis treatment and secondary fracture rates following primary fragility fractures remains unclear.

METHODS

Patients aged 50 and older who sustained primary fragility fractures and had no prior osteoporosis treatment were identified using a large national database. Patients were stratified by the presence of adverse SDOH. Kaplan-Meier and multivariate Cox proportional hazards regression analyses were performed to evaluate the cumulative incidence of osteoporosis treatment within 1 year (including bisphosphonates, biologics, parathyroid hormone analogs, estrogens, and selective estrogen receptor modulators) and rates of secondary fractures within two years.

RESULTS

A total of 276,845 patients were included in this study. Overall, 4.4% of patients with adverse SDOH and 5.3% of patients without were prescribed osteoporosis treatment within a year of fracture; however, this difference was not significant after controlling for confounders (hazard ratio (HR) 0.98; P = 0.82). Patients with adverse SDOH had significantly higher rates of secondary fractures within 2 years (7.4% versus 6.0%; HR 1.29; P < 0.001).

CONCLUSION

Adverse SDOH were associated with increased rates of secondary fractures among patients with primary fragility fractures, despite similar osteoporosis management rates between groups. Overall, osteoporosis treatment rates remain low. Targeted strategies to optimize secondary prevention and tailored interventions are needed, particularly for socioeconomically disadvantaged populations.

Trends in screening and treatment of osteoporosis after periprosthetic fractures from 2010 to 2020

Osteoporosis is often underrecognized and undertreated following periprosthetic fractures (PPF). Our study found that between 2010 and 2020, there has been no significant change in the rates of osteoporosis screening or treatment within 1 year following PPF. Orthopedic surgeons can play an integral role in helping to curtail the osteoporosis epidemic.

PURPOSE

Periprosthetic fractures (PPF) typically occur from low-energy mechanisms and are pathognomonic for osteoporosis. However, osteoporosis is often underrecognized and undertreated. The aim of this study was to examine trends in dual energy X-ray absorptiometry (DXA) scans and treatment of osteoporosis after PPF between 2010 and 2020.

METHODS

Patients older than 40 who experienced a lower extremity PPF between 2010 and 2020 and had no prior history of osteoporosis screening or treatment were identified utilizing a large national administrative database. Rates of bone mineral density (BMD) measurement using DXA and anti-osteoporotic treatment with pharmacotherapy, or either intervention within 1 year following experiencing a PPF were determined. The rate of change for these interventions was calculated using the compounded annual growth rate (CAGR), with linear regression used to determine whether trends were statistically significant.

RESULTS

In total, 5.7% and 3.6% of patients were screened and treated for osteoporosis, respectively. Between 2010 and 2020, there was no significant change in rates of osteoporosis screening (CAGR + 0.1%; p = 0.13), treatment (CAGR - 2.4%; p = 0.29), or either intervention (CAGR - 1.1%; p = 0.77) within 1 year following PPF. Factors associated with intervention included older age, female sex, and increased comorbidities.

CONCLUSION

Our study found that there has been no significant change in the rates of osteoporosis screening or treatment within 1 year following PPF. Orthopedic surgeons and allied healthcare workers can play an integral role in helping to curtail the osteoporosis epidemic.

Suboptimal osteoporosis care in hospitalized patients: a retrospective analysis of vertebral compression fractures detected on computed tomography

Vertebral compression fractures (VCFs) are the most common osteoporotic fractures. Only 1/3 of patients with VCFs are clinically diagnosed. In our institution, the Fracture Liaison Service (FLS) was launched in 2017 to improve osteoporosis management for hospitalized patients. (1) To assess osteoporosis awareness among medical providers for emergency department (ED)/hospitalized patients aged 50 or greater; (2) To estimate the rate of FLS consults or referrals to primary care providers (FLS/PCP) by primary teams. A centralized radiology system was used to examine all thoracic and lumbar computed tomography (CT) scans conducted between June 1, 2017 and June 1, 2022. 449 studies were identified with the radiologic impression "compression fracture". 182 studies were excluded after manual chart review. 267 hospitalizations/ED visits with lumbar and/or thoracic spine CT scans were included. Referrals to FLS (26) or PCP (27) were made in 53 cases (~ 20% of the total). In the ED subgroup (131 hospitalizations), only 17 patients had FLS/PCP referrals. The "compression fracture" was mentioned in 227 (85%) discharge notes (any part), while "osteoporosis" was mentioned in only 74 (28%) hospitalizations. A statistically significant difference was found between the two groups when "osteoporosis" was mentioned in the "assessment and plan" section (p = 0.02). Our data show that the overall osteoporosis care for affected patients is suboptimal. Medical providers often overlook the presence of osteoporosis, leading to a lack of consultation with the FLS of referral to PCPs for further evaluation and treatment.

Individuals with a fragility fracture and a prescription for bone active medication have a positive perception of the medication but do not associate it with fracture risk reduction

Most participants reported a positive perception of bone active medication despite sustaining a fracture while taking the medication, reporting medication side effects, or having a healthcare provider stop the prescription. Participants did not appear to connect the medication to fracture risk, suggesting this connection should be emphasized by healthcare providers.

OBJECTIVE

Our purpose was to examine perceptions about bone active medication from individuals with a fragility fracture and a prescription for bone active medication.

METHODS

In this qualitative description study, eligible participants were those who attended an Osteoporosis Canada education session, and reported sustaining a previous fragility fracture and receiving a prescription for bone active medication. We conducted one-on-one interviews and analyzed the data using the analytic hierarchy approach.

RESULTS

We interviewed 32 female participants (age range 58-89 years). Based on our analysis, two themes were developed: (1) most participants spoke positively about bone active medication, indicating they were willing to start, or continue to take, their medication. Positive perceptions were held by participants who sustained a fracture while taking bone active medication, participants whose healthcare provider had stopped the prescription, and participants who reported side effects from the medication; (2) most participants did not discuss bone active medication in relation to their fracture and did not appear to connect the medication to the concept of fracture risk. Instead, participants talked about the medication in relation to bone health in general, or to bone density.

CONCLUSION

Participants appeared to have positive perceptions of bone active medication, despite sustaining a fracture while taking the medication, reporting medication side effects, or having a healthcare provider stop the prescription. Participants did not connect bone active medication to the concept of fracture risk, illustrating the need for healthcare providers to emphasize the connection between fracture risk and bone active medication.

Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures

BACKGROUND

Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures.

MATERIALS AND METHODS

This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contralateral hip fracture, with the second treated at our tertiary referral center.

RESULTS

The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event.

CONCLUSION

Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 2024;47(5):264-269.].

Characterization and effectiveness of a Fracture Liaison Services program in Colombia

PURPOSE

Fracture Liaison Services programs reduce mortality and the risk of refracture and increase treatment and adherence rates. Greater coverage is an important priority for the future. The aim was to determine the characteristics of patients over 50 years old who suffered fractures and the effectiveness of a Fracture Liaison Services program in a health care institution in Colombia.

METHODS

This was a retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services program. Sociodemographic, clinical and pharmacological variables were identified. Key performance indicators were used to evaluate the effectiveness of the program. Descriptive and bivariate analysis was performed.

RESULTS

A total of 438 patients were analyzed. The average age was 77.5 years, and 78.5% were women. Hip and vertebral fractures were the most common (25.3% and 24.9%, respectively). Vertebral fractures prevailed in men (33.0% vs 22.7%; p = 0.041) and those of the radius/ulna in women (20.3% vs 10.6%; p = 0.031). A total of 29.7% had experienced a previous fracture, and 16.7% had received antiosteoporosis drugs. A total of 63.5% of the cases were managed surgically. At discharge, 58.8% received prescriptions for calcium/vitamin D, and 50.7% with prescriptions of antiosteoporotic therapy, especially teriparatide (21.2%) and denosumab (16.4%), without significant differences by sex. However, in women with hip fractures, anti-osteoporotic management prevailed (83.7% vs 64.0; p = 0.032). The effectiveness of the overall program per year was 74.6%. On follow-up, only 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture. A total of 4.3% died during follow-up.

CONCLUSIONS

Good adherence to the recommendations of the country's clinical practice guidelines was found, and overall, the effectiveness of the program was very satisfactory, with a low incidence of new fractures during follow-up. Fracture Liaison Services programs reduce mortality and the risk of refracture. A retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services, showed that the effectiveness was 73.6%. On follow-up, 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture.

Preventing the next fragility fracture: a cross-sectional survey of secondary fragility fracture prevention services worldwide

BACKGROUND

There has been an increasing awareness of the public health impact of fragility fractures due to osteoporosis and the imperative of addressing this health burden with well-designed secondary fragility fracture prevention services (SFFPS). The objectives of this survey, conducted within the international membership of the Fragility Fracture Network (FFN), were to identify gaps in services and identify the needs for further training and mentorship to improve the quality of SFFPS provided to patients who sustain fragility fractures.

METHODS

We conducted an electronic cross-sectional survey of FFN Secondary Fracture Prevention Special Interest Group (SIG) members from April 2021 to June 2021 using SurveyMonkey. The survey questions were developed by four SIG members from New Zealand, Australia, Canada and the Netherlands, who have experience in developing, implementing and evaluating SFFPS. The sampling framework was convenience sampling of all 1162 registered FFN Secondary Fracture Prevention SIG members. Descriptive analyses were performed for all variables and presented as frequencies and percentages.

RESULTS

69 individuals participated in the survey, from 34 different countries over six continents, with a response rate of 6% (69/1162). Almost one-third of respondents (22/69) were from 15 countries within the European continent. Key findings included: (1) 25% of SFFPS only included patients with hip fracture; (2) less than 5% of SFFPS had any mandatory core competencies for training; (3) 38.7% of SFFPS were required to collect key performance indicators; and (4) 9% were collecting patient-reported outcome measures.

CONCLUSIONS

This survey identified key areas for improving SFFPS, including: expanding the reach of SFFPS to more patients with fragility fracture, developing international core competencies for health provider training, using key performance indicators to improve SFFPS and including the patient voice in SFFPS development. These findings will be used by the FFN to support SFFPS development internationally.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019

The purpose of this study was to determine whether there has been any change in osteoporosis treatment following primary fragility fractures and what agents were being given. The study found an overall low utilization rate with no difference in treatment utilization from 2011 to 2019.

PURPOSE

The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed.

METHODS

Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1 year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type.

RESULTS

This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74 years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74 years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001).

CONCLUSION

Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

Predicting the Subsequent Contralateral Hip Fracture: Is FRAX the Answer?

OBJECTIVES

To (1) determine the ability of the Fracture Risk Assessment Tool (FRAX) to identify the probability of contralateral hip fractures within 2 years of index fracture and (2) identify independent risk factors for a subsequent hip fracture.

DESIGN

Retrospective.

SETTING

Urban, academic medical center.

PATIENTS

This study included a consecutive series of patients treated for unilateral hip fractures between September 2015 and July 2019.

RESULTS

Eight hundred thirty-two consecutive patients were included in the analysis with a mean age of 81.2 ± 9.9 years. Thirty-one (3.7%) patients sustained a contralateral hip fracture within 2 years with these patients sustaining the second fracture at a mean 294.1 days ± 197.7 days. The average FRAX score for the entire cohort was 11.9 ± 7.4, and the area under receiving operating characteristic curve (AUROC) for FRAX score was 0.682 (95% CI, 0.596-0.767). Patients in the high-risk FRAX group had a >7% risk of contralateral hip fracture within 2 years. Independent risk factors for contralateral hip fracture risk included patient age 80 years or older and decreasing BMI.

CONCLUSIONS

This study demonstrates the strong ability of the FRAX score to triage patients at risk of subsequent contralateral hip fracture within 2 years. In this high-risk FRAX group, patients age older than 80 years and who have decreasing BMI after their index fracture have a 12.5% increased risk of fracture within 2 years which is 4× higher than the current World Health Organization 10-year 3% hip fracture risk standard used to initiate pharmacologic treatment. Therefore, high-risk patients identified using this methodology should be targeted more aggressively with preventative measures including social, medical, and potentially surgical interventions.

LEVEL OF EVIDENCE

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

High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly

BACKGROUND

Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients.

METHODS

As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects.

RESULTS

In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication.

CONCLUSIONS

Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications.

INTRODUCTION

The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression.

RESULTS

A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40).

CONCLUSION

Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.

Osteoporosis Diagnosis, Management, and Referral Practice After Fragility Fractures

PURPOSE OF REVIEW

The purpose of this manuscript is to review the current diagnosis, management, and referral practices of patients with osteoporosis after a fragility fracture from the orthopedic surgeon's perspective.

RECENT FINDINGS

Effective treatments are available for osteoporosis that significantly decrease the risk of additional fractures. Despite recommendations for improved post-fragility fracture osteoporosis management, the rate of diagnosis and treatment is still unacceptably low. Patients sustaining a low-energy fracture should be evaluated for osteoporosis with discussion of beginning pharmacological treatment. Antiresorptive and anabolic agents are available treatment options. Fracture Liaison Services can help to coordinate the care of these patients and improve the rate of diagnosis and initiation of therapy. Dartmouth-Hitchcock is working to improve the bone health for our patients utilizing a multidisciplinary team-based approach. This process is intended to lead to increased recognition of osteoporosis within our institution and close the capture gap between hospital discharge and initiation of osteoporosis pharmacotherapy.