Original ArticleOsteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners
Introduction
Osteoporosis is common, as shown by the 40% likelihood of experiencing an osteoporotic fracture after 50 years of age in Caucasian women [1]. Osteoporosis defined as a bone mineral density (BMD) T-score decrease of at least 2.5 standard deviations is present at the hip, spine or forearm in 30% of postmenopausal Caucasian women [2]. Bone absorptiometry can detect asymptomatic osteoporosis, thereby allowing treatment initiation before the occurrence of fractures. Unfortunately, absorptiometry is not widely available. The French agency for healthcare evaluation (ANAES) has issued recommendations for defining high-risk populations and selecting patients who require absorptiometry [3]. Nevertheless, a subset of patients with osteoporosis fails to meet these criteria and consequently escape detection. In addition, BMD is only one of several factors that influence bone strength. Microarchitectural alterations responsible for an increased fracture risk are not detected by absorptiometry. Thus, the diagnosis of osteoporosis is frequently missed until the first fracture occurs. The National Osteoporosis Foundation recommends routine investigations for osteoporosis in postmenopausal women with fractures, followed by treatment if appropriate [4]. Fracture sites associated with a very high likelihood of osteoporosis are the distal forearm, proximal femur, proximal humerus, pelvis and spine. However, all low-impact fractures should suggest osteoporosis, except at the digits, skull and cervical spine. Vertebral fractures at the thoracic and lumbar spine are highly suggestive of osteoporosis but are frequently asymptomatic and therefore undetected. Fractures of the distal radius occur earliest in the natural history of osteoporosis, and their incidence rises sharply after 50 years of age [1]; nevertheless, physicians tend to overlook the association between distal radial fractures and osteoporosis. Establishing the diagnosis of osteoporosis is crucial, as several drug classes are effective in preventing further osteoporotic fractures. In most studies, low-impact peripheral fractures rarely prompted investigations and treatment for osteoporosis [5], [6], [7], [8], [9], [10], [11], [12], [13], [14].
The objective of the present prospective study was to determine the rate of osteoporosis treatment initiation by general practitioners in postmenopausal women managed at the Clermont-Ferrand Teaching Hospital emergency room for peripheral fractures. The original feature of our study is that we sent the general practitioners a standard letter emphasizing the need for considering and treating osteoporosis in postmenopausal women with peripheral fractures.
Section snippets
Patients
We included consecutive postmenopausal women managed at the Surgical Emergency Department of the Clermont-Ferrand Teaching Hospital between July 1 and September 30, 2000, for peripheral fractures related to minimal trauma (fall from the standing position at the most). Patients with vertebral fractures were excluded.
Methods
At emergency room admission, the following information was recorded on a standardized form: age, time since menopause, body weight, history of hormone replacement therapy (HRT)
Study population
During the 3-month study period, 78 patients met our inclusion criteria and were entered prospectively into the study. Table 1 reports their main characteristics. Mean age was 81.5 years, with a range of 50–99 years. The fracture site was the femoral neck in nearly half the patients and the distal radius in about one fourth. Table 2 provides additional detail on fracture site distribution.
Patient follow-up
Of the 78 patients, 66 (85%) required transfer to a ward; among them, 47 were admitted to a surgical ward
Discussion
A low-impact fracture usually indicates bone loss. Among women with wrist fractures, most have osteopenia or osteoporosis at one or more of the sites typically used for BMD measurement (lumbar spine, hip and radius) [15]. Numerous studies found that a history of fracture at any site was associated with a 2-fold increase in the risk of further fractures at any site [16]. In addition, the association between a history of fracture and an increased risk of further fractures was independent from BMD
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Development of fracture liaison services: What have we learned?
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Management of osteoporosis after a forearm fracture: Analysis from a Health Insurance database
2015, Revue du Rhumatisme (Edition Francaise)Management of osteoporosis in women after forearm fracture: Data from a French health insurance database
2015, Joint Bone SpineCitation Excerpt :As well, morbidity and mortality are increased after a severe osteoporotic or forearm fracture in patients older than 75 years [10,11], which represents a burden for society [12]. However, despite effective drugs, less than one third of women with peripheral osteoporotic fracture receive such treatment [13–17]. In the present study, we used health insurance data for a large sample of women 50 years of age or older in France to estimate the rate of BMD assessment and anti-osteoporotic drug prescription after forearm fracture in women.
Evaluation of the practices of general practitioners for the screening and treatment of osteoporosis in women aged 60 and over
2013, Revue du Rhumatisme (Edition Francaise)Medication initiation rates are not directly comparable across secondary fracture prevention programs: Reporting standards based on a systematic review
2013, Journal of Clinical EpidemiologyCitation Excerpt :A total of 28 combinations of numerators and denominators for medication initiation rates were reported across 49 of the 64 interventions. Of the remaining 15 interventions, 1 intervention reported a rate for medication initiation, but the numerator and denominator were unknown [64]; 4 interventions reported no rate for medication initiation but reported a variety of numerators and denominators [15,21,50]; 2 interventions reported pharmacotherapy data but not medication initiation [43,45]; and 8 interventions reported no medication data [13,30,32,39,41,44,49] (see Appendix A; available on the journal's website at www.jclinepi.com). The exclusion criterion that most critically influenced the denominators further was the exclusion of patients who were admitted to programs with a fragility fracture while already on OP pharmacotherapy.
Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture
2007, Joint Bone SpineCitation Excerpt :As shown by the Fracture Liaison Service experiment in Glasgow [6], software can be used in emergency rooms to identify and record patients, send the information via intranet, and automatically issue emails to alert the patient and primary-care physician about the possibility of osteoporosis. Rates of appropriate management were very low when information was sent to primary-care physicians without initiating osteoporosis management in the hospital [25]. Therefore, every effort should be made to initiate the diagnostic and therapeutic process during the hospital stay.