Fragility Fractures and the Osteoporosis Care Gap: An International Phenomenon

https://doi.org/10.1016/j.semarthrit.2005.11.001Get rights and content

Objectives

To describe practice patterns in the management of osteoporosis after fragility fracture.

Methods

Systematic review of articles in MEDLINE, EMBASE, Cochrane, and CINAHL databases (1996 to February 2005). Diagnostic outcomes included clinical osteoporosis diagnoses, laboratory tests, and bone density scans. Treatment outcomes included initiation of calcium, vitamin D, hormone replacement therapy, bisphosphonates, calcitonin, raloxifene and falls assessments.

Results

Thirty-five studies met our inclusion criteria and demonstrated that adults who experience fragility fracture are not receiving osteoporosis management. An osteoporosis diagnosis was reported in 1 to 45% of patients with fractures; laboratory tests were ordered for 1 to 49% and 1 to 32% of patients had bone density scans. Calcium/vitamin D and pharmacological therapy was reported in 2 to 62% and 1 to 65% of patients, respectively. Osteoporosis treatment was recommended more often in women than men, and more often in patients with vertebral fractures than in patients with nonvertebral fractures. Older patients were more likely to be diagnosed with osteoporosis, but treatment was more likely in younger patients. A history of prior fracture was reported in 7 to 67% of patients. Between 1 and 22% of patients had a subsequent fracture during follow-up periods of 6 months to 5 years. Falls assessments were not often reported; when they were, they were infrequently performed. A greater proportion of patients were diagnosed/treated during follow-up studies than in studies evaluating diagnosis/treatment on discharge from acute care.

Conclusions

The majority of individuals who sustain fragility fractures are not receiving adequate osteoporosis management. Future research should address barriers to appropriate management and the efficacy of implementation strategies designed to close the osteoporosis care gap.

Relevance

This article is of particular importance to health care professionals who provide care for patients with fragility fracture.

Section snippets

Study Search and Selection

A literature search was conducted in MEDLINE, EMBASE, Cochrane, and CINAHL databases, from 1996 until February 2005. The search strategy included the terms hip fracture [intertrochanteric, subtrochanteric, trochanteric, femoral neck], spinal fractures, vertebral fractures, wrist fractures, osteoporosis [diagnosis, prevention, and control; diet therapy; drug therapy; surgery; therapy], and secondary prevention. Additional articles were identified by consultation with experts and hand searching

Description of Studies

Thirty-five studies met the eligibility criteria (Fig. 1). Three distinct study types were identified (Table 1). Twelve studies investigated diagnosis/treatment outcomes at the time of hospital discharge only (52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63). Three of these studies are listed twice as they examined 2 distinct patient groups (53, 54, 59). Thirteen studies assessed diagnosis/treatment outcomes using an administrative database or from a chart review at a specified time after the

Discussion

The current systematic review provides evidence that individuals in the United Kingdom, New Zealand, Australia, South Africa, Israel, Denmark, France, Canada, the Netherlands, and the United States who experience fragility fracture are not receiving adequate osteoporosis management. Many patients had a history of fracture or went on to experience subsequent fractures. The proportion of patients diagnosed or treated appeared to be greater in follow-up studies than in studies that evaluated

Acknowledgments

This research was supported by a grant-in-aid provided by Merck Frosst. L. Giangregorio is the recipient of a Health Research Partnership Award from the Ontario March of Dimes and the Canadian Institutes of Health Research. A. Cranney holds a research salary award from the Canadian Institutes of Health Research.

References (92)

  • Osteoporosis prevention, diagnosis and therapy

    NIH consensus statements

    (2000)
  • Physician’s Guide to the Prevention and Treatment of Osteoporosis

    (2003)
  • J.P. Brown et al.

    2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada

    Canadian Medical Association Journal

    (2002)
  • C.M. Klotzbuecher et al.

    Patients with prior fractures have an increased risk of future fracturesa summary of the literature and statistical synthesis

    J Bone Miner Res

    (2000)
  • C. Cooper et al.

    Hip fractures in the elderlya world-wide projection

    Osteoporos Int

    (1992)
  • M.E. Wiktorowicz et al.

    Economic implications of hip fracturehealth service use, institutional care and cost in Canada

    Osteoporos Int

    (2001)
  • M.C. Chapuy et al.

    Vitamin D3 and calcium to prevent hip fractures in the elderly women

    N Engl J Med

    (1992)
  • H. Castel et al.

    Awareness of osteoporosis and compliance with management guidelines in patients with newly diagnosed low-impact fractures

    Osteoporos Int

    (2001)
  • K.B. Freedman et al.

    Treatment of osteoporosisare physicians missing an opportunity?

    J Bone Joint Surg Am

    (2000)
  • M.J. Gardner et al.

    Improvement in the undertreatment of osteoporosis following hip fracture

    J Bone Joint Surg Am

    (2002)
  • G.M. Kiebzak et al.

    Undertreatment of osteoporosis in men with hip fracture

    Arch Intern Med

    (2002)
  • G. Onder et al.

    Treatment of osteoporosis among older adults discharged from hospital in Italy

    Eur J Clin Pharmacol

    (2001)
  • R.L. Riley et al.

    Outcomes and secondary prevention strategies for male hip fractures

    Ann Pharmacother

    (2002)
  • C. Simonelli et al.

    Evaluation and management of osteoporosis following hospitalization for low-impact fracture

    J Gen Intern Med

    (2003)
  • D.J. Torgerson et al.

    Prescribing by general practitioners after an osteoporotic fracture

    Ann Rheum Dis

    (1998)
  • A. Papaioannou et al.

    The osteoporosis care gap in Canada

    BMC Musculoskelet Disord

    (2004)
  • E.S. Siris et al.

    Pins and plaster aren’t enougha call for the evaluation and treatment of patients with osteoporotic fractures

    J Clin Endocrinol Metab

    (2003)
  • A.W. Al-Allaf et al.

    An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment

    Clin Exp Rheumatol

    (1998)
  • S.B. Broy et al.

    Are physicians treating osteoporosis after hip fracture?

    J Bone Miner Res

    (2000)
  • C.P. Charalambous et al.

    Management of osteoporosis in an orthopaedic departmentaudit improves practice

    Int J Clin Pract

    (2002)
  • T. Chevalley et al.

    An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture

    Osteoporos Int

    (2002)
  • M.T. Cuddihy et al.

    A prospective clinical practice intervention to improve osteoporosis management following distal forearm fracture

    Osteoporos Int

    (2004)
  • L.C. Curry et al.

    Osteoporosiseducation and awareness can make a difference

    AJN Am J Nurs

    (2002)
  • T. Diamond et al.

    Osteoporosis detection in the community

    Are patients adequately managed? Aust Fam Physician

    (2002)
  • V. Elliot-Gibson et al.

    Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracturea systematic review

    Osteoporos Int

    (2004)
  • A. Fitzsimmons et al.

    Failure to diagnose osteoporosis

    Am J Phys Med Rehabil

    (1995)
  • T.C. Gallagher et al.

    Missed opportunities for prevention of osteoporotic fracture

    Arch Intern Med

    (2002)
  • S.H. Gehlbach et al.

    Recognition of osteoporosis by primary care physicians

    Am J Public Health

    (2002)
  • H.K. Kamel et al.

    The underuse of therapy in the secondary prevention of hip fractures

    Drugs Aging

    (2002)
  • H.K. Kamel et al.

    Secondary prevention of hip fractures in veteranscan we do better?

    J Am Geriatr Soc

    (2004)
  • J.D. Kaufman et al.

    Barriers and solutions to osteoporosis care in patients with a hip fracture

    J Bone Joint Surg Am

    (2003)
  • N. Kim et al.

    Underreporting of vertebral fractures on routine chest radiography

    AJR Am J Roentgenol

    (2004)
  • S.R. Majumdar et al.

    A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture

    Ann Intern Med

    (2004)
  • T. Masud et al.

    Distal forearm fracture history in an older community-dwelling populationthe Nottingham Community Osteoporosis (NOCOS) study

    Age Ageing

    (2001)
  • D. Mazanec

    Osteoporosis screeningtime to take responsibility

    Arch Intern Med

    (2004)
  • A. Ohldin et al.

    Unrecognized risks among Veterans with hip fracturesopportunities for improvements

    J South Orthop Assoc

    (2003)
  • Cited by (0)

    Funding Sources: Grant-in-Aid from Merck Frosst

    View full text