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Keywords:

  • Osteoporosis;
  • Hip fracture

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Objective

To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis.

Methods

Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment.

Results

DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2–10% receiving a bisphosphonate.

Conclusion

Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Hip fracture has a high impact on patients' health and medical costs. A high risk for hip fracture is predicted by low bone density, prior fragility fractures, and a high risk of falling (1–4). In particular, an initial hip fracture defines a select group of patients at a very high risk for additional fractures, including a 5% risk of another hip fracture within the next year, a 29% risk in the following 20 years, and a 17–21% risk of any fracture within 16–21 months (4–6).

Effective treatments are now available to reduce hip fractures in these high-risk patients, including the newer bisphosphonates (alendronate and risedronate) (7, 8), calcium and vitamin D (9), and hip protectors for patients at increased risk of falling (10). This information has been presented widely to physicians through the medical literature and continuing education programs, yet recent reports suggest that hip fracture patients are not receiving adequate evaluation and treatment for osteoporosis (11–15).

This study investigates the use of bone densitometry (dual x-ray absorptiometry [DXA]), calcium and vitamin D supplementation, and pharmacologic therapies in hip fracture patients treated in 4 US health systems. These patients are currently receiving care, are at a high risk for additional fractures, and should be highly motivated to comply with therapies that might reduce their risk for additional fractures. If, in fact, they are not being treated, it should stimulate a search for new approaches to improve osteoporosis care.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Study design.

The authors collaborated in planning similar retrospective record reviews of hip fracture care to initiate osteoporosis improvement projects in 4 health systems. Specific information analyzed for each patient included: 1) Was a DXA scan performed, either before or after hip fracture? 2) Was attention to calcium and vitamin D intake documented after hip fracture? 3) Was antiresorptive treatment for osteoporosis either begun or continued following fracture, and if so, what drugs were used?

This study was reviewed by the University of Wisconsin Institutional Review Board, Madison, Wisconsin. Because the study was considered to be clinical process improvement rather than research, assured patient anonymity, was retrospective, and lacked any intervention it was exempted. In view of this opinion, the authors considered further site-by-site review to be unnecessary.

Study sites.

Four health systems in the Midwestern United States participated: site I, the Advocate Medical Group, Park Ridge, Illinois; site II, the Cleveland Clinic, Cleveland, Ohio; site III, the University of Wisconsin Health–Physicians Plus Division, Madison, Wisconsin; and site IV, Wooster Clinic, a Regional Practice of the Cleveland Clinic, Wooster, Ohio. The sites vary widely in number of hospital beds and physicians, type of professional organization, ownership, and practice environment, as detailed in Table 1. They are representative of the health care environments within this region. All have DXA services, subspecialty physicians dedicated to osteoporosis management, and a record of continuing medical education related to osteoporosis.

Table 1. Study site characteristics*
Study siteSite I AMGSite II CLCLSite III UW-PPDSite IV Wooster
  • *

    AMG = Advocate Medical Group; CLCL = Cleveland Clinic; UW-PPD = University of Wisconsin Health—Physicians Plus Division; Wooster = Wooster Clinic; DPA/DXA = dual photon absorptiometry/dual x-ray absorptiometry.

Hospital typeCommunity teachingTertiary referralCommunity teachingCommunity
Beds, n4501000+450130
Physician organizationMedical groupClinic staffMedical groupHospital staff
Physicians, n275700–800230120
DPA/DXA1985198819851998

Patient populations.

All patients (“Total patients” in Table 2) treated for hip fracture during 1–2-year periods ending in 1999 were identified at each site using International Classification of Diseases, Ninth Revision codes 820.1, 820.2, 820.21, and 820.8, and either hospital discharge or system billing data. Sites I and II included patients older than 40 years and excluded those with traumatic fractures. Sites III and IV included all patients older than 50 years. Only female patients were studied at Site I. “Patients studied” (Table 2) are those whose available primary care and/or specialty records, when reviewed by one of the authors, documented their postfracture care. Most excluded patients were receiving ongoing health care from a practice other than the study site. A small number of these patients' records were available, but the information was not adequate to determine care. Most patients' charts were reviewed at least 4 months after fracture admission. Available records at Site II were limited to orthopedics and medical specialties in ∼50% of patients studied, in contrast to the other sites where primary care records were generally more accessible.

Table 2. Hip fracture patients studied at the 4 study sites*
Study siteSite I AMGSite II CLCLSite III UW-PPDSite IV Wooster
  • *

    See Table 1 for definitions.

Study dates4/97–3/991/98–6/991/98–6/991/99–12/99
Total patients58523219267
Patients studied16314814051
Females/males163/094/54114/2643/8
Median age, years82748382

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Table 2 describes the 4 case series studied. The retrospective study periods varied from 1 to 2 years. The considerable differences between total patients and patients studied reflect the absence of available or adequate records to determine if care was provided for osteoporosis in the excluded cases. There is no reason to believe that care of these excluded patients was different from those studied, or that care was provided to the patients studied, but not documented.

Table 3 indicates the number of the patients at each site who had documentation in their clinical records that they received a DXA scan, calcium and vitamin D supplementation, and/or any prescription drug for osteoporosis. Although the percentages vary somewhat among sites, the overall data indicate low rates of receiving a DXA scan (12–24%), calcium/vitamin D supplementation (5–27%), and prescription medications (5–37%) after hip fracture in the 4 health care systems. Furthermore, only 2–10% of patients received alendronate, the only drug with clinical trial evidence supporting its use at the time these patients were treated. The total percentage is not always the sum of individual drug treatments because several patients were receiving more than 1 medication.

Table 3. Osteoporosis management of hip fracture patients by study site*
Study siteSite I AMGSite II CLCLSite III UW-PPDSite IV Wooster
  • *

    See Table 1 for definitions.

  • Several patients were receiving more than 1 medication.

Patients studied, n16314814051
DXA, n (%)20 (12)18 (12)18 (13)12 (24)
Calcium/vitamin D,  n (%)44 (27)12 (8)7 (5)13 (25)
Prescription drugs,  n (%)
 Estrogen17 (10)9 (6)0 (0)7 (14)
 Alendronate14 (8)3 (2)5 (4)5 (10)
 Calcitonin18 (11)0 (0)0 (0)7 (14)
 Raloxifene1 (1)0 (0)2 (1)3 (6)
 Total43 (26)12 (8)7 (5)19 (37)

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

We elected to analyze hip fracture patients within the broader osteoporosis population because their need for intervention is so compelling. The documented lack of osteoporosis management after hip fracture in the 4 health systems is similar to results documented in other recent reports (11–15). Neither orthopedic surgeons who treat acute hip fractures nor primary physicians who provide long-term health care to many of these same patients appear to be engaged in secondary prevention, in spite of the availability of DXA, more effective treatment options, and extensive continuing education efforts. Unfortunately, other osteoporosis patients also appear to be undermanaged, including those treated with long-term glucocorticoids (16), wrist fracture patients (17, 18), patients exhibiting any fragility fracture (19), and those diagnosed by DXA (20). We believe that this is probably the best management that can be expected from traditional health care delivery methods.

The purpose of this study is not only to emphasize the gap between knowledge and practice in osteoporosis care, but more importantly to create a call to action for improving the situation. Collecting this data is only a first step in our osteoporosis improvement projects. We recognize that a retrospective analysis of available clinical records lacks the rigor of a prospective clinical study, as indicated by the number of patients excluded because of inaccessible records. However, this approach is consistent with that recommended by Berwick and Nolan as most appropriate for initiating clinical process improvement (21). The absence of data for some patients does not compromise our message or its usefulness.

Physicians will generally view this and many other health system problems as individual oversights, and herein lies a fundamental barrier to improving care (22, 23). We must recognize that capable individual physicians can only get the job done with the support of reliable system-wide disease management programs, which are lacking in our systems and elsewhere. Health care system redesign will be needed to reduce osteoporotic fractures. Other commonly cited reasons for lack of osteoporosis care in some health care environments, such as access to DXA, cost of treatment, and patient adherence issues, do not explain our data. These same types of problems have been well documented in the traditional management of many other serious diseases in US health care (24–26).

We propose several steps to improve the treatment of osteoporosis after hip fracture: 1) develop system-wide management programs to provide education, full rehabilitation, timely DXA, and effective drug treatment and monitoring; 2) define the roles of hospital staff, orthopedists, primary physicians, medical consultants, and osteoporosis program managers in providing these services; and 3) verify and improve program performance through continuous process and outcomes monitoring. These are the elements of effective quality improvement that have been used more widely in other industries than in health care (21, 27). We are implementing these steps in our health systems, and encourage more widespread efforts by others to do so. We will also extend these efforts to others at high risk for osteoporosis, including women older than 65 years, younger postmenopausal women with clinical risk factors, and patients receiving long-term glucocorticoid treatment, as recommended in the National Osteoporosis Foundation guidelines (28) and the American College of Rheumatology recommendations for glucocorticoid-induced osteoporosis (29).

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Supported by a grant from the North Central Osteoporosis Board, the Alliance for Better Bone Health (Procter & Gamble and Aventis Pharmaceuticals). The design and performance of this research has been the sole responsibility of the authors.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
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