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Osteoporosis Treatment After Hip Fracture: Missed Opportunities
Abstract & Commentary
By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.
Synopsis: After hip fracture due to osteoporosis, only 2% of patients had ideal treatment initiated in the hospital with antiresorptive or bone-forming medications combined with calcium and vitamin D.
Source: Jennings LA, et al. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc 2010;58:650-657.
Using a proprietary hospital database that collects clinical and financial information from 318 hospitals spread across the United States, 51,325 hospital admissions for procedures to correct an osteoporotic femoral fracture in patients age 65 and older were identified during the time period October 2003 through September 2005. Cases were excluded that involved significant precipitating trauma such as car accidents, and also patients receiving palliative care or who had significant metabolic calcium disorders such as end-stage renal disease and hormonal disorders.
That left 51,346 cases that presumably would benefit from treatment of osteoporosis; the cohort was mostly female, white, aged 75 and older, and 68% had a medical provider or consultation in addition to the surgical care. Approximately 7% received either calcium, vitamin D, or an antiresorptive or bone-forming medication during their hospitalization, but only 2% received ideal therapy of medication combined with calcium and vitamin D. Rates for males and blacks were less than females and whites, but otherwise the odds of receiving osteoporosis treatment did not vary by age group or hospital size. By comparison, fully 84% received perioperative antibiotics, and 74% had DVT prophylaxis.
We know that one osteoporotic hip fracture leads to a 2-4 times increased risk for another (and 10% within the first year), and we know that antiresorptive or bone-forming medication combined with calcium and vitamin D leads to fewer fractures. But how well are we doing in starting that treatment? A recent report from an outpatient fracture service in Cambridge showed only 30% receiving medications and 35% taking calcium and vitamin D.1
One obvious reason our patients don't get started on osteoporosis treatment after fractures is the fragmentation of care that occurs between the hospital orthopedist and the office primary care clinician. This study confirms that very little osteoporosis treatment is initiated during hospitalization, and suggests this might be a missed opportunity. The American Orthopedic Association recently established a web-based quality improvement program titled "Own the Bone" to promote awareness and better coordination for this post-fracture care.
A promising advance in osteoporosis treatment that may overcome these issues is the new availability of once-yearly infusions, which could be arranged at the time of hospital discharge.2 These produce significant (although not complete) reduction in subsequent fractures, and would eliminate the compliance problems of ongoing medications. Although it would seem most efficient to administer these infusions during the fracture hospitalization, animal studies suggest they may interfere with acute bone healing. In humans, post-hoc analysis of infusions given after fracture repair now suggests the best results occur when it is administered 2 weeks or more after surgery.3
1. Premaor MO, et al. Low rates of treatment in postmenopausal women with a history of low trauma fractures: Results of audit in a Fracture Liaison Service. QJM 2010;103:33-40.
2. Boonen S, et al. Efficacy and safety of a once-yearly intravenous zoledronic acid 5 mg for fracture prevention in elderly postmenopausal women with osteoporosis aged 75 and older. J Am Geriatr Soc 2010;58:292-299.
3. Eriksen EF, et al. Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture. J Bone Miner Res 2009;24:1308-1313.