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CLINICAL PERSPECTIVE |
Department of Medicine (E.S.S., J.P.B., M.R.R.), College of Physicians and Surgeons of Columbia University, New York, New York 10032; Department of Epidemiology and Biostatistics (D.M.B.), University of California–San Francisco, San Francisco, California 94105; Department of Medicine (R.S.B.), Weill-Cornell Medical College, New York, New York 10021; Michigan Bone and Mineral Clinic (H.G.B.), Detroit, Michigan 48236; Department of Medicine (M.C.H.), University of Maryland School of Medicine, Baltimore, Maryland 21201; Oregon Osteoporosis Center (M.R.M.), Portland, Oregon 97218; and Department of Medicine (T.J.S.), Northwestern University Medical School, Chicago, Illinois 60611
Address all correspondence and requests for reprints to: Ethel Siris, M.D., Department of Medicine, Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, HP 9-964, New York, New York 10032. E-mail: es27{at}columbia.edu.
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OSTEOPOROSIS IS A SKELETAL disorder characterized by reduced bone strength, due to a loss of bone mass and compromised bone quality (1). Patients with this disease are at high risk for low trauma or fragility fractures. Both vertebral and hip fractures, which are most common in postmenopausal women, are associated with substantial morbidity and excess mortality (2, 3, 4). The risk of fracture in postmenopausal women can be estimated by determining bone mass through the measurement of bone mineral density (BMD), and the BMD test has become well established as the gold standard for the diagnosis of osteoporosis. According to the World Health Organization (5), bone density in postmenopausal women is characterized as normal, osteopenic (low bone mass), or osteoporotic by comparing a patient’s result with the mean value at the spine, hip, or forearm in a healthy young normal population at peak bone mass. The results are expressed in SD above or below the mean for that reference group, as a T-score. The bone density test thus permits a diagnosis of osteoporosis to be based not on the presence of a fracture, but rather on the basis of fracture risk, i.e. before a fracture event. Measurement of BMD, coupled with information regarding the presence or absence of additional independent risk factors for fracture, such as increasing age, family history, factors prediposing to falls, and, very importantly, past history of fractures in adulthood, allows for the identification of patients at highest risk for future fractures. Because aspects of bone structure not reflected in BMD are important for fracture risk, one fracture significantly increases the risk for other fractures, even in patients with similar BMD measurements.
The goal of osteoporosis treatment is the prevention of fractures. Recent prospective, randomized, placebo-controlled clinical trials have studied the therapeutic benefits of calcium and vitamin D supplementation; of antibone-resorbing drugs including estrogen, raloxifene, calcitonin, and the bisphosphonates alendronate, risedronate, zoledronic acid, etidronate, and clodronate (the last three not registered in the United States for the treatment of osteoporosis); and of the anabolic agent teriparatide (human PTH 1–34). These studies have demonstrated the capacity of several of these agents to reduce significantly the risk of vertebral fractures (6, 7, 8, 9, 10, 11, 12, 13, 14, 15), nonvertebral fractures (9, 10, 11, 15, 16), and hip fractures (9, 17, 18) in postmenopausal women with osteoporosis. Both alendronate and teriparatide have been shown to reduce vertebral fracture risk in men with osteoporosis (19, 20). Many of these studies intentionally enrolled patients who had a history of one or more prevalent vertebral fractures (9, 11, 12, 13, 14, 15, 17, 19), recognizing that such patients are at the highest short-term risk of additional fractures during the study period.
Clinical guidelines, based on cost-effectiveness strategies, fully support the use of therapies proven to reduce fracture risk when they are prescribed for those patients who are at highest risk for osteoporotic fractures (4). Unfortunately, it has become apparent that the medical community is largely ignoring this recommendation in precisely those patients with the greatest need for intervention, i.e. in individuals who have already sustained an osteoporotic fracture.
A low trauma fracture is a powerful predictor of future fractures (21). A distal radial (Colles’s) fracture, a common fracture in women in their 60s, doubles the risk of a future hip fracture (22); the presence of a vertebral fracture deformity on a radiograph, often an asymptomatic finding noted incidentally, increases the risk of additional vertebral fractures by 4- to 5-fold, as well as doubling the risk of hip fracture (23); among untreated patients with a new vertebral fracture, the risk of an additional vertebral fracture during the next year is nearly 20% (24). Indeed, the presence of any fracture after age 50 increases the risk of hip fracture (25). Among patients who sustain a hip fracture, the risk of a second hip fracture is increased 6-fold (26). Based on these data and a cost-effectiveness analysis, the National Osteoporosis Foundation (NOF) calls for BMD testing in all postmenopausal women who present with fractures to confirm the diagnosis of osteoporosis and recommends treatment with a U.S. Food and Drug Administration-approved agent when that is clinically indicated (4). Although the release of the NOF guidelines was associated with a small increase in osteoporosis treatment in patients with fractures, from 11% to 29% (27), these numbers are still notably inadequate.
Despite these powerful statistics and the medical strategies that they support, it is apparent that most physicians who are responsible for the management of osteoporotic fractures are not pursuing the indicated evaluation and the subsequent treatment with the effective therapies that are now available. In virtually all the reports that have been published in the past few years, physicians who deal directly with the fracture event rarely take appropriate action. This includes radiologists who review x-rays that include the spine, orthopedic surgeons who treat acute fractures, physiatrists who oversee rehabilitation after the fracture, and primary care doctors to whom the patient returns for overall care once the fracture has healed. Standards of care for further evaluation and medical management of these high-risk patients are, unfortunately, neither recognized nor practiced.
In one study, Gehlbach et al. (28) examined the recognition of vertebral fractures in the clinical setting by radiologists and primary care physicians. Over a 2-yr period, 934 women over age 60 who were hospitalized in the New England area had routine chest x-rays that were later reviewed by two study radiologists. Moderate or severe vertebral fractures, diagnosed according to a protocol adapted from the semiquantitative technique of Genant et al. (29), were identified by the study team in 132 of the women (14.1%). However, in only 1.8% of the 934 patients was a vertebral fracture noted as a discharge diagnosis by the primary physician. Of those with fractures, only 17% had the fracture mentioned by their personal physicians in either the medical record or discharge summary. Hospital radiologists commented on a vertebral fracture in the body of the x-ray report only 52% of the time, despite the fact that these fractures were moderate to severe. Only 23% of the radiology reports made note of a vertebral fracture in the summary of the findings. Finally, only 18% of the medical records indicated that those with moderate or severe vertebral fractures had been prescribed calcium, vitamin D, or an antibone-resorbing medication.
Simonelli et al. (30) reported that when 227 postmenopausal women were admitted with a low-impact fracture (hip, spine, wrist, or humerus) to a hospital in Minnesota, osteoporosis was considered in only 26%. Interestingly, osteoporosis was more likely to be considered in the setting of a vertebral rather than hip fracture, possibly because vertebral fractures are usually spontaneous and not attributed to a discrete event, such as a fall. Within 12 months of discharge, only 10% had undergone BMD testing and only 26% were prescribed osteoporosis treatment (30). In another study, Cuddihy et al. (31) found that only 5% of 343 postmenopausal women admitted with a minimal trauma forearm fracture underwent bone density measurement in the subsequent 12 months. Only 18% were administered any intervention during the year after fracture (31). Harrington et al. (32) reported that in four midwestern United States health systems, bone densitometry was performed in an average of only 15% of hip fracture patients, calcium and vitamin D supplements were prescribed in an average of 14%, and antiresorptive therapy was prescribed in an average of 21% of these patients. Most recently, Follin et al. (33) found that of 118 patients admitted with a low trauma hip fracture, only 4% of patients were evaluated for osteoporosis during hospitalization and only 9% during the subsequent 12 months. Only 25% of patients received documented treatment for osteoporosis on discharge or follow-up (33).
This hesitancy by physicians to act is similar to that found in surveys of primary care practices in other countries. In reports from England, up to 95% of women with recent hip or wrist fractures were not being treated with antiosteoporosis regimens (34), and nearly two thirds of women with recent vertebral fractures were untreated (35). In an Italian study, only 53% of patients with a discharge diagnosis of osteoporosis received any treatment (36). An Australian report showed that of 218 patients sustaining hip and wrist fractures, only 32% had BMD measurement and only 39% were offered osteoporosis treatment (37). A study from Israel showed that among nearly 300 patients with osteoporotic fractures, between 60 and 70% of patients received no osteoporosis therapy in the 6 months after the fracture event (38). In one Canadian study, only 50% of patients who had sustained an atraumatic wrist fracture within the previous 6 months to 3 yr were receiving osteoporosis follow-up (39). Sixty-two percent were taking calcium and vitamin D, whereas 38% were receiving antiresorptive treatment (39). In another Canadian study, osteoporosis was overlooked in a majority of patients over age 65 admitted with a new diagnosis of hip fracture (40). The diagnosis was considered by only 23% of internists, 13% of geriatric consultants, and 14% of orthopedic surgeons.
Three studies, including two from the United States and one from Canada, have noted that orthopedic surgeons who treat acute fractures rarely refer patients for follow-up medical evaluation and treatment for osteoporosis. Freedman et al. (41) reported that among 1162 women, all greater than 65 yr of age and treated for distal radial fractures, coming from 22 states throughout the United States, only 2.8% were sent for bone density testing to evaluate and document the presence of osteoporosis and only 22.9% of the women with fractures received any subsequent antiosteoporosis medical treatment. Moreover, this study found that the likelihood of evaluation and treatment decreased significantly with advancing patient age, even though older patients are at even greater risk of future fracture because of their age. Kamel et al. (42) found that among 170 elderly patients (average age, 80 yr) with hip fractures treated in a large teaching hospital in Long Island, New York, only 3% were referred for bone density testing either while in the hospital or after discharge. Only 5% were prescribed calcium, vitamin D, or the bisphosphonate alendronate at discharge by the orthopedic surgeon treating them. Interestingly, over 93% of the patients had been seen by a medical consultant during their hospitalization, but this did not influence the frequency of an osteoporosis diagnosis or initiation of treatment at discharge. A Canadian study by Hajcsar et al. (43) reported on a representative sample of patients with fragility fractures predominantly of the distal radius, proximal humerus, or proximal femur who were cared for in three hospital-based fracture clinics in Ontario. They found that fewer than 20% were evaluated for osteoporosis and appropriately treated during the year after the fracture.
Many patients with serious fractures are subsequently managed for a period of time by physiatrists who undertake their rehabilitation care. Fitzsimmons et al. (44) described a series of 89 patients in a rehabilitation medicine facility in eastern Pennsylvania. These individuals, age 60 and older, were studied after the investigators realized that none of the patients on the service, which included many who were recovering from hip fractures, were receiving treatment or had even been evaluated for risk of fracture. Subsequent assessment revealed that over 77% of the women were at significant risk for future fractures. Other data have shown that during rehabilitation after a fracture, even when acute management of the fracture was no longer paramount, only 10% of patients were administered osteoporosis treatment (40).
Throughout these studies, osteoporosis was even less likely to be considered when certain features were present. Elderly men with fragility fractures were virtually ignored (40, 45) even though it is known that men have a higher mortality rate than women in acute care after hip fracture (46). In one study, of 363 patients hospitalized for atraumatic hip fractures, only 4.5% of men were treated for osteoporosis, compared with 27% of women (45). Over 1–5 yr of subsequent follow-up, only 11% of men had undergone BMD testing, although the women did not fare much better at 27% (45). Osteoporosis was also less likely to be sought in elderly patients (36), even though antiresorptive therapy is known to reduce fracture risk in the very oldest patients (21, 47).
The failure to evaluate and treat patients with osteoporotic fractures, so as to prevent additional fractures, is a grave problem worldwide. The fragility fracture should signal a resounding call to action to prevent the next one. At present, however, the fragility fracture is simply treated by the orthopedic surgeon; the patient is given rehabilitation care by the physiatrist and returned to the primary care physician. In this setting, therefore, one that should be ideal for action to prevent further complications of osteoporosis, little or no such action is taken.
This regrettable situation may be the result of several factors. Many physicians may not take osteoporosis seriously, believing that they do not see fractures in their own practices despite the statistics. A recent study of over 200,000 postmenopausal women (average age, 65 yr) from over 4,000 primary care practices in the United States had as an entry criterion no prior diagnosis of osteoporosis by the patient’s physician; despite this, 11% of the women reported at baseline a history of a fragility fracture after age 45 (48), suggesting a clear lack of connection between the history of a low trauma fracture and a diagnosis of osteoporosis.
Many primary care physicians may, in addition, not be knowledgeable about the usefulness of bone densitometry as a safe, noninvasive, and accurate diagnostic tool. The recent approvals of a number of effective osteoporosis therapies may not have yet made sufficient impact on the physicians who care for the patient who has fractured. They may not know how to administer them. Rather, these medications are used with more frequency and familiarity by specialists like endocrinologists, rheumatologists, and gynecologists, not the physicians who are more typically involved in the treatment of the osteoporotic fracture itself. Some of the controversy about when to treat to prevent a first fracture (1) may have extended to uncertainty about treating the patient who has already sustained an osteoporotic fracture. Some physicians may believe that once an older patient has had a first fracture that it is too late to prevent another one, regardless of what is done. This view is clearly incorrect. The patient who has fractured is just as likely to benefit from antiosteoporosis therapy as the one who has not (9, 11, 12, 13, 14, 15).
Professional societies representing orthopedic surgeons, radiologists, physiatrists, internists, and family practitioners need to establish standards of care for patients with fractures to reduce the risk of future fractures. Radiologists who note a vertebral fracture as an incidental finding in a middle-aged or older woman or man should have specific methods for reporting the finding and a recommendation for bone density testing to evaluate the possibility of osteoporosis if clinically indicated. Orthopedic surgeons treating low trauma fractures in postmenopausal women and older men need to routinely take the next step, either to initiate an evaluation for osteoporosis themselves or to refer the patient back to the primary care physician or to a medical specialist with a specific request for evaluation and appropriate treatment. For example, Chevalley et al. (49) implemented a promising osteoporosis clinical pathway in Switzerland, in which fracture patients were identified, diagnosed, and treated. At 6 months, 67% of patients were taking antiresorptives and 86% were taking calcium and vitamin D. If a patient is receiving postfracture care in a rehabilitation center, the physiatrist must recognize also the need for diagnostic and therapeutic interventions to limit the possibility of future fractures.
In all cases, these older patients require assessment to rule out secondary causes of low bone mass, such as calcium or vitamin D deficiency, primary hyperparathyroidism, use of medications that predispose to impaired bone quality, undetected hypogonadism in men, as well as other documented causes (50). Appropriate history and physical examination and simple laboratory testing (e.g. complete blood count to rule out anemia, measurement of serum and urinary calcium and creatinine and serum phosphate, hepatic function tests and TSH to screen for a variety of metabolic abnormalities), as well as judicious use of additional and more expensive testing when indicated (e.g. vitamin D metabolite levels, PTH or cortisol measurements, etc.), will identify problems that contribute to fractures that are often easily and simply rectified. Repletion of calcium and vitamin D is a universal recommendation. In most cases, selection of an approved pharmacological therapy is indicated in both postmenopasual women and older men who have sustained an osteoporotic fracture. The choice of the agent to be prescribed can be based on the patient’s individual circumstances and the characteristics of the various agents that are now available, including the data regarding reduction in risk for vertebral, nonvertebral, or hip fractures and the adverse event profiles of each of these drugs. There is no evidence from the clinical trials described earlier that use of these agents soon after fracture impairs fracture healing.
Specialty societies representing bone metabolism specialists, endocrinologists, and rheumatologists, as well as the NOF, all well known for their proactive programs to discover and treat osteoporosis, should be sought out as partners by the professional societies representing orthopedic surgeons, radiologists, physiatrists, and primary care physicians to develop and implement educational programs for their members. In this way, recent advances in the diagnosis and treatment of osteoporosis can be extended to the caregivers who treat the patient with an acute fracture, creating clearly stated standards of care. The hesitancy of physicians to address the management of osteoporosis must end. We have learned what we need to do for these high-risk patients, and now we must act.
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Received April 1, 2003.
Accepted May 16, 2003.
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