A retrospective observational study of osteoporosis management after a fragility fracture in primary care

Abstract

Summary In many countries, osteoporosis is predominantly managed by primary care physicians; however, management after a fragility fracture has not been widely investigated. We describe osteoporosis care gaps in a real-world patient cohort. Our findings help inform initiatives to identify and overcome obstacles to effective management of patients after fragility fracture. Purpose A fragility fracture is a major risk factor for subsequent fracture in adults aged ≥ 50 years. This retrospective observational study aimed to characterize post-fracture management in Canadian primary care. Methods A total of 778 patients with an index fragility fracture (low-trauma, excluding small bones) occurring between 2014 and 2016 were identified from medical records at 76 primary care centers in Canada, with follow-up until January 2018. Results Of 778 patients (80.5% female, median age [IQR] 73 [64–80]), 215 were on osteoporosis treatment and 269 had osteoporosis diagnosis recorded prior to their index fracture. The median follow-up was 363 (IQR 91–808) days. Of patients not on osteoporosis treatment at their index fracture, 60.2% (n = 339/563) remained untreated after their index fracture and 62.2% (n = 23/37) continued untreated after their subsequent fracture. After their index fracture, fracture risk assessment (FRAX or CAROC) was not performed in 83.2% (n = 647/778) of patients, and 59.9% (n = 466/778) of patients did not receive bone mineral density testing. Of patients without osteoporosis diagnosis recorded prior to their index date, 61.3% (n = 300/489) remained undiagnosed after their index fracture. At least one subsequent fracture occurred in 11.5% (n = 86/778) of patients. Conclusion In the primary care setting, fragility fracture infrequently resulted in osteoporosis treatment or fracture risk assessment, even after multiple fragility fractures. These results suggest a fragility fracture is not recognized as a major risk factor for subsequent fracture and its occurrence does not prompt primary care physicians to intervene. These data urge initiatives to identify and overcome obstacles to primary care physicians’ effective management of patients after fragility fractures.

Management of Vertebral Fragility Fracture in Older People: Recommendations from a Spanish Consensus of Experts

“…Primary care physicians and/or specialists in osteoporosis should be involved in the follow-up of patients with VFF in the acute and chronic phases when treated with bisphosphonates or denosumab, whereas a geriatrician should be responsible for the follow-up of frail or disabled subjects. However, despite achieving 100% agreement on the role of primary care physicians in the management of fragility fractures in older people, it has been shown that the diagnosis and treatment of osteoporosis, as well as fracture risk assessment, is frequently lacking in the primary care setting [ 46 , 47 ]. Therefore, effective communication with primary care professionals (e-consultation or other resources of telemedicine) is a critical aspect of the appropriate interdisciplinary management of older patients with VFF.…”

An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture

“…6 Many interventions aimed at identifying and improving fragility fracture prevention in routine primary care settings have had little impact. 18–20 Therefore, novel interventions are needed in clinical settings that deliver acute ambulatory healthcare services, such as the Emergency Department (ED).…”