Rates of Osteoporosis Management and Secondary Preventative Treatment After Primary Fragility Fractures

Abstract

Background: Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture. Methods: A retrospective review of the PearlDiver database was conducted using the International Classification of Diseases, Ninth Revision (ICD-9) and ICD, Tenth Revision (ICD-10) and Current Procedural Terminology codes. Patients who were 60 to 80 years of age and had primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other unspecified locations were included. The rates of dual x-ray absorptiometry (DXA) screening and osteoporosis pharmacotherapy were assessed for 2 years before and 2 years after the primary fracture. Results: In this study, 48,668 patients with a primary fragility fracture were identified. Within this cohort, 25.8% (12,573 of 48,668) had received osteoporosis screening or treatment in the prior 2 years. In the 36,095 patients with no management before the fracture, 19% (6,799 patients) were diagnosed with osteoporosis and 18.4% (6,653 patients) received a DXA scan and/or filed claims for pharmacotherapy in the following 2 years. Patients with an osteoporosis diagnosis were more likely to receive both types of management (odds ratio [OR], 11.55 [95% confidence (CI), 10.31 to 12.95]), and male patients were less likely to receive both types of management (OR, 0.23 [95% CI, 0.17 to 0.27]). Secondary fragility fractures within the next 2 years were diagnosed in 8.4% (3,038 of 36,095) of patients at a mean of 221 days following the primary fracture. Conclusions: The rates of appropriate osteoporosis evaluation, diagnosis, and management following primary fragility fractures remain unacceptably low. Less than one-third of patients with primary fragility fractures had been evaluated or treated for osteoporosis in the 2 years prior to fracture. Furthermore, among patients without pre-fracture management, <20% received osteoporosis screening or treatment within the next 2 years. Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

How age and gender influence proximal humerus fracture management in patients older than fifty years

“… 36 Although screening patients at risk for osteoporosis and giving pharmacological treatment when indicated decreases the risk of proximal humerus fractures by 45%, Ross et al reported these strategies have been initiated in less than 20% of patients after fragility fractures. 41 , 44 …”

Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?

“…To include fractures caused by lowenergy trauma only, we excluded all events that were likely to have been caused by high-energy events (such as a motor vehicle collision) at the same time these fractures occurred. This methodology of defining fragility fractures using ICD diagnosis codes was based on published works [1,25].…”

“…Regarding fractures, there are no specific ICD codes for fragility fractures. Therefore, to define fragility fractures as accurately as possible, we used published works that have used the PearlDiver Database [1,25]. Regarding a comparison of patients at low risk versus those at high risk, we are limited in the reporting of intraoperative information; thus, the study is at risk of selection bias.…”

Editor’s Spotlight/Take 5: Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?

“…Dr. Leopold: Given how ineffective we’ve been in getting patients who’ve had major fractures and other sentinel events screened [7], why do you believe we might have more success if we intervene at the time of elective surgery in this patient population?…”

“…I'm mindful of how easy it is for patients not to get the care they need and ought to have. Large studies bear out this worry: Most patients who have a fragility fracture do not receive suitable follow-up, screening, or treatment [7]. This happens despite the concept of sentinel events being known since, well, not long after I learned how to walk.…”