- Email: [email protected]
Management of osteoporosis in women after forearm fracture: Data from a French health insurance database
Joint Bone Spine 82 (2015) 52–55
Available online at
ScienceDirect www.sciencedirect.com
Original article
Management of osteoporosis in women after forearm fracture: Data from a French health insurance database Florence Erny a , Aurélie Auvinet b , Delphine Chu Miow Lin a , Ambre Pioger b , Ken Haguenoer a , Philippe Tauveron c , Franc¸ois Jacquot c , Emmanuel Rusch a , Philippe Goupille a , Denis Mulleman a,∗ a
Université Franc¸ois-Rabelais de Tours, 37000 Tours, France Service de statistique de la Caisse Primaire d’Assurance Maladie d’Indre-et-Loire, 37000 Tours, France c Cabinet de Rhumatologie, Centre de l’Ostéoporose, 37000 Tours, France b
a r t i c l e
i n f o
Article history: Accepted 29 July 2014 Available online 17 September 2014 Keywords: Distal forearm fracture Osteoporosis Bone mineral density Medical databases
a b s t r a c t Introduction: Despite reliable diagnostic methods and effective drugs, the prevention and management of osteoporosis seems insufficient in France. We evaluated bone mineral density (BMD) assessment and prescription of anti-osteoporotic drugs after forearm fracture in women. Methods: We used a health insurance database for outpatients from private clinics in a French population of more than 500,000 inhabitants. Medical expenses were analyzed for women 50 years of age or older who had a forearm fracture between August 1, 2010 and June 30, 2012. Results: We identified 250 forearm fractures in women during the study period. In total, 12 women (4.8%) underwent BMD assessment before the fracture and were not taken into account in the analysis. For the 238 others, 24 (10.1%) had undergone BMD assessment at a median of 4 months after the fracture. A total of 32 women (13.4%) received an anti-osteoporotic drug at the time of the fracture and 14 of 206 untreated women (6.8%) received an anti-osteoporotic drug at a median of 3.8 months after the fracture. Receipt of an anti-osteoporotic drug was more frequent for women with than without BMD assessment after the fracture (8/19 [40.1%] versus 6/187 [3.2%]; P < 0.005). Conclusion: This work, performed in a large sample, suggests that only 10% of women 50 years of age or older in France undergo BMD assessment after a forearm fracture and that BMD assessment is associated with anti-osteoporotic drug prescription. © 2014 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Osteoporosis is a highly prevalent condition characterized by bone fragility leading to fractures, most often of the forearm, vertebra and hip. An estimated 40% of women 50 years of age or older will have a bone fracture during their lifetime, 16% a forearm fracture [1]. Each year in France, nearly 40,000 forearm fractures occur [2]. The fracture is considered a warning and should lead to the diagnosis and management of osteoporosis, especially in women; bone mineral density (BMD) is reduced in women who have had such fractures [3–6]. BMD assessment is recommended and has been financially reimbursed since 2006 [7] according to national guidelines in France [8].
The occurrence of osteoporotic fracture is approximately 2 times higher with than without a forearm fracture [9]. As well, morbidity and mortality are increased after a severe osteoporotic or forearm fracture in patients older than 75 years [10,11], which represents a burden for society [12]. However, despite effective drugs, less than one third of women with peripheral osteoporotic fracture receive such treatment [13–17]. In the present study, we used health insurance data for a large sample of women 50 years of age or older in France to estimate the rate of BMD assessment and anti-osteoporotic drug prescription after forearm fracture in women. 2. Methods 2.1. Medical databases and population
∗ Corresponding author. Service de Rhumatologie, université Franc¸ois-Rabelais de Tours, Tours, France. Tel.: +33 2 47 47 59 17; fax: +33 02 47 47 46 39. E-mail address: [email protected] (D. Mulleman).
In France, the Système Informationnel de l’Assurance Maladie– Extraction Recherche Analyse pour un Suivi Médico-Economique
http://dx.doi.org/10.1016/j.jbspin.2014.07.007 1297-319X/© 2014 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
F. Erny et al. / Joint Bone Spine 82 (2015) 52–55
53
(SIAM-ERASME) health insurance database of the national social insurance program Caisse Primaire d’Assurance Maladie (CPAM) collects data for 2 consecutive years of reimbursed medical activity and medication. This database covers private clinic expenses for outpatients [18]. The population of the Indre-et-Loire district in midwest France is 590,515 people and the population covered by the unified health insurance program is 519,339 people. On December 31, 2012, this area was serviced by 19 rheumatologists, 602 general practitioners, 4 private hospitals and 7 public hospitals. As an example, in 2012, 3622 of the insured people had undergone at least one BMD assessment (performed in outpatient private clinics); among them were 3295 women aged 50 years and older. 2.2. Patients We identified women aged 50 years of age or older who underwent immobilization or reduction for a forearm fracture between August 1, 2010 and June 30, 2012, via the French common classification for medical procedures [Classification Commune des Actes Médicaux (CCAM)] with the following codes: MZMP004 (making of a rigid device on the forearm or hand for initial immobilization for a fracture of the upper limb, without reduction), MZMP013 (making of an ante-brachio-palmar rigid device for initial immobilization for a fracture of the upper limb, without reduction) and MCEP001 (orthopedic reduction for a fracture or epiphyseal detachment of one or the 2 bones of the distal forearm). Patients who underwent BMD assessment between August 1, 2010 and June 30, 2012 or received an anti-osteoporotic drug prescription (bisphosphonates, strontium ranelate, raloxifene or teriparatide) from August 1, 2010 to August 28, 2012 were identified. The BMD assessment was identified with the code PAQK007 (BMD obtained by dual-energy X-ray absorptiometry). We studied whether age, having a long-term illness and prescription of an anti-osteoporotic drug were associated with BMD assessment. Long-term illnesses are severe or chronic illnesses for which the health insurance system in France covers 100% of the medical expenses and can be used as an indirect marker of co-morbidities.
Fig. 1. Cumulative percentage of bone mineral density (BMD) assessment after forearm fracture over time in women older than 50 years of age. One third (12/36) of BMD assessments were performed before the fracture. Table 1 Effect of having a long-term illness on undergoing bone mineral density (BMD) assessment after forearm fracture in women older than 50 years of age. BMD assessment
Long-term illness No long-term illness Total
Yes
No
Total
3 (3.6) 21 (13.6) 24 (10.1)
81 (96.4) 133 (86.4) 214 (89.9)
84 154 238
Data are number (percentage). Long-term illnesses are severe or chronic illnesses for which the health insurance system in France covers 100% of the medical expenses.
250 BMD before fracture?
Yes
12
No
238 BMD after fracture?
No
Yes
214
24
Treatment?
Treatment?
2.3. Statistical analysis
Yes, before fracture
chi2
Data are presented as median (range). We used test to assess any link between BMD assessment and prescription of anti-osteoporotic drugs and between long-term illness and BMD assessment and the cumulative frequency of BMD assessments after fracture. R 2.14.1 (http://www.R-project.org, the R Foundation for Statistical Computing, Vienna, Austria) was used for analysis. 3. Results Between August 1, 2010 and June 30, 2012, we identified 250 forearm fractures [MCEP001: 79 women, MZMP004: 16 women, MZMP013: 156 women; one fracture coded twice (MCEP001 and MZMP013)]. The analysis involved 238 women because 12 women had already undergone BMD assessment before the fracture. The median age at the time of the fracture was 73.5 years (50–104). A total of 24 women (10.1%) had undergone BMD assessment at a median of 118.5 days (16–520) after the fracture (Fig. 1). Women with and without long-term illness did not differ in undergoing BMD (3.6% and 13.6%, P > 0.05) (Table 1). Treatments by the presence or absence of BMD assessment are in Fig. 2. In total, 32 women were receiving anti-osteoporotic drugs at the time of the fracture. For the 206 others, only 14 (6.8%) received anti-osteoporotic drugs at a median of 114.5 days (1–256) after the fracture; 8 were among the 19 women who had undergone
Yes, after fracture
5
8
No
11
Yes, before fracture
27
Yes, after fracture
No
6
181
Fig. 2. Number of women older than 50 years of age receiving treatment by BMD assessment after forearm fracture.
BMD and the 6 others were among the 187 who had not undergone BMD assessment. Thus, receipt of an anti-osteoporotic drug was more frequent among women with than without BMD assessment (40.1% vs 3.2%; P < 0.005). The most commonly prescribed anti-osteoporotic treatments were bisphosphonates (Table 2). Table 2 Type of anti-osteoporotic treatments prescribed in women older than 50 years of age after forearm fracture by BMD assessment. Anti-osteoporotic treatments
Bisphosphonates Selective estrogen receptor modulators Strontium ranelate Teriparatide Total
BMD assessment Yes
No
Total
7 1 0 0 8
4 1 1 0 6
11 2 1 0 14
Fourteen on 206 patients (6.8%) received anti-osteoporotic drugs after the fracture, 8 (40.1%) had undergone BMD and 6 (3.2%) had not undergone BMD assessment.
54
F. Erny et al. / Joint Bone Spine 82 (2015) 52–55
4. Discussion Our study is the first to investigate the management of osteoporosis after a forearm fracture in a large population in France. It points to the poor impact of the occurrence of such fractures on osteoporosis management, with only 10.1% of BMD performed after forearm fracture. Using data from 1994 to 1997 in North American databases, Freedman et al. found that only 2.8% (33/1162) of women 55 years of age and over had undergone BMD assessment 6 months after a forearm fracture [17]. Our study suggests that BMD assessment in our district is still insufficient in terms of 2006 national rules for reimbursement of BMD for a large number of indications, including peripheral fractures [7]. Forearm fractures are often managed in an emergency context, and the diagnosis of osteoporosis is not considered initially. General practitioners’ awareness of the diagnosis and prevention of post-menopausal osteoporosis in this situation must be increased. We found that anti-osteoporotic drugs were prescribed for 6.8% of patients after a forearm fracture. The women with a prescription for an anti-osteoporotic drug without BMD assessment may not have needed it and those who were not given a drug may need one. French guidelines recommend that for forearm fracture, BMD should be assessed and the FRAX score calculated (fracture risk assessment tool) and, depending on the results, an anti-osteoporotic drug should be prescribed [8,19]. Here, we estimated the proportion of women who undergo BMD assessment after forearm fracture, but patients who did not undergo BMD assessment may have had an individualized risk of fracture estimated by clinical risk factors. However, the proportion of women in our study, who were prescribed an anti-osteoporotic drug after the fracture, is still low. Our study has several limitations. We estimated the proportion of women who underwent BMD assessment and who received an anti-osteoporotic drug after a forearm fracture. However, whether the diagnostic and the therapeutic decision were directly linked to the fracture event is unknown. Indeed, some women could have undergone BMD assessment and received an anti-osteoporotic drug independently of the fracture. Also, we cannot exclude that in some cases the forearm fracture may have occurred in a high energy traumatic context which may explain the absence of BMD assessment in such circumstances. In our population, one third of the BMD assessments were performed before the forearm fracture. Another osteoporotic fracture may have occurred before the study period or the BMD assessment was performed because of other osteoporosis risk factors. Similarly, some women “without BMD” and who received an antiosteoporotic drug may have undergone BMD assessment before the study period. Since many diseases and disorders have been associated with osteoporosis, we seek to examine, in the context of a forearm fracture, the relationship between long-term illness and BMD assessment. In our population, having a longterm illness did not affect the decision for BMD assessment. It would be interesting in further studies to examine whether factors, such as co-morbidities are associated with BMD prescription. Also, concomitant drugs, such as corticosteroid, hormone replacement therapy or aromatase inhibitors may have helped justify the BMD assessment. Our analysis is limited to outpatients from private clinics, which may have underestimated the percentage of BMD assessment. It is theoretically possible that some women underwent BMD assessment in a public clinic after having the fracture managed in a private clinic or inversely. Because most women with a forearm fracture are not hospitalized [20], ambulatory data seem relevant to meet our objectives. Further studies are needed to confirm these results with a larger sample including public and private in- and outpatients.
In conclusion, only 10% of women older than 50 years of age with forearm fracture underwent BMD assessment at a median of 4 months. This finding could be an impetus to improve the management of osteoporosis. A study in a larger population and extended to the public clinic or hospital would help confirm our results. Author contributions FE analyzed the results and drafted the manuscript; DCML and DM initiated and coordinated the work, participated in the analyses and drafted the manuscript. FJ, PT and PG contributed to the development of the work. AA and AP performed the statistical analyses. KH and ER participated in the results analyses. All authors read and improved the manuscript. This article is the result of the “Prevention of osteoporosis after distal forearm fracture – Prévention de l’Ostéoporose après fracture du Poignet (POP)” study group. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We thank Dr Bruno Giraudeau (Centre for Clinical Investigations – INSERM 1415), Dr Emilie Ducourau (Department of Rheumatology, University Hospital of Tours), Dr Emilie Marteau (Department of Orthopedic Surgery, University Hospital of Tours) and Dr Christophe Le Dû (Department of Orthopedic Surgery, Clinique de l’Alliance, Tours) for advice. This work would not have been possible without the support of the Health Insurance Centre – Caisse Primaire d’Assurance Maladie (CPAM) of Indre-et-Loire district and the Research and Information Group on Osteoporosis (GRIO). References [1] Melton 3rd LJ, Chrischilles EA, Cooper C, et al. Perspective. How many women have osteoporosis? J Bone Miner Res 1992;7:1005–10. [2] Maravic M, Taupin P, Landais P, et al. Hospitalized forearm fractures in France: incidence and burden trend changes. Orthop Traumatol Surg Res 2010;96:662–6. [3] Fiorano-Charlier C, Ostertag A, Aquino JP, et al. Reduced bone mineral density in postmenopausal women self-reporting premenopausal forearm fractures. Bone 2002;31:102–6. [4] Peel NF, Barrington NA, Smith TW, et al. Distal forearm fracture as risk factor for vertebral osteoporosis. BMJ 1994;308:1543–4. [5] Mallmin H, Ljunghall S. Distal radius fracture is an early sign of general osteoporosis: bone mass measurements in a population-based study. Osteoporos Int 1994;4:357–61. [6] Earnshaw SA, Cawte SA, Worley A, et al. Colles’ fracture of the forearm as an indicator of underlying osteoporosis in postmenopausal women: a prospective study of bone mineral density and bone turnover rate. Osteoporos Int 1998;8:53–60. [7] Haute Autorité de santé. http://www.has-sante.fr [8] Briot K, Cortet B, Thomas T, et al. 2012 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis. Joint Bone Spine 2012;79:304–13. [9] Cuddihy MT, Gabriel SE, Crowson CS, et al. Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 1999;9:469–75. [10] Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with lowtrauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301:513–21. [11] Leboime A, Confavreux CB, Mehsen N, et al. Osteoporosis and mortality. Joint Bone Spine 2010;77:S107–12. [12] Maravic M, Le Bihan C, Landais P, et al. Incidence and cost of osteoporotic fractures in France during 2001. A methodological approach by the national hospital database. Osteoporos Int 2005;16:1475–80. [13] Levasseur R, Sabatier JP, Guilcher C, et al. Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture. Joint Bone Spine 2007;74:160–5. [14] Malochet-Guinamand S, Chalard N, Billault C, et al. Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners. Joint Bone Spine 2005;72:562–6.
F. Erny et al. / Joint Bone Spine 82 (2015) 52–55 [15] Briancon D, de Gaudemar JB, Forestier R. Management of osteoporosis in women with peripheral osteoporotic fractures after 50 years of age: a study of practices. Joint Bone Spine 2004;71:128–30. [16] Cuddihy MT, Gabriel SE, Crowson CS, et al. Osteoporosis intervention following distal forearm fractures: a missed opportunity? Arch Intern Med 2002;162:421–6. [17] Freedman KB, Kaplan FS, Bilker WB, et al. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am 2000;82–A:1063–70.
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[18] Haut Conseil de la Santé Publique. http://www.hcsp.fr [19] Kanis JA, Johnell O, Oden A, et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008;19: 385–97. [20] Holroyd C, Cooper C, Dennison E. Epidemiology of osteoporosis. Best Pract Res Clin Endocrinol Metab 2008;22:671–85.
Available online at
ScienceDirect www.sciencedirect.com
Original article
Management of osteoporosis in women after forearm fracture: Data from a French health insurance database Florence Erny a , Aurélie Auvinet b , Delphine Chu Miow Lin a , Ambre Pioger b , Ken Haguenoer a , Philippe Tauveron c , Franc¸ois Jacquot c , Emmanuel Rusch a , Philippe Goupille a , Denis Mulleman a,∗ a
Université Franc¸ois-Rabelais de Tours, 37000 Tours, France Service de statistique de la Caisse Primaire d’Assurance Maladie d’Indre-et-Loire, 37000 Tours, France c Cabinet de Rhumatologie, Centre de l’Ostéoporose, 37000 Tours, France b
a r t i c l e
i n f o
Article history: Accepted 29 July 2014 Available online 17 September 2014 Keywords: Distal forearm fracture Osteoporosis Bone mineral density Medical databases
a b s t r a c t Introduction: Despite reliable diagnostic methods and effective drugs, the prevention and management of osteoporosis seems insufficient in France. We evaluated bone mineral density (BMD) assessment and prescription of anti-osteoporotic drugs after forearm fracture in women. Methods: We used a health insurance database for outpatients from private clinics in a French population of more than 500,000 inhabitants. Medical expenses were analyzed for women 50 years of age or older who had a forearm fracture between August 1, 2010 and June 30, 2012. Results: We identified 250 forearm fractures in women during the study period. In total, 12 women (4.8%) underwent BMD assessment before the fracture and were not taken into account in the analysis. For the 238 others, 24 (10.1%) had undergone BMD assessment at a median of 4 months after the fracture. A total of 32 women (13.4%) received an anti-osteoporotic drug at the time of the fracture and 14 of 206 untreated women (6.8%) received an anti-osteoporotic drug at a median of 3.8 months after the fracture. Receipt of an anti-osteoporotic drug was more frequent for women with than without BMD assessment after the fracture (8/19 [40.1%] versus 6/187 [3.2%]; P < 0.005). Conclusion: This work, performed in a large sample, suggests that only 10% of women 50 years of age or older in France undergo BMD assessment after a forearm fracture and that BMD assessment is associated with anti-osteoporotic drug prescription. © 2014 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Osteoporosis is a highly prevalent condition characterized by bone fragility leading to fractures, most often of the forearm, vertebra and hip. An estimated 40% of women 50 years of age or older will have a bone fracture during their lifetime, 16% a forearm fracture [1]. Each year in France, nearly 40,000 forearm fractures occur [2]. The fracture is considered a warning and should lead to the diagnosis and management of osteoporosis, especially in women; bone mineral density (BMD) is reduced in women who have had such fractures [3–6]. BMD assessment is recommended and has been financially reimbursed since 2006 [7] according to national guidelines in France [8].
The occurrence of osteoporotic fracture is approximately 2 times higher with than without a forearm fracture [9]. As well, morbidity and mortality are increased after a severe osteoporotic or forearm fracture in patients older than 75 years [10,11], which represents a burden for society [12]. However, despite effective drugs, less than one third of women with peripheral osteoporotic fracture receive such treatment [13–17]. In the present study, we used health insurance data for a large sample of women 50 years of age or older in France to estimate the rate of BMD assessment and anti-osteoporotic drug prescription after forearm fracture in women. 2. Methods 2.1. Medical databases and population
∗ Corresponding author. Service de Rhumatologie, université Franc¸ois-Rabelais de Tours, Tours, France. Tel.: +33 2 47 47 59 17; fax: +33 02 47 47 46 39. E-mail address: [email protected] (D. Mulleman).
In France, the Système Informationnel de l’Assurance Maladie– Extraction Recherche Analyse pour un Suivi Médico-Economique
http://dx.doi.org/10.1016/j.jbspin.2014.07.007 1297-319X/© 2014 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
F. Erny et al. / Joint Bone Spine 82 (2015) 52–55
53
(SIAM-ERASME) health insurance database of the national social insurance program Caisse Primaire d’Assurance Maladie (CPAM) collects data for 2 consecutive years of reimbursed medical activity and medication. This database covers private clinic expenses for outpatients [18]. The population of the Indre-et-Loire district in midwest France is 590,515 people and the population covered by the unified health insurance program is 519,339 people. On December 31, 2012, this area was serviced by 19 rheumatologists, 602 general practitioners, 4 private hospitals and 7 public hospitals. As an example, in 2012, 3622 of the insured people had undergone at least one BMD assessment (performed in outpatient private clinics); among them were 3295 women aged 50 years and older. 2.2. Patients We identified women aged 50 years of age or older who underwent immobilization or reduction for a forearm fracture between August 1, 2010 and June 30, 2012, via the French common classification for medical procedures [Classification Commune des Actes Médicaux (CCAM)] with the following codes: MZMP004 (making of a rigid device on the forearm or hand for initial immobilization for a fracture of the upper limb, without reduction), MZMP013 (making of an ante-brachio-palmar rigid device for initial immobilization for a fracture of the upper limb, without reduction) and MCEP001 (orthopedic reduction for a fracture or epiphyseal detachment of one or the 2 bones of the distal forearm). Patients who underwent BMD assessment between August 1, 2010 and June 30, 2012 or received an anti-osteoporotic drug prescription (bisphosphonates, strontium ranelate, raloxifene or teriparatide) from August 1, 2010 to August 28, 2012 were identified. The BMD assessment was identified with the code PAQK007 (BMD obtained by dual-energy X-ray absorptiometry). We studied whether age, having a long-term illness and prescription of an anti-osteoporotic drug were associated with BMD assessment. Long-term illnesses are severe or chronic illnesses for which the health insurance system in France covers 100% of the medical expenses and can be used as an indirect marker of co-morbidities.
Fig. 1. Cumulative percentage of bone mineral density (BMD) assessment after forearm fracture over time in women older than 50 years of age. One third (12/36) of BMD assessments were performed before the fracture. Table 1 Effect of having a long-term illness on undergoing bone mineral density (BMD) assessment after forearm fracture in women older than 50 years of age. BMD assessment
Long-term illness No long-term illness Total
Yes
No
Total
3 (3.6) 21 (13.6) 24 (10.1)
81 (96.4) 133 (86.4) 214 (89.9)
84 154 238
Data are number (percentage). Long-term illnesses are severe or chronic illnesses for which the health insurance system in France covers 100% of the medical expenses.
250 BMD before fracture?
Yes
12
No
238 BMD after fracture?
No
Yes
214
24
Treatment?
Treatment?
2.3. Statistical analysis
Yes, before fracture
chi2
Data are presented as median (range). We used test to assess any link between BMD assessment and prescription of anti-osteoporotic drugs and between long-term illness and BMD assessment and the cumulative frequency of BMD assessments after fracture. R 2.14.1 (http://www.R-project.org, the R Foundation for Statistical Computing, Vienna, Austria) was used for analysis. 3. Results Between August 1, 2010 and June 30, 2012, we identified 250 forearm fractures [MCEP001: 79 women, MZMP004: 16 women, MZMP013: 156 women; one fracture coded twice (MCEP001 and MZMP013)]. The analysis involved 238 women because 12 women had already undergone BMD assessment before the fracture. The median age at the time of the fracture was 73.5 years (50–104). A total of 24 women (10.1%) had undergone BMD assessment at a median of 118.5 days (16–520) after the fracture (Fig. 1). Women with and without long-term illness did not differ in undergoing BMD (3.6% and 13.6%, P > 0.05) (Table 1). Treatments by the presence or absence of BMD assessment are in Fig. 2. In total, 32 women were receiving anti-osteoporotic drugs at the time of the fracture. For the 206 others, only 14 (6.8%) received anti-osteoporotic drugs at a median of 114.5 days (1–256) after the fracture; 8 were among the 19 women who had undergone
Yes, after fracture
5
8
No
11
Yes, before fracture
27
Yes, after fracture
No
6
181
Fig. 2. Number of women older than 50 years of age receiving treatment by BMD assessment after forearm fracture.
BMD and the 6 others were among the 187 who had not undergone BMD assessment. Thus, receipt of an anti-osteoporotic drug was more frequent among women with than without BMD assessment (40.1% vs 3.2%; P < 0.005). The most commonly prescribed anti-osteoporotic treatments were bisphosphonates (Table 2). Table 2 Type of anti-osteoporotic treatments prescribed in women older than 50 years of age after forearm fracture by BMD assessment. Anti-osteoporotic treatments
Bisphosphonates Selective estrogen receptor modulators Strontium ranelate Teriparatide Total
BMD assessment Yes
No
Total
7 1 0 0 8
4 1 1 0 6
11 2 1 0 14
Fourteen on 206 patients (6.8%) received anti-osteoporotic drugs after the fracture, 8 (40.1%) had undergone BMD and 6 (3.2%) had not undergone BMD assessment.
54
F. Erny et al. / Joint Bone Spine 82 (2015) 52–55
4. Discussion Our study is the first to investigate the management of osteoporosis after a forearm fracture in a large population in France. It points to the poor impact of the occurrence of such fractures on osteoporosis management, with only 10.1% of BMD performed after forearm fracture. Using data from 1994 to 1997 in North American databases, Freedman et al. found that only 2.8% (33/1162) of women 55 years of age and over had undergone BMD assessment 6 months after a forearm fracture [17]. Our study suggests that BMD assessment in our district is still insufficient in terms of 2006 national rules for reimbursement of BMD for a large number of indications, including peripheral fractures [7]. Forearm fractures are often managed in an emergency context, and the diagnosis of osteoporosis is not considered initially. General practitioners’ awareness of the diagnosis and prevention of post-menopausal osteoporosis in this situation must be increased. We found that anti-osteoporotic drugs were prescribed for 6.8% of patients after a forearm fracture. The women with a prescription for an anti-osteoporotic drug without BMD assessment may not have needed it and those who were not given a drug may need one. French guidelines recommend that for forearm fracture, BMD should be assessed and the FRAX score calculated (fracture risk assessment tool) and, depending on the results, an anti-osteoporotic drug should be prescribed [8,19]. Here, we estimated the proportion of women who undergo BMD assessment after forearm fracture, but patients who did not undergo BMD assessment may have had an individualized risk of fracture estimated by clinical risk factors. However, the proportion of women in our study, who were prescribed an anti-osteoporotic drug after the fracture, is still low. Our study has several limitations. We estimated the proportion of women who underwent BMD assessment and who received an anti-osteoporotic drug after a forearm fracture. However, whether the diagnostic and the therapeutic decision were directly linked to the fracture event is unknown. Indeed, some women could have undergone BMD assessment and received an anti-osteoporotic drug independently of the fracture. Also, we cannot exclude that in some cases the forearm fracture may have occurred in a high energy traumatic context which may explain the absence of BMD assessment in such circumstances. In our population, one third of the BMD assessments were performed before the forearm fracture. Another osteoporotic fracture may have occurred before the study period or the BMD assessment was performed because of other osteoporosis risk factors. Similarly, some women “without BMD” and who received an antiosteoporotic drug may have undergone BMD assessment before the study period. Since many diseases and disorders have been associated with osteoporosis, we seek to examine, in the context of a forearm fracture, the relationship between long-term illness and BMD assessment. In our population, having a longterm illness did not affect the decision for BMD assessment. It would be interesting in further studies to examine whether factors, such as co-morbidities are associated with BMD prescription. Also, concomitant drugs, such as corticosteroid, hormone replacement therapy or aromatase inhibitors may have helped justify the BMD assessment. Our analysis is limited to outpatients from private clinics, which may have underestimated the percentage of BMD assessment. It is theoretically possible that some women underwent BMD assessment in a public clinic after having the fracture managed in a private clinic or inversely. Because most women with a forearm fracture are not hospitalized [20], ambulatory data seem relevant to meet our objectives. Further studies are needed to confirm these results with a larger sample including public and private in- and outpatients.
In conclusion, only 10% of women older than 50 years of age with forearm fracture underwent BMD assessment at a median of 4 months. This finding could be an impetus to improve the management of osteoporosis. A study in a larger population and extended to the public clinic or hospital would help confirm our results. Author contributions FE analyzed the results and drafted the manuscript; DCML and DM initiated and coordinated the work, participated in the analyses and drafted the manuscript. FJ, PT and PG contributed to the development of the work. AA and AP performed the statistical analyses. KH and ER participated in the results analyses. All authors read and improved the manuscript. This article is the result of the “Prevention of osteoporosis after distal forearm fracture – Prévention de l’Ostéoporose après fracture du Poignet (POP)” study group. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We thank Dr Bruno Giraudeau (Centre for Clinical Investigations – INSERM 1415), Dr Emilie Ducourau (Department of Rheumatology, University Hospital of Tours), Dr Emilie Marteau (Department of Orthopedic Surgery, University Hospital of Tours) and Dr Christophe Le Dû (Department of Orthopedic Surgery, Clinique de l’Alliance, Tours) for advice. This work would not have been possible without the support of the Health Insurance Centre – Caisse Primaire d’Assurance Maladie (CPAM) of Indre-et-Loire district and the Research and Information Group on Osteoporosis (GRIO). References [1] Melton 3rd LJ, Chrischilles EA, Cooper C, et al. Perspective. How many women have osteoporosis? J Bone Miner Res 1992;7:1005–10. [2] Maravic M, Taupin P, Landais P, et al. Hospitalized forearm fractures in France: incidence and burden trend changes. Orthop Traumatol Surg Res 2010;96:662–6. [3] Fiorano-Charlier C, Ostertag A, Aquino JP, et al. Reduced bone mineral density in postmenopausal women self-reporting premenopausal forearm fractures. Bone 2002;31:102–6. [4] Peel NF, Barrington NA, Smith TW, et al. Distal forearm fracture as risk factor for vertebral osteoporosis. BMJ 1994;308:1543–4. [5] Mallmin H, Ljunghall S. Distal radius fracture is an early sign of general osteoporosis: bone mass measurements in a population-based study. Osteoporos Int 1994;4:357–61. [6] Earnshaw SA, Cawte SA, Worley A, et al. Colles’ fracture of the forearm as an indicator of underlying osteoporosis in postmenopausal women: a prospective study of bone mineral density and bone turnover rate. Osteoporos Int 1998;8:53–60. [7] Haute Autorité de santé. http://www.has-sante.fr [8] Briot K, Cortet B, Thomas T, et al. 2012 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis. Joint Bone Spine 2012;79:304–13. [9] Cuddihy MT, Gabriel SE, Crowson CS, et al. Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 1999;9:469–75. [10] Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with lowtrauma osteoporotic fracture and subsequent fracture in men and women. JAMA 2009;301:513–21. [11] Leboime A, Confavreux CB, Mehsen N, et al. Osteoporosis and mortality. Joint Bone Spine 2010;77:S107–12. [12] Maravic M, Le Bihan C, Landais P, et al. Incidence and cost of osteoporotic fractures in France during 2001. A methodological approach by the national hospital database. Osteoporos Int 2005;16:1475–80. [13] Levasseur R, Sabatier JP, Guilcher C, et al. Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture. Joint Bone Spine 2007;74:160–5. [14] Malochet-Guinamand S, Chalard N, Billault C, et al. Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of information to general practitioners. Joint Bone Spine 2005;72:562–6.
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