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Osteoporotic fractures: ignorance is bliss?
Osteoporotic Fractures: Ignorance is Bliss? Douglas C. Bauer, MD
O
steoporosis is a systemic, progressive disease, characterized by low bone mass and microarchitectural deterioration (1). From the perspective of a patient, however, the most important consequences of osteoporosis are devastating fractures that affect daily life. For example, about half of patients who survive a hip fracture must be admitted to nursing homes. Primary care providers can recognize and treat this common condition before the occurrence of fracture. Unfortunately, there is ample evidence that clinicians have not heard or heeded the message that osteoporosis is treatable, and that selected patients, particularly those who have already suffered a fracture, should be counseled to receive preventive therapy. Epidemiologic studies have demonstrated that a history of hip, vertebral, or wrist fracture places a patient at very high risk of future fractures. For example, Black et al (2) found that the presence of a vertebral deformity on a spinal radiograph increased the risk of future spine fractures nearly threefold, and Mallmin et al (3) found that wrist fractures substantially increased the risk of subsequent hip fractures. The largest prospective study, the Study of Osteoporotic Fractures, found that any fracture after the age of 50 years increased the risk of hip fracture in women by 50% (4). These effects persisted even after accounting for bone mineral density, suggesting that other mechanisms, such as poor bone quality, may matter. Thus, the occurrence of a fracture in postmenopausal women should routinely prompt primary care providers to consider osteoporosis and the prevention of future events. Despite strong evidence that a fracture increases the risk of future fractures, several studies of the management of osteoporotic patients have found that clinicians do not consistently initiate treatment for skeletal fragility, even after one or more fractures has occurred. One year after the occurrence of a symptomatic fracture, for example, although 39% of women with a vertebral fracture were taking effective therapy, the rates of treatment among women with hip or wrist fracture were about 5%, and did not differ from a control group without fracture (5). To make matters worse, when an osteoporotic fracture occurs, patients are rarely counseled about their increased risk of future fractures (6). Two papers in this month’s Green Journal further demonstrate that the occurrence of fractures are under-
Am J Med. 2000;109:338 –339. From the Prevention Sciences Group, University of California San Francisco, San Francisco, California. Requests for reprints should be addressed to Douglas C. Bauer, MD, Prevention Sciences Group, USCF Box 0886, 74 New Montgomery Street, Suite 600, San Francisco, California 94105. 338
䉷2000 by Excerpta Medica, Inc. All rights reserved.
appreciated sentinel events in both men and women. Colon-Emeric et al (7) report in men what is well known in women: after a hip fracture, the risk of a second hip fracture is remarkably high. The authors found that men with hip fracture admitted to the Durham VA Medical Center between 1994 and 1998 were very likely to suffer a second fracture during follow-up (9.5% per year). Compared with a control group of men admitted for knee replacement, the risk of recurrent fracture was more than sixfold greater among men admitted with fracture. This comparison, however, may not be completely valid as most knee replacements are for osteoarthritis, a condition that is associated with a reduced risk of osteoporosis (8). The authors found remarkably similar results in a prospective analysis of men with hip fracture admitted to eight community hospitals. More than half of the subsequent fractures occurred within the first year of follow-up, suggesting that effective interventions should be started as soon as possible. Another study in this issue by Kamel et al (9) is interesting because it confirms that surgical and medical specialists who treat the consequences of osteoporosis (fracture) often ignore the underlying condition (10). Kamel quantified the likelihood of starting effective pharmacologic therapy among 170 women admitted to a community hospital with a hip fracture from 1996 to 1998. Only a small number of women (5%) left the hospital with a new medication prescribed to prevent another fracture. Medical consultation during the hospitalization did not increase the likelihood that a hip fracture patient left the hospital on effective therapy. Because there was no follow-up in this relatively small study, we do not know whether primary care providers began effective outpatient treatment, but based on other data (11), this seems unlikely. The results of these and other studies argue for a better approach to recognizing, evaluating, and treating middle-aged and older women and men who have suffered a fracture. Just as information technology has improved our ability to provide routine preventive services with scheduled reminders and tracking systems (12), a similar approach could be used to improve outcomes for osteoporotic patients. Systems could be developed, for example, that identify abnormal skeletal radiology reports and trigger a reminder to primary care providers that their patient may need further evaluation and treatment. The research community must better educate patients and doctors about the high risk conferred by a fracture and the availability of safe and effective treatments. Lastly, assessment of fracture risk should become part of the 0002-9343/00/$–see front matter PII S0002-9343(00)00541-6
Osteoporotic Fractures/Bauer
routine array of preventive services offered to postmenopausal women. Evidence-based guidelines, although not perfect, can help the busy clinician who needs a set of simple algorithms and thresholds to identify and treat patients at high risk of fracture. Several organizations have created such documents (13,14), but none have been as extensively researched or meticulously crafted as those produced by the National Osteoporosis Foundation (NOF) (15). These guidelines stress that in addition to counseling about lifestyle factors, such as exercise, smoking, and calcium intake, it is worthwhile to offer measurement of hip bone mineral density to Caucasian women more than 65 years old if they are not already taking medications for osteoporosis. Furthermore, the NOF analyses conclude that measurement of hip bone mineral density should be offered to postmenopausal women less than age 65 years who have specific risk factors, including a previous fracture, family history (a parent with hip, wrist, or spine fracture after age 50 years), current cigarette smoking, or low body weight (⬍58 kg). The NOF report also provides guidance about treatment thresholds, suggesting that it is worthwhile to treat postmenopausal women without other risk factors when hip bone mineral density is low (more than 2 to 2.5 SD below peak bone mineral density [t score less than ⫺2.0 to ⫺2.5]). Women with risk factors should be offered treatment at a higher threshold (t score less than ⫺1.5 to ⫺2.0), while those with vertebral fractures are at such high risk of subsequent fractures that treatment may be offered without measurement of bone mineral density. Efficacious and well-tolerated pharmacologic (16) and nonpharmacologic treatments (17) are widely available, and clinicians should chose therapies based on demonstrated fracture efficacy in controlled trails and patient preferences. What should be done now? Additional research on new and innovative methods to quantify fracture risk are needed, as are novel methods to increase provider awareness and competence. Additional studies of certain populations, such as men and ethnic minorities, are necessary, as most studies have been among white women. But most importantly, clinicians should think about fracture prevention as part of routine health care, ask all patients about previous fractures, and pay attention to new fractures when they occur. Although much has been learned about osteoporosis in the last 20 years, too many patients
still needlessly suffer the consequences of unrecognized and untreated skeletal fragility.
REFERENCES 1. Consensus development conference. diagnosis, prophylaxis and treatment of osteoporosis. Am J Med. 1993;94:646 – 650. 2. Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1999;14:821– 828. 3. Mallmin H, Ljunghall S, Persson I, et al. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif Tissue Int. 1993;52: 269 –272. 4. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332:767–773. 5. Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis. 1998;57:378 –379. 6. Pal B. Questionnaire survey of advice given to patients with fractures. BMJ. 1999;318:500 –501. 7. Colon-Emeric CS, Sloane R, Hawkes WG, et al. The risk of subsequent fractures in community-dwelling men and male veterans with hip fracture. Am J Med. 2000;109:326 –328. 8. Zhang Y, Hannan MT, Chaisson CE, et al. Bone mineral density and risk of incident and progressive radiographic knee osteoarthritis in women: the Framingham Study. J Rheumatol. 2000;27:1032– 1037. 9. Kamel HK, Hussain MS, Tariq S, et al. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326 –328. 10. Tosi LL, Lane JM. Osteoporosis prevention and the orthopaedic surgeon: when fracture care is not enough. J Bone Joint Surg Am. 1998;80:1567–1569. 11. Cuddihy MT, Gabriel SE, Crowson CS, Melton LJ. Osteoporosis management after low impact distal forearm fracture in postmenopausal women. Osteoporos Int. 2000;11(suppl 2):S91. Abstract. 12. Balas EA, Weingarten S, Garb CT, et al. Improving preventive care by prompting physicians. Arch Intern Med. 2000;160:301–308. 13. Scientific Advisory Board. Clinical practice guidelines for the diagnosis, and management of osteoporosis. Osteoporosis Society of Canada. Can Med Assoc J. 1996;155:1113–1133. 14. Meunier PJ, Delmas PD, Eastell R, et al. Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther. 1999;21:1025–1044. 15. Osteoporosis. Review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Executive summary. Osteoporos Int. 1998;8(suppl 4):S3– 6. 16. Reid IR. Pharmacological management of osteoporosis in postmenopausal women: a comparative review. Drugs Aging. 1999;15: 349 –363. 17. Ekman A, Mallmin H, Michaelsson K, Ljunghall S. External hip protectors to prevent osteoporotic hip fractures. Lancet. 1997;350: 563–564.
September 2000
THE AMERICAN JOURNAL OF MEDICINE威
Volume 109 339
O
steoporosis is a systemic, progressive disease, characterized by low bone mass and microarchitectural deterioration (1). From the perspective of a patient, however, the most important consequences of osteoporosis are devastating fractures that affect daily life. For example, about half of patients who survive a hip fracture must be admitted to nursing homes. Primary care providers can recognize and treat this common condition before the occurrence of fracture. Unfortunately, there is ample evidence that clinicians have not heard or heeded the message that osteoporosis is treatable, and that selected patients, particularly those who have already suffered a fracture, should be counseled to receive preventive therapy. Epidemiologic studies have demonstrated that a history of hip, vertebral, or wrist fracture places a patient at very high risk of future fractures. For example, Black et al (2) found that the presence of a vertebral deformity on a spinal radiograph increased the risk of future spine fractures nearly threefold, and Mallmin et al (3) found that wrist fractures substantially increased the risk of subsequent hip fractures. The largest prospective study, the Study of Osteoporotic Fractures, found that any fracture after the age of 50 years increased the risk of hip fracture in women by 50% (4). These effects persisted even after accounting for bone mineral density, suggesting that other mechanisms, such as poor bone quality, may matter. Thus, the occurrence of a fracture in postmenopausal women should routinely prompt primary care providers to consider osteoporosis and the prevention of future events. Despite strong evidence that a fracture increases the risk of future fractures, several studies of the management of osteoporotic patients have found that clinicians do not consistently initiate treatment for skeletal fragility, even after one or more fractures has occurred. One year after the occurrence of a symptomatic fracture, for example, although 39% of women with a vertebral fracture were taking effective therapy, the rates of treatment among women with hip or wrist fracture were about 5%, and did not differ from a control group without fracture (5). To make matters worse, when an osteoporotic fracture occurs, patients are rarely counseled about their increased risk of future fractures (6). Two papers in this month’s Green Journal further demonstrate that the occurrence of fractures are under-
Am J Med. 2000;109:338 –339. From the Prevention Sciences Group, University of California San Francisco, San Francisco, California. Requests for reprints should be addressed to Douglas C. Bauer, MD, Prevention Sciences Group, USCF Box 0886, 74 New Montgomery Street, Suite 600, San Francisco, California 94105. 338
䉷2000 by Excerpta Medica, Inc. All rights reserved.
appreciated sentinel events in both men and women. Colon-Emeric et al (7) report in men what is well known in women: after a hip fracture, the risk of a second hip fracture is remarkably high. The authors found that men with hip fracture admitted to the Durham VA Medical Center between 1994 and 1998 were very likely to suffer a second fracture during follow-up (9.5% per year). Compared with a control group of men admitted for knee replacement, the risk of recurrent fracture was more than sixfold greater among men admitted with fracture. This comparison, however, may not be completely valid as most knee replacements are for osteoarthritis, a condition that is associated with a reduced risk of osteoporosis (8). The authors found remarkably similar results in a prospective analysis of men with hip fracture admitted to eight community hospitals. More than half of the subsequent fractures occurred within the first year of follow-up, suggesting that effective interventions should be started as soon as possible. Another study in this issue by Kamel et al (9) is interesting because it confirms that surgical and medical specialists who treat the consequences of osteoporosis (fracture) often ignore the underlying condition (10). Kamel quantified the likelihood of starting effective pharmacologic therapy among 170 women admitted to a community hospital with a hip fracture from 1996 to 1998. Only a small number of women (5%) left the hospital with a new medication prescribed to prevent another fracture. Medical consultation during the hospitalization did not increase the likelihood that a hip fracture patient left the hospital on effective therapy. Because there was no follow-up in this relatively small study, we do not know whether primary care providers began effective outpatient treatment, but based on other data (11), this seems unlikely. The results of these and other studies argue for a better approach to recognizing, evaluating, and treating middle-aged and older women and men who have suffered a fracture. Just as information technology has improved our ability to provide routine preventive services with scheduled reminders and tracking systems (12), a similar approach could be used to improve outcomes for osteoporotic patients. Systems could be developed, for example, that identify abnormal skeletal radiology reports and trigger a reminder to primary care providers that their patient may need further evaluation and treatment. The research community must better educate patients and doctors about the high risk conferred by a fracture and the availability of safe and effective treatments. Lastly, assessment of fracture risk should become part of the 0002-9343/00/$–see front matter PII S0002-9343(00)00541-6
Osteoporotic Fractures/Bauer
routine array of preventive services offered to postmenopausal women. Evidence-based guidelines, although not perfect, can help the busy clinician who needs a set of simple algorithms and thresholds to identify and treat patients at high risk of fracture. Several organizations have created such documents (13,14), but none have been as extensively researched or meticulously crafted as those produced by the National Osteoporosis Foundation (NOF) (15). These guidelines stress that in addition to counseling about lifestyle factors, such as exercise, smoking, and calcium intake, it is worthwhile to offer measurement of hip bone mineral density to Caucasian women more than 65 years old if they are not already taking medications for osteoporosis. Furthermore, the NOF analyses conclude that measurement of hip bone mineral density should be offered to postmenopausal women less than age 65 years who have specific risk factors, including a previous fracture, family history (a parent with hip, wrist, or spine fracture after age 50 years), current cigarette smoking, or low body weight (⬍58 kg). The NOF report also provides guidance about treatment thresholds, suggesting that it is worthwhile to treat postmenopausal women without other risk factors when hip bone mineral density is low (more than 2 to 2.5 SD below peak bone mineral density [t score less than ⫺2.0 to ⫺2.5]). Women with risk factors should be offered treatment at a higher threshold (t score less than ⫺1.5 to ⫺2.0), while those with vertebral fractures are at such high risk of subsequent fractures that treatment may be offered without measurement of bone mineral density. Efficacious and well-tolerated pharmacologic (16) and nonpharmacologic treatments (17) are widely available, and clinicians should chose therapies based on demonstrated fracture efficacy in controlled trails and patient preferences. What should be done now? Additional research on new and innovative methods to quantify fracture risk are needed, as are novel methods to increase provider awareness and competence. Additional studies of certain populations, such as men and ethnic minorities, are necessary, as most studies have been among white women. But most importantly, clinicians should think about fracture prevention as part of routine health care, ask all patients about previous fractures, and pay attention to new fractures when they occur. Although much has been learned about osteoporosis in the last 20 years, too many patients
still needlessly suffer the consequences of unrecognized and untreated skeletal fragility.
REFERENCES 1. Consensus development conference. diagnosis, prophylaxis and treatment of osteoporosis. Am J Med. 1993;94:646 – 650. 2. Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1999;14:821– 828. 3. Mallmin H, Ljunghall S, Persson I, et al. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif Tissue Int. 1993;52: 269 –272. 4. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332:767–773. 5. Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis. 1998;57:378 –379. 6. Pal B. Questionnaire survey of advice given to patients with fractures. BMJ. 1999;318:500 –501. 7. Colon-Emeric CS, Sloane R, Hawkes WG, et al. The risk of subsequent fractures in community-dwelling men and male veterans with hip fracture. Am J Med. 2000;109:326 –328. 8. Zhang Y, Hannan MT, Chaisson CE, et al. Bone mineral density and risk of incident and progressive radiographic knee osteoarthritis in women: the Framingham Study. J Rheumatol. 2000;27:1032– 1037. 9. Kamel HK, Hussain MS, Tariq S, et al. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326 –328. 10. Tosi LL, Lane JM. Osteoporosis prevention and the orthopaedic surgeon: when fracture care is not enough. J Bone Joint Surg Am. 1998;80:1567–1569. 11. Cuddihy MT, Gabriel SE, Crowson CS, Melton LJ. Osteoporosis management after low impact distal forearm fracture in postmenopausal women. Osteoporos Int. 2000;11(suppl 2):S91. Abstract. 12. Balas EA, Weingarten S, Garb CT, et al. Improving preventive care by prompting physicians. Arch Intern Med. 2000;160:301–308. 13. Scientific Advisory Board. Clinical practice guidelines for the diagnosis, and management of osteoporosis. Osteoporosis Society of Canada. Can Med Assoc J. 1996;155:1113–1133. 14. Meunier PJ, Delmas PD, Eastell R, et al. Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther. 1999;21:1025–1044. 15. Osteoporosis. Review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Executive summary. Osteoporos Int. 1998;8(suppl 4):S3– 6. 16. Reid IR. Pharmacological management of osteoporosis in postmenopausal women: a comparative review. Drugs Aging. 1999;15: 349 –363. 17. Ekman A, Mallmin H, Michaelsson K, Ljunghall S. External hip protectors to prevent osteoporotic hip fractures. Lancet. 1997;350: 563–564.
September 2000
THE AMERICAN JOURNAL OF MEDICINE威
Volume 109 339