Missed Opportunities in Treating Osteoporosis
June 15, 2002
Missed Opportunities in Treating Osteoporosis
Abstract & Commentary
Synopsis: Only 17% of postmenopausal women with distal forearm fractures due to minimal trauma who saw a nonorthopedist physician within 12 months of injury were offered pharmacologic treatment for osteoporosis, despite their high risk for future complications of this disease.
Source: Cuddihy MT, et al. Arch Intern Med. 2002;162:421-426.
Cuddihy and colleagues at the Mayo Clinic in Rochester, Minn, were able to identify all women within their county aged 45 years and older who sustained distal forearm fractures (most often Colles fractures) in the 5-year period from 1993-1997. Of these 409 women, 343 were identified as both postmenopausal and with the fracture resulting from minimal trauma, defined as a fall from standing height or less and without a speed greater than walking. Medical records for this entire group were then reviewed for up to 6 subsequent years, and data on follow-up analyzed for the first 12 months after the fracture.
The study cohort had a mean age of 70.5 years (range, 45-99), and 66% of the fractures occurred in women older than 65 years. Nearly all were Caucasians, reflecting the demographics of that community. Records were reviewed for evidence of offering estrogens, bisphosphonates, selective estrogen receptor modulators (SERMs), calcitonin, or nonpharmacologic recommendations of increased calcium, vitamin D, or weight-bearing exercise.
Within the first 12 months after fracture, 75% of women were seen by a physician other than their orthopedist, mostly by general internists or family physicians. Only 100 of the 343 women had any documentation of osteoporosis treatment advice (an additional 36 were receiving prior treatment such as estrogen but no notation was made of osteoporosis). Of this group, only 58 (17% of total cohort) were offered pharmacologic therapy, primarily estrogen. Six additional women were offered non-pharmacologic advice. There were no statistically significant differences in recommendations offered to women of different ages. Even the 100 women in the total cohort who had previous distal forearm fractures had no difference in the rate of treatment advice.
Only 5% of the study cohort had bone densitometry testing, and the majority of those results confirmed osteoporosis. Cuddihy et al conclude that physicians and patients did not appear to recognize that minimal trauma forearm fractures in postmenopausal women are most likely a manifestation of osteoporosis.
Comment by Mary Elina Ferris, MD
This interesting article had a rich data source unavailable to most researchers: complete medical records for all visits, both inpatient and outpatient, enabling them to truly track the medical care of women with fractures suggestive of osteoporosis. It confirms what has long been suspected: we are missing many opportunities to intervene and treat this relentless disease with so many painful and disabling consequences. Many studies have been published linking postmenopausal distal forearm fractures with low bone density,1 and epidemiological evidence shows they predispose to future fractures.2
Part of the explanation for the lack of treatment may be this study’s time period, 1993-1998, when effective drugs for osteoporosis were just becoming more accepted and available. The side effects of some of the available medications may have deterred prescribing, particularly in the older group, and we do not know if the mental status of some of the study group was so impaired that the balance of treatment risks outweighed the benefits. Nonetheless, Cuddihy et al did not find any correlation with lack of treatment and confounding comorbidities (including dementia), or with past medical history.
Another interesting finding was the lack of bone densitometry use (only 5% within 12 months of the fracture). The argument could be made that this test was unnecessary since the forearm fracture had already established the diagnosis of osteoporosis, but more likely it is another indication of lack of attention to the disease. Since this study, Medicare has increased payment coverage for both diagnostic and screening bone mineral density (BMD) testing, thus reducing cost barriers to more widespread osteoporosis testing.
National guidelines for osteoporosis treatment and prevention have been established since at least 1998, including the need to evaluate and treat low-impact fractures in postmenopausal women.3,4 This is a great area for "healthcare quality improvement:" with this abysmal baseline, educational interventions should be undertaken and remeasurement instituted. One can only hope that great improvements in osteoporosis treatment use would be found if this measurement was repeated today.
References
1. Seely DG, et al. Ann Intern Med. 1991;115:837-842.
2. Cuddihy MT, et al. Osteoporos Int. 1999;9:469-475.
3. European Congress on Osteoporosis. Osteoporos Int. 1998;8(Suppl 3):1-88.
4. Meunier P, et al. Clin Ther. 1999;21:1025-1044.
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