Aim 1: A Retrospective Review of Practice Patterns
Following approval by our institutional review board, the inpatient and outpatient records of 298 consecutive patients treated in our institution between 2002 and 2005 for a fragility fracture of the distal part of the radius were reviewed. During this time period, there was no standardized osteoporosis evaluation or treatment program for patients seen with a fracture at our institution. On the basis of recommended guidelines, patients who were over the age of fifty years, had had a low-energy mechanism of injury, and had been treated with closed or open means were included in this review19,20. Patients younger than the age of fifty and those in whom the injury had been the result of high-energy trauma were excluded, as were patients with concomitant orthopaedic injuries. Patients who had been followed for less than six months following the injury were also excluded.
Medical records before and after the distal radial fracture were examined for the presence of one of two outcomes: (1) evaluation with a bone mineral density test within six months after the injury and (2) treatment with osteoporosis-targeting medication within six months after injury. Calcium and vitamin D, antiresorptive medications, and anabolic medications were all considered to be treatment for the purposes of this analysis. Detailed information on the type of medication as well as the specialty of the prescribing physician was also collected. Our institution has fully electronic medical records, allowing easy retrieval of complete information. In addition, a random sample of seventy patients (generated by a computer randomized list) was subsequently contacted by telephone to validate and confirm the results of the medical record review.
Aim 2: Prospective Intervention to Improve Osteoporosis Evaluation and Treatment Rates
The second aim of this study was to compare two simple interventions designed to improve rates of evaluation and treatment for osteoporosis following fractures of the distal part of the radius. For this purpose, a prospective randomized trial was launched in the orthopaedic outpatient clinic following approval by our institutional review board.
Fifty consecutive patients with a fragility fracture of the distal part of the radius who met the inclusion and exclusion criteria listed below were identified in the outpatient setting. Fragility fractures were defined as those resulting from a fall from a standing height or less. The patients' primary care physician of record was confirmed at the time of the visit.
The inclusion criteria included an age of over fifty years (for women) or over sixty-five years (for men), a fragility fracture of the distal part of the radius, no evaluation with a bone mineral density examination within two years before the fracture, and no current treatment with antiresorptive medication or hormone replacement therapy. The exclusion criteria included a fracture related to high-energy trauma, a bone mineral density measurement performed within two years before the fracture, and current treatment with antiresorptive medication or hormone replacement therapy (but not treatment with calcium and vitamin D).
Patients were randomized to one of two interventions. In Intervention 1, the treating orthopaedic surgeon ordered a bone mineral density test during the patient's initial office visit for fracture care. The results were reviewed and forwarded (by mail and e-mail) to the primary care physician of record. In Intervention 2, the treating orthopaedic surgeon sent a brief letter (by mail and e-mail) to the patient's primary care physician outlining national guidelines for evaluating and treating osteoporosis after fragility fractures (Fig. 1). These guidelines included ordering a bone mineral density examination within six months after the injury. Final treatment decisions were made by the primary care physician.
Patients were contacted by telephone six months after the injury, and a short questionnaire was administered. The questionnaire assessed three primary outcomes: (1) whether the patient had had a bone mineral density test, (2) whether treatment for osteoporosis was discussed with the primary care physician, and (3) whether treatment for osteoporosis was initiated. The patients' medical records were also reviewed to confirm the dates and types of evaluation and treatment.
A power analysis indicated that approximately fifty patients would be necessary to achieve 80% power for detecting a 10% difference in evaluation and treatment rates between the two interventions. Statistical analyses were performed with use of chi-square and Fisher exact tests for nonparametric data and the Student t test for parametric data, with a level of significance of 0.05.
Aim 1: A Retrospective Review of Practice Patterns
Of 298 consecutive patients, 240 met the follow-up criteria and had complete electronic medical records for review. There were 181 women and fifty-nine men with a mean age of 68.4 years (range, fifty to 102 years). The average duration of follow-up was 23.4 months (range, six to 57.7 months). All patients had sustained the fracture in a fall from a standing height. Fracture treatment methods consisted of closed management for 56.3% of the patients, percutaneous pin and/or external fixation for 6.9%, and open reduction and internal fixation for 36.7%. The method of fracture stabilization was determined by the treating surgeon on an individual basis.
Data Prior to Distal Radial Fracture
Our retrospective record review revealed that, prior to the distal radial fracture, 30.0% of the 240 patients had undergone a bone mineral density test whereas 70.0% had not. Of the patients who had had a bone mineral density test prior to the injury, 19% had normal bone density, 50% had a diagnosis of osteopenia, and 31% had osteoporosis (Fig. 2). Prior to the distal radial fracture, 78.3% of the 240 patients had never been treated for osteoporosis, 4.2% had been treated with calcium and vitamin D, 6.7%, had been treated with bisphosphonates, 3.8% had been treated with hormone replacement therapy, and 7.1% had been treated with a combined regimen (Fig. 3). Prior to the fracture, 41% of the patients with an abnormal result of the bone mineral density test were being treated with medication for osteoporosis. Thirty-nine percent of the patients with a prior bone mineral density test and 14% of the patients without a prior bone mineral density test were being treated with medication for osteoporosis (p < 0.001). Prior to the fracture, 37.6% of the women and 6.8% of the men had had a bone mineral density test and 27.6% of the women and 3.4% of the men were being treated for osteoporosis.
Data After Distal Radial Fracture
Only 8.3% of the patients underwent a bone mineral density test within six months following the distal radial fracture. A total of 21.3% had a bone mineral density test at some point (range, zero to thirty-nine months) following the fracture, and 78.7% were not screened for osteoporosis with a bone mineral density test. Of the patients who underwent bone mineral density testing after the fracture, 57% had a diagnosis of osteopenia, 33.3% had osteoporosis, and 10% had normal bone density (Fig. 4). In total, 90% of the patients who underwent evaluation with a bone mineral density test following the distal radial fracture had abnormal bone density.
After the injury, 72.5% of the patients received no medication, 6.7% began taking calcium and vitamin D, 11.3% were treated with bisphosphonates, 2.5% were treated with hormone replacement therapy, and 7.1% were treated with a combination regimen (Fig. 5). The patients who had undergone bone mineral density testing had significantly higher treatment rates compared with those who had not (53% compared with 21%, p < 0.001). Before the fracture, 21.7% of the patients were taking medication for underlying osteoporosis. After the fracture, an additional twenty-five patients (10.4%) were started on medication. After the fracture, 26.5% of the women and 5.1% of the men had a bone mineral density test and 34.3% of the women and 6.8% of the men were treated for osteoporosis.
Aim 2: Prospective Intervention to Improve Osteoporosis Evaluation and Treatment Rates
Between January 2006 and January 2007, fifty patients who met the inclusion and exclusion criteria were prospectively enrolled in this study. The average age at the time of the fracture was sixty-five years (range, fifty to eighty-six years), and all patients had sustained the fracture in a fall from a standing height. Thirty-two patients were treated with closed means, and eighteen underwent operative treatment of the injury.
Twenty-seven patients were randomized to Intervention 1 (the orthopaedic surgeon ordering the bone mineral density examination), and twenty-three patients were randomized to Intervention 2 (the orthopaedic surgeon sending a letter with screening and treatment guidelines to the primary care physician). All fifty patients were followed for six months.
Intervention 1 was used for twenty-six women and one man with an average age of sixty-three years (range, fifty to eighty-six years). Intervention 2 was used for three men and twenty women with an average age of sixty-seven years (range, fifty-one to eighty-six years). Of the patients randomized to Intervention 1, eighteen had been treated with closed means and nine had undergone operative fixation of the fracture. Of those randomized to Intervention 2, fourteen had been treated with closed means and nine had undergone operative fixation. With the numbers studied, no difference was detected between the intervention groups with regard to age (p = 0.2) or the type of fracture treatment (p = 0.33).
The rate of bone mineral density testing following the distal radial fracture was significantly higher for patients randomized to Intervention 1 than it was for those randomized to Intervention 2 (93% compared with 30%, p < 0.001). These testing rates, in both groups, were higher than the bone mineral density testing rates in our practice prior to the initiation of the intervention programs (8.3% at six months after the fracture). Of the thirty-two patients in total (randomized to either intervention) who underwent bone mineral density testing, 84% had an abnormal bone density. Osteopenia was the most common diagnosis (sixteen patients; 50%). Eleven patients (34%) had osteoporosis, and five (16%) had a normal bone density.
The proportion of patients who discussed osteoporosis treatment with their primary care physician was significantly higher in the group for which Intervention 1 had been carried out than it was in the group that had received Intervention 2 (twenty-four [89%] of twenty-seven compared with eight [35%] of twenty-three, p < 0.001). Twenty-four of the twenty-five patients who had been randomized to Intervention 1 and had had a bone mineral density test discussed treatment for the prevention of osteoporosis with their primary care physician. In the group for which Intervention 2 had been carried out, six of the seven patients with a bone mineral density examination and two additional patients who had not had a bone mineral density examination discussed treatment with their primary care physician. Patients who had undergone bone mineral density testing were significantly more likely to discuss treatment for osteoporosis with their primary care physician than were those who had not undergone bone mineral density testing (thirty [94%] of thirty-two compared with two [11%] of eighteen, p < 0.001).
Treatment for osteoporosis was initiated much more frequently for patients randomized to Intervention 1 than it was for those randomized to Intervention 2 (74% compared with 26%, p < 0.001). In the Intervention-1 group, the treatment rate was 80% for those who had undergone a bone mineral density examination and 95% for those who had been diagnosed as having either osteopenia (twelve patients) or osteoporosis (nine patients). Of the twenty patients in the Intervention-1 group who received medication for osteoporosis, twelve were treated with calcium and vitamin D; four, with bisphosphonates; three, with a combination of calcium and vitamin D and bisphosphonates; and one, with teriparatide. Eight of the nine osteoporotic patients were treated: five with a bisphosphonate, one with teriparatide, and two with calcium and vitamin D. One patient with osteoporosis declined further treatment.
In the Intervention-2 group, the overall treatment rate was 26%, with the rate increasing to 67% for patients who had undergone bone mineral density testing and were diagnosed as having osteopenia or osteoporosis. Of the patients with an abnormal result on the bone mineral density test (four with osteopenia and two with osteoporosis), two were not treated, two osteopenic patients and one osteoporotic patient were treated with calcium and vitamin D with a bisphosphonate, and one osteoporotic patient was treated with calcitonin. In addition, one patient was taking calcium and vitamin D on her own volition without obtaining a bone mineral density test and one patient was started on a bisphosphonate without a bone mineral density test.
In the series as a whole (both interventions), all but one patient who was treated had had a prior bone mineral density test. After the bone mineral density tests were performed, the treatment rates for the patients with an abnormal result were not significantly different between the two intervention groups (p = 0.22, Fisher exact test).
Our findings are summarized in Table I.
Our review of practice patterns in a tertiary care center revealed that the rates of evaluation and treatment for osteoporosis six months after a fragility fracture are alarmingly low (8.3% and 27.5%, respectively). These results are comparable with those in previously published studies demonstrating that few postmenopausal women are effectively screened and treated for osteoporosis following fragility fractures15-17. The 2004 State of Health Care Quality study determined that only 11.6% of women over sixty-five years of age who had a symptomatic fragility fracture were treated for osteoporosis in the year following the fracture21. As such, current physician practices remain ineffective with regard to the evaluation and treatment of patients for osteoporosis following a fragility fracture.
In addition, we confirmed that patients who undergo a screening bone mineral density examination are more likely to be subsequently treated for osteoporosis. While 21% of patients without a bone mineral density test were treated, 53% with a bone mineral density test were started on preventive medication (p < 0.001). With a rate of 57%, osteopenia was the most common diagnosis after a distal radial fracture; this presents treating orthopaedic surgeons with a unique opportunity to initiate preventive strategies and avoid future fragility fractures.
Our observation that approximately 10% to 20% of individuals who sustained a wrist fracture and underwent bone mineral density testing did not have abnormal bone mineral density was expected, since previous studies have shown that up to 50% of individuals with a fragility fracture have bone mineral density values that are higher than the World Health Organization's operational definition of osteoporosis22-24. This observation has highlighted the need for new noninvasive assessment of bone strength that may improve the sensitivity and specificity of fracture-risk prediction25,26.
To date, several methods to improve the evaluation and treatment of osteoporosis in the outpatient population have been tested, with varying results. Mailing of educational material to adults over the age of sixty-five years who were participating in a state pharmacy benefit program did not result in improvements in knowledge, perception of susceptibility, or institution of measures to prevent osteoporosis27. Majumdar et al. identified women over the age of fifty years presenting to the emergency department with a wrist fracture and faxed treatment guidelines for osteoporosis to the patients' primary care physicians28. At six months, 40% of the patients were being treated for osteoporosis compared with 10% of a control group. Similarly, after sending electronic reminders detailing fracture risk and listing osteoporosis treatment guidelines to primary care physicians whose patients had sustained a fragility fracture, Feldstein et al. reported that 51.5% of the patients had undergone bone mineral density testing or had started osteoporosis treatment six months after the fracture29.
Orthopaedic surgeons have also taken the lead in initiating comprehensive fracture-treatment pathways. Chevalley et al. designed a clinical pathway for the management of fragility fractures that included evaluation by a nurse practitioner, performance of a bone mineral density test, and coordination with primary care physicians30. Among patients enrolled in this program, 63% underwent evaluation with a bone mineral density test and 67% were treated with antiresorptive medication. The Fracture Liaison Service established in Glasgow, Scotland, referred patients who had sustained a fracture to an osteoporosis specialist nurse and reported that three-quarters of the patients were candidates for bone mineral density testing and 82.3% of those tested had either osteopenia or osteoporosis at the hip or spine31,32. Similarly, Bogoch et al. designated a fragility fracture program coordinator to screen patients, refer them for bone mineral density testing, and coordinate care with primary care physicians and metabolic bone disease specialists33. In this setting, 96.8% of the patients received adequate care. Although highly effective, a comprehensive fracture-care model involving full-time providers and multiple specialties demands substantial resources and is a costly proposition for most orthopaedic practices.
Our results indicate that a simple intervention in the orthopaedic clinic can dramatically improve osteoporosis evaluation and treatment rates. We found that, of the two tested interventions, the one requiring the orthopaedic surgeon to order a bone mineral density examination at the time of the initial fracture-care visit led to an evaluation rate (93%) that was three times higher than the rate found when this step had been left to the primary care physicians (30%). In addition, when the bone mineral density test was ordered in the orthopaedic clinic, 89% of patients discussed osteoporosis treatment with their primary care physician compared with only 35% when a letter had been sent to the primary care physician.
It is interesting to note that most patients with a fragility fracture of the distal part of the radius and underlying osteopenia are currently being treated by their primary care physician with calcium and vitamin-D supplements. It is unclear whether calcium and vitamin D alone are sufficient to arrest bone loss that may be occurring in individuals after menopause or to provide adequate fracture risk reduction among those who have already sustained a fracture6. In our study, surprisingly few patients were started on bisphosphonates, despite the ability of these drugs to reduce fracture risk beyond the effect of calcium and vitamin D34,35. To date, we are not aware of any trials designed specifically to examine risks and benefits of bisphosphonate therapy for younger, osteopenic patients with fragility fractures. Trials focusing on younger women (and men) may be necessary before patients with fragility fractures are targeted for pharmacologic treatment.
Our suggested intervention has several limitations. Given that the prevalence of fragility fractures of the distal part of the radius at the age of fifty years is lower in men than in women36, we chose a higher age cutoff for inclusion of men in the study population. Also, all of the patients in our study had a primary care physician of record. Thus, our results are difficult to generalize to populations for whom primary care is not available. An additional concern is that not all patients visited their primary care physician to discuss evaluation and treatment within the six-month follow-up period. However, although several patients were not seen during this time frame, we do not think that that affected our results: a letter sent to the primary care physician was less likely to lead to a bone mineral density examination or a discussion about treatment than was ordering a bone mineral density test at the time of the orthopaedic visit.
Additional concerns for orthopaedic surgeons surround the legal responsibility that comes with ordering a bone mineral density test and prescribing treatment37,38. If the test shows osteoporosis and the primary care physician chooses not to act on it and the patient sustains a second fracture, will the orthopaedic surgeon be held liable? Alternatively, as pay-for-performance measures are introduced into practice, orthopaedic surgeons may be held liable for failure to treat underlying osteoporosis if a patient sustains a second fracture. In addition, primary care physicians are sometimes uneasy when confronted with results of a test that they did not order39,40. While these are real issues, we found that many of these concerns can be alleviated by educating the patient at the time of the initial visit and effectively communicating our intentions to the treating primary care physician. In primary settings as well as tertiary care centers, a referral to an endocrinologist for evaluation and treatment can also be considered. Such a referral becomes particularly important in cases in which a suspected metabolic abnormality has led to secondary osteoporosis. Finally, some orthopaedic surgeons may choose to treat the underlying osteoporosis themselves. This is certainly an option for those familiar with the various medications and their common side effects.
In conclusion, with a growing elderly population, fragility fractures have rapidly become a leading cause of patient morbidity and mortality. As treating physicians, orthopaedic surgeons have a responsibility to treat fragility fractures as well as to provide a plan for treatment of the underlying osteoporosis and associated comorbidities. Current rates of evaluation and treatment for osteoporosis following fragility fractures remain unacceptably low. A simple, low-cost intervention initiated in the orthopaedic outpatient setting—an orthopaedic surgeon ordering a bone mineral density examination—can dramatically improve rates of both evaluation and treatment for underlying osteoporosis in patients with fragility fractures, thereby reducing the risk of future fracture. 