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Addressing Secondary Prevention of Osteoporosis in Fracture Care: Follow-up to “Own the Bone”
Beatrice J. Edwards, MD, MPH1; Kenneth Koval, MD2; Andrew D. Bunta, MD1; Kristy Genuario, OD2; Allison Hahr, MD1; Lidia Andruszyn, APN, DNP, CNP1; Mark Williams, MD1
1 Bone Health and Osteoporosis Center, Department of Medicine (B.J.E., A.D.B., A.H., and M.W.) and Department of Orthopaedic Surgery (B.J.E., A.D.B., and L.A.), Feinberg School of Medicine, Northwestern University, 645 North Michigan Avenue, Suite 630, Chicago, IL 60611. E-mail address for B.J. Edwards: Bje168@northwestern.edu
2 Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Aug 03;93(15):e87 1-7. doi: 10.2106/JBJS.I.00540
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The majority of the 1.8 million individuals who sustain a fracture annually in the United States have osteopenia or osteoporosis, yet <15% of these patients subsequently receive treatment for osteoporosis. A prospective cohort study was conducted to assess the effect of two different interventions on the rate of osteoporosis treatment in patients with a fragility fracture. Patients who were fifty years of age or older and were hospitalized for the treatment of a fragility fracture at either of two academic institutions were eligible for inclusion in the study. The intervention at one hospital involved immediate care for osteoporosis, including initiation of pharmacologic therapy during hospitalization. The intervention at the other hospital involved delayed care, including recommendations for osteoporosis counseling, bone-mineral density testing, and potential treatment for osteoporosis that were communicated to the primary care physician after the patient was discharged from the hospital. Patients were surveyed by telephone six months after the fracture, and their medical and pharmacy records were reviewed to verify the osteoporosis treatment that they had received. The mean age was 73 ± 10 years in the immediate-care group and 74 ± 12 years in the delayed-care group. Eighty percent of the patients were women. Sixty-five percent of the patients in each group completed the telephone interview six months after the fracture, and most had seen their primary care physician and undergone bone-mineral density testing. The rate of bone-mineral density testing was 92% in the immediate-care group compared with 76% in the delayed-care group. Both immediate and delayed care for osteoporosis resulted in a significant increase in the treatment rate compared with the baseline rate of 0% (p < 0.001). However, the primary care physician had initiated osteoporosis therapy by six months after the fracture in only 30% of the patients in the delayed-care group compared with a treatment rate of 67% in the immediate-care group (p < 0.001). Limitations of the study include the possibility that the findings resulted from a difference between the two study centers rather than between the two strategies. In addition, because of the academic and integrated nature of the medical systems at which the study was conducted, the findings cannot necessarily be extrapolated to other types of institutions. In summary, a recommendation for osteoporosis treatment made by an orthopaedic surgeon to the patient's primary care physician resulted in an increase in the rate of bone-mineral density testing and in the rate of therapy compared with baseline. However, immediate initiation of osteoporosis care during hospitalization for the fragility fracture resulted in a higher rate of treatment—with two-thirds of the patients receiving therapy six months after the fracture—compared with delayed initiation.

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    Jan Vaculík, MD, Jan Štěpán MD
    Posted on January 29, 2012
    Secondary prevention of fractures is undervalued
    Orthopedic Department of the Bulovka Hospital, Charles University Faculty of Medicine 1, Prague, Czech Republic

    This study demonstrated the very positive effects of recommending and initiating secondary fracture prevention during hospitalization (1). Six months after fracture, only 30 per cent of patients were treated in the delayed care group as compared with 67 per cent in the immediate osteoporosis care group. Interestingly, calcium was applied in 86 and 90 percent of patients in both groups respectively. Such immediate osteoporosis care contrasts with the current situation (2, 3). Also in our country the majority of physicians agree on the importance of the secondary prevention of fractures. However, neither specialty is inclined to initiate the appropriate assessments themselves. Consequently, the majority of patients with a fragility fracture are discharged without being investigated for osteoporosis, whilst the majority of GPs would not trigger assessment even if prompted to do so by the surgeon. Our comment is based on our own experience arising from the evaluation of the impact of secondary fracture prevention. In our department, 325 consecutive patients with proximal femoral low-impact fracture were contacted by the Fracture Liaison Service and they received a qualified written recommendation during hospitalization or a letter after discharge. The information they received included the diagnosis of the osteoporotic fracture, assessment of the 10-year fracture probability using the FRAX tool (4), a recommendation that they take calcium supplementation and vitamin D bolus (60,000 IU Vitamin D3), and a recommendation that they receive antiresorptive therapy. An additional 65 patients, 16.7% of those with proximal femoral fracture, suffering from dementia, were not addressed. In our patient series, 67.3% of patients were contacted successfully between 3 and 6 months after fracture treatment. When considering all recommendations, secondary prevention modalities of some kind were reported during follow-up in an average of 27.9% of the patients. Our experience is in agreement with the systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis (5). Although it should be taken into consideration that results in our country are influenced by different economic and social circumstances than in some other countries, it is certain that secondary prevention of fractures is undervalued. Financial resources within the healthcare system mean that the administration of medicines for osteoporosis is limited, considering the frequency with which they are needed. We conclude that correct diagnosis, proper recommendation for osteoporosis evaluation provided by an orthopaedic surgeon after management of the fracture, and the patient´s awareness of the consequences of the fracture and determination to undergo treatment are very important but not sufficient. The final success of secondary prevention measures depends on outpatient follow up by their primary care physician after patients return to their home environment. Therefore, we highly appreciate the idea by Edwards et al. that an immediate osteoporosis evaluation and initiation of treatment during hospitalization for hip fracture should be a standard of secondary preventive care to reduce fragility fractures among the ageing population. REFERENCES: (1) Edwards BJ, Koval K, Bunta AD, Genuario K, Hahr A, Andruszyn L, et al. Addressing secondary prevention of osteoporosis in fracture care: follow-up to 'own the bone'. J Bone Joint Surg Am. 2011;93(15):e87. Epub 2011/09/15. (2) Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 2006;35(5):293-305. Epub 2006/04/18. (3) Harrington JT, Deal CL. Successes and failures in improving osteoporosis care after fragility fracture: results of a multiple-site clinical improvement project. Arthritis Rheum. 2006;55(5):724-8. Epub 2006/10/03. (4) WHO. Assessment of osteoporosis at the primary health care level. Report of a WHO Study Group. Kanis JA, editor. Sheffield: University of Sheffield Medical School, UK; 2007. 288 p. (5) Little EA, Eccles MP. A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis. Implementation science 2010;5:80. Epub 2010/10/26.

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