Osteoporosis International

, 20:1911

Factors influencing the treatment of osteoporosis following fragility fracture

Authors

    • Department of Medicine, CHUL Research CentreLaval University
  • S. Jean
    • Institut National de Santé Publique du Québec
  • K. S. Davison
    • Department of Medicine, CHUL Research CentreLaval University
  • S. Roy
    • Institut National de Santé Publique du Québec
  • L.-G. Ste-Marie
    • Department of Medicine, Centre de Recherche du CHUM, Hôpital Saint-LucUniversity of Montreal
  • J. P. Brown
    • Department of Medicine, CHUL Research CentreLaval University
Original Article

DOI: 10.1007/s00198-009-0898-x

Cite this article as:
Bessette, L., Jean, S., Davison, K.S. et al. Osteoporos Int (2009) 20: 1911. doi:10.1007/s00198-009-0898-x

Abstract

Summary

Treatment rates of osteoporosis after fracture are very low. Women who suffer a fragility fracture have a greater chance of receiving anti-fracture treatment if they had low bone mineral density (BMD), a fracture at the hip, femur or pelvis, administration of calcium and vitamin D supplements and/or an age ≥60 years.

Introduction

This investigation identifies the predictors of osteoporosis treatment 6 to 8 months following fragility fracture in women >50 years of age.

Methods

In this prospective cohort study, women were recruited 0 to 16 weeks following fracture and classified as having experienced fragility or traumatic fractures (phase 1). Six to 8 months following fracture, women completed a questionnaire on demographic features, clinical characteristics and risk factors for osteoporosis (phase 2). Osteoporosis treatment was defined as initiating anti-fracture therapy (bisphosphonate, raloxifene, nasal calcitonin and teriparatide) after fracture in those previously untreated.

Results

Of the 1,273 women completing phase 1, 1,001 (79%) sustained a fragility fracture, and of these women, 738 were untreated for osteoporosis at phase 1 and completed the phase 2 questionnaire. Significant predictors of treatment included BMD result, fracture site, administration of calcium and vitamin D supplements at the time of fracture and age ≥60 years. All other risk factors for osteoporosis, such as fracture history after the age of 40 years, family history of osteoporosis and comorbidities did not significantly influence the treatment rate.

Conclusions

Physicians largely based their decision to treat on BMD results and not on the clinical event—fragility fracture.

Keywords

Care gapDeterminantsFragility fractureOsteoporosisTreatment predictors

Introduction

The occurrence of fragility fracture is a major public health concern due to associated increased premature mortality, morbidity, and financial burden [14]. A prior fragility fracture represents a significant risk for subsequent fracture, independent of bone mineral density (BMD) [511].

Despite the comparatively simple diagnostic criteria for osteoporosis and the availability of a number of effective anti-fracture treatments [1218], osteoporosis is under-investigated and under-treated [1924], even in high-risk groups of individuals who have suffered a previous fragility fracture [19]. Even though the care gap in the management of the disease has been widely recognised, few studies have investigated the determinants of treatment following fragility fracture.

The Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) programme is a prospective cohort study and disease health management programme aimed at evaluating the diagnostic and treatment care gap following a fragility fracture and proposing pragmatic interventions to improve the diagnosis and treatment of osteoporosis. Previous results from ROCQ demonstrated that >80% of women 50 years and over are not provided anti-fracture therapy 6 to 8 months following a fragility fracture [19]. These findings need to be further considered in light of the comprehensive health care system in Quebec that provides readily available and free access to dual energy X-ray absorptiometry (DXA) and to all currently available osteoporotic therapies.

The objective of this analysis was to evaluate which factors were associated with the treatment of osteoporosis following a fragility fracture.

Materials and methods

Setting and participants

Detailed methods of the ROCQ programme have been published previously [25]. Briefly, ROCQ enrolled women within 16 weeks of their respective fracture date within 17 different hospitals in the province of Quebec, Canada. Inclusion criteria included: ≥50 years of age, not residing in a long-term care home prior to fracture, able to understand programme information and consent form and able to answer questionnaires via phone interviews. Participants must have experienced a fragility or traumatic fracture at one or more of the following sites: wrist, forearm, humerus, scapula, clavicle, sternum, thoracic or lumbar vertebrae, pelvis, sacrum, hip, femur, proximal and distal tibia, fibula (including ankle) or foot. Participants with a fracture of one of the following sites were not eligible to participate in the programme: the cervical spine, skull or face, hand or finger, toe, metatarsus or patella. These fracture sites were not considered osteoporotic because they are not associated with low BMD and their frequency does not increase with age [26]. Patients were excluded from the programme if their fracture was deemed pathologic, defined as when a fracture occurs at the site of an underlying metabolic bone disease, a brown tumour associated with hyperparathyroidism, multiple myeloma, osteopetrosis (Albers–Schönberg disease), renal osteodystrophy, osteomalacia, osteogenesis imperfecta or an osteolytic lesion related to a benign tumour or primary/metastatic neoplasia. Fractures were not confirmed radiographically by ROCQ staff; however, participants in the ROCQ trials were initially identified by the cast-clinic employees based on the presence of radiographic evidence of fracture. Women who were currently participating in a clinical trial requiring them to take a medication for osteoporosis were also excluded.

Fragility fracture was defined as a fracture that occurred spontaneously or following a minor trauma, such as a fall from standing height or a height less than a metre, a fall from the sitting position or a fall from laying down on a bed or a reclining deck chair from less than a metre high, a fall after having missed one to three steps in a staircase, after a movement outside of the typical plane of motion or coughing [2631].

Data collection

Phase 1

At the hospital, potential women were invited, up to 16 weeks following the fracture date, to sign an authorization form allowing a member of the ROCQ personnel to contact them by phone at a later date. Each woman also received two copies of the consent form. Within 1 week after receiving their authorization form, women were contacted by phone by a trained interviewer at the coordinating centre (CHUL, Quebec City). A predetermined phone scenario was used in order to standardise the method of recruitment. During this phone scenario, no reference was made to the link between fragility fracture and osteoporosis. However, the link between the occurrence of a fragility fracture and the increased risk for sustaining a subsequent fracture was revealed to them, as necessitated by the ethics boards of the ROCQ programme. During the phone contact, inclusion and exclusion criteria were reviewed and information pertaining to the programme was provided to the potential participants. Those agreeing to participate in the programme were asked to sign, date and return one copy of the consent form and retain one copy for themselves. Women who accepted to participate in the programme were asked to complete a short questionnaire on the anatomic site, cause and circumstances of their fracture. This questionnaire, which was adapted with permission from the Canadian Multicentre Osteoporosis Study (CaMos) fracture questionnaire, assisted in determining whether their fracture was a fragility or traumatic fracture [32].

Phase 2

Six to 8 months after the fracture, all participants with a fragility fracture who signed the consent form at phase 1 were re-contacted by phone for phase 2 to complete a baseline questionnaire, again using a standardised script. The baseline questionnaire reviewed personal and clinical characteristics of the participant including the investigation (X-ray, DXA, blood tests) and diagnosis of osteoporosis before and after the current fracture, current and past medications for osteoporosis, comorbidities, fracture history, risk factors for fracture and health care resources utilisation. The DXA results were self-reported. This questionnaire established the baseline level of care provided by the health care system. Most of the questions' wording were taken from the CaMos questionnaires (CaMos 1995 and 2000) which were validated with women from Quebec City aged between 25 and 90 years old [32].

Outcomes and measurements

The primary outcome for this analysis was the treatment rate for osteoporosis 6 to 8 months after sustaining a fragility fracture for women who were osteoporosis treatment-naive (excluding calcium, vitamin D and oestrogens) at the time of their current fracture (phase 1). A woman was considered treated for osteoporosis if she initiated a bisphosphonate, raloxifene, nasal calcitonin or teriparatide.

Statistical analysis

Standard descriptive statistics (proportions, mean, standard deviation, median and quartiles) were performed to characterise the study population. The proportions of women having received a treatment for osteoporosis were determined with contingency tables.

The treatment rate corresponded to the ratio of the number of women with a fragility fracture who were treated for osteoporosis over the amount of person-time accumulated during the same period by the cohort of women with fragility fractures. The person-time of follow-up contributed by a woman corresponded to the time from the date of fragility fracture to the earlier of the following events: the date of osteoporosis treatment (event of interest), the date of death (censure), the date of the telephone interview at phase 2 for women completing this interview and for women refusing to complete this interview but accepting to complete the refusal questionnaire (censure) or the date that corresponds to 3.5 months of follow-up for women lost to follow-up between phases 1 and 2 (censure). Lost to follow-up is defined as a woman who was not contacted or did not complete the refusal questionnaire at phase 2.

Kaplan–Meier survival analysis was used to calculate the cumulative probability of an osteoporosis treatment in the 8 months following a fragility fracture. The log–rank test was used to evaluate if there was a significant difference in cumulative probability of an osteoporosis treatment relative to DXA BMD measurement before and after the fracture.

A univariate Cox proportional hazard model was performed to identify which factors were a predictor of the treatment rate. Each factor with a p value of 0.10 and lower was included in the multivariate analysis. The final multivariate model was based on a stepwise selection of factors. Backward and forward selections were also examined to ensure that the methods used for the selection of variable had no impact on the final models.

All statistics were performed using the SAS software version 9.1 (SAS, Cary, NC, USA). This study was approved by the institutional review boards at each participating hospital.

Role of the funding source

The ROCQ Programme was funded by Merck Frosst Canada, Procter and Gamble Pharmaceuticals, Sanofi-Aventis Group, Eli Lilly Canada and Novartis Pharmaceuticals Canada. None of the funding sources had a role in the study's design, conduct or reporting.

Results

At phase 1, a total of 1,273 patients consented to being included in the study; of those, 1,001 were classified as suffering a fragility fracture (78.6%) and their data were retained for further analyses. Patients were excluded due to already being administered an anti-fracture therapy (165), withdrawing for personal reasons (14) or refusing to participate in phase 2 (84). Therefore, 738 (74%) of the fragility fracture patients remained for analyses. For the analysis to estimate treatment rate and cumulative probability, 836 patients (1,001 − 165) were used, but for the analysis using the Cox model, the 738 patients having completed phase 2 were used.

Table 1 outlines the general characteristics of the women at study entry. Notably, hip, pelvis, femur and wrist fractures accounted for 40% of the fractures observed and 28% of the women had previously suffered a fracture after the age of 40 years. Less than 41% of the women had been taking calcium or vitamin D supplements when the index fracture occurred and 8.5% of the women had previously been on anti-fracture therapy. Approximately a quarter of the cohort had some problems with mobility before the fracture and 61% were considered overweight or obese according to their body mass index (BMI). A further remarkable statistic was that 70% of the women had consulted a physician, excluding an orthopaedic surgeon, between phases 1 and 2.
Table 1

Baseline characteristics of women with a fragility fracture with no treatment at phase 1 and who completed the phase 2 questionnaire 6 to 8 months after the fracture event (n = 738)

Variable

Value

Mean age in years (±standard deviation)

62.6 (9.00)

Age distribution (%)

 

 50–59 years of age

46.3

 60–69 year of age

31.7

 ≥70 years of age

22.0

College/university education (%)

43.2

Living alone (%)

37.4

Working full-time or part-time (%)

39.3

Fracture site (%)

 

 Hip, pelvis, femur

5.4

 Wrist

34.3

 Other sites

60.3

Smoker (%)

16.0

Fracture >40 years of age (%)

28.3

Family history of osteoporotic fracture (%)

43.6

Consulted a physician between phases 1 and 2 (%)

69.9

DXA BMD measurement before the current fracture (%)

31.4

Informed of having osteoporosis before the current fracture (%)

14.0

Treatment for osteoporosis before current fracture (%)

8.5

DXA BMD measurement between phases 1 and 2 (%)

27.0

Social deprivation index (quintile) (%)

 

 No data

3.0

 1 (very privileged)

13.8

 2

13.4

 3

17.2

 4

22.4

 5 (very underprivileged)

30.2

Kyphosis (%)

18.0

BMI (%)

 

 No data

1.9

 Underweight

1.9

 Normal

34.8

 Overweight or obese

61.4

Taking calcium and vitamin D supplements at the time of the fracture (%)

 

 No calcium and vitamin D

58.4

 Calcium only

3.7

 Vitamin D only

2.7

 Calcium and vitamin D

35.2

Comorbidity score ≥ 1 (Charlson index)

39.3

HRT usage (current, prior?) (%)

 

 Prior

39.6

 Current

15.9

 ≥4 caffeinated drink per day

10.6

 ≥7 alcoholic drinks per week

16.1

Menopause (%)

 

 No data

3.8

 No

6.0

 Yes (≤45 years of age)

26.6

 Yes (>45 years of age)

63.7

Level of physical activity (kilocalories per week) (%)

 

 1st quartile [0–14.9]

24.0

 2nd quartile [>14.9–28.9]

26.3

 3rd quartile [>28.9–48.8]

24.8

 4th quartile [>48.8]

24.9

Physical health or emotional problems interfered with social activities (%)

 

 Sometimes/seldom

47.6

 Most or all the time

16.9

In physical pain (%)

74.0

Some problem with mobility or confined to bed (%)

24.1

Figure 1 graphically presents the cumulative percentage of obtaining a treatment for osteoporosis following a fragility fracture. After 8 months, the percentage of the cohort on anti-fracture therapy was approximately 16% with a relatively linear rate of treatment adoption from baseline.
https://static-content.springer.com/image/art%3A10.1007%2Fs00198-009-0898-x/MediaObjects/198_2009_898_Fig1_HTML.gif
Fig. 1

Cumulative percentages of obtaining a treatment for osteoporosis following a fragility fracture

Table 2 presents the treatment relative risk (RR) for independent variables identified a priori in univariate analyses. The RR for treatment of osteoporosis within 6 to 8 months following fragility fracture was significantly higher with advancing age, if the individual was retired or unemployed, being socially underprivileged, if the fracture occurred at a site generally associated with osteoporosis (hip, femur, pelvis, wrist), if the woman had received a DXA BMD before or after the fracture (higher RR after), if the self-reported result of the BMD test was unknown, low or very low, if there was use of calcium and vitamin D supplements at the time of fracture and within the lower two quartiles of physical activity levels.
Table 2

Relative risk of treatment in univariate analyses

Variables

Treatment

Relative risk (Cox) (95%CI)

Type 3 p value

Age

 

0.0001

 50–59 years of age

1.0

 60–69 years of age

2.16 (1.37–3.41)

 ≥70 years of age

2.67 (1.66–4.29)

Employment

 

0.0085

 Full-time or part-time job

1.0

 Retired or unemployed

1.73 (1.15–2.61)

Social deprivation index (by quintile)

 

0.0274

 1 (very privileged)

1.0

 2

1.03 (0.42–2.37)

 3

0.85 (0.37–1.92)

 4

2.32 (1.12–4.29)

 5 (very underprivileged)

1.49 (0.76–2.93)

 No data

2.42 (0.84–6.97)

Site of the fracture

 

<0.0001

 All other sites

1.0

 Hip, femur, pelvis

4.64 (2.63–8.17)

 Wrist

1.90 (1.27–2.82)

DXA BMD measurement

 

<0.0001

 No BMD

1.0

 BMD before the fracture

3.10 (1.77–5.42)

 BMD between phases 1 and 2

5.28 (3.10–8.98)

Result of the DXA BMD test

 

<0.0001

 Referent group

1.0

 BMD before only, do not know

3.97 (1.78–8.83)

 BMD before only, normal

0.99 (0.415–2.37)

 BMD before only, low

5.80 (2.60–12.9)

 BMD before very, low

8.50 (4.22–17.1)

 BMD after, do not know

3.58 (1.72–7.43)

 BMD after, normal

1.28 (0.47–3.44)

 BMD after, low

5.62 (2.59–12.2)

 BMD after, very low

19.5 (10.8–35.3)

Smoking tobacco

 

0.1877

 Non-smoker

1.0

 Ex-smoker

0.75 (0.50–1.12)

 Smoker

0.64 (0.36–1.14)

Calcium and vitamin D supplements at the time of the fracture

 

0.0017

 No calcium and vitamin D

1.0

 Calcium only

0.65 (0.16–2.65)

 Vitamin D only

2.47 (0.98–6.19)

 Calcium and vitamin D

1.99 (1.36–2.91)

Menopause

 

0.2245

 Yes (≤45 years of age)

1.0

 Yes (>45 years of age)

0.94 (0.62–1.41)

 No data

0.83 (0.29–2.33)

 No

0.12 (0.02–0.89)

Level of physical activity (kilocalories per week)

 

0.0027

 1st quartile [0–14.9]

2.69 (1.53–4.73)

 2nd quartile [>14.9–28.9]

1.85 (1.03–3.34)

 3rd quartile [>28.9–48.8]

1.38 (0.74–2.58)

 4th quartile [>48.8]

1.0

Physical health or emotional problems interfered with social activities

 

0.2120

 Referent group

1.0

 Sometimes/seldom

1.24 (0.81–1.90)

 All the time/most of the time

1.60 (0.95–2.70)

Some problems with mobility or confined to bed

 

0.1566

 No

1.0

 Yes

1.34 (0.89–2.01)

95%CI 95% confidence interval

Table 3 provides the results of the multivariate analysis for factors that influence the treatment of osteoporosis after a fragility fracture. Significant predictors of treatment in this multivariate model included age over 60 years, low, very low or unknown BMD before or after fracture (stronger trends for after), fracture at the hip, femur, pelvis or wrist and vitamin D consumption at time of fracture.
Table 3

Factors that influence the treatment of osteoporosis 6 to 8 months following a fragility fracture in a multivariate analysis (hazard ratios)

Variables

Hazard ratio (95%CI)

p value

Age (years)

 

0.0261

 50–59

1.0

 60–69

1.64 (1.03–2.61)

 70+

1.94 (1.17–3.22)

BMD results before fracture

 

<0.0001

 No BMD before and after

1.0

 BMD before only, do not know

3.28 (1.45–7.41)

 BMD before only, normal

0.96 (0.40–2.30)

 BMD before only, low

5.58 (2.44–12.8)

 BMD before only, very low

7.15 (3.48–14.7)

 BMD after, do not know

2.97 (1.44–6.26)

 BMD after, normal

1.31 (0.48–3.55)

 BMD after, low

4.76 (2.15–10.5)

 BMD after, very low

16.38 (8.95–29.9)

Fracture site

 

0.0002

 All other sites

1.0

 Hip, femur, pelvis

3.26 (1.78–9.95)

 Wrist

1.70 (1.14–2.55)

Calcium and vitamin D supplements at the time of the fracture

  

 No calcium and vitamin D

1.0

0.0147

 Calcium only

0.34 (0.08–1.42)

 Vitamin D only

3.31 (1.29–8.46)

 Calcium and vitamin D

1.39 (0.93–2.07)

95%CI 95% confidence interval

Figure 2a, b demonstrates the impact of DXA BMD measurement before and after the fracture, respectively, on the rate of osteoporosis treatment within 8 months of fracture. Having acquired a BMD test either before or after the fracture event significantly increased the probability of attaining anti-fracture therapy; this increased probability was especially large when DXA testing was performed after the fracture.
https://static-content.springer.com/image/art%3A10.1007%2Fs00198-009-0898-x/MediaObjects/198_2009_898_Fig2_HTML.gif
Fig. 2

a and b Cumulative percentages of obtaining a treatment for osteoporosis following a fragility fracture (ROCQ)

Figure 3a, b displays the impact of the BMD test results performed before or after the fracture, respectively, on the probability of attaining therapy within 8 months of experiencing a fragility fracture. In general, the worse the result of the BMD test, the more probable it was that the woman would be provided anti-fracture therapy. The BMD result of tests conducted after the fracture was a strong predictor of treatment. The probability of being treated at 8 months was especially high if the DXA was done after the fracture and the result was a very low BMD (osteoporosis). The probability that a woman who had a BMD test with a normal result after a fracture was identical to a subject who had no BMD evaluation (Fig. 3b).
https://static-content.springer.com/image/art%3A10.1007%2Fs00198-009-0898-x/MediaObjects/198_2009_898_Fig3_HTML.gif
Fig. 3

a and b Cumulative percentages of obtaining a treatment for osteoporosis following a fragility fracture (ROCQ)

Discussion

In these analyses, it was possible to determine that factors that influenced whether a woman who had suffered a fragility fracture would receive anti-fracture therapy. Age over 60 years, having a DXA test performed, having been informed that a DXA BMD test was low or very low, a fracture at a site typically associated with osteoporosis and vitamin D consumption at the time of fracture all significantly increased the odds of being treated after a fragility fracture in this cohort of women. At the end of 8 months, only 16% of the women who had suffered fragility fracture and were untreated at the time of fracture were provided some form of anti-fracture therapy. A personal history of a fragility fracture is one of the most robust predictors of future fragility fracture [511]. Therefore, those who have suffered a fragility fracture may represent the population that is at greatest need for anti-fracture therapy.

Age is a significant determinant of fracture risk and, as such, has been incorporated into several algorithms to assess fracture risk along with BMD and other clinical risk factors [3335]. The finding that age over 60 years was a significant predictor of treatment was not surprising as increasing age is well-recognised as a risk for fracture independent of BMD.

Another expected finding was that of the impact of the site of fracture—those who had experienced a fragility fracture at a site that was traditionally associated with osteoporosis had a higher probability of treatment than having a fragility fracture at another site. However, 60% of the fragility fractures in this cohort were found to be at sites that are not traditionally considered osteoporotic. It is possible that clinicians unfamiliar with osteoporosis would hesitate in labelling a fracture “osteoporotic” when confronted with a fracture at a site that is not generally ascribed to osteoporosis. Therefore, educating clinicians to define and recognise fragility fractures based on the trauma associated with the fracture rather than the site of the fracture may be of importance in assuring that those in need for anti-fracture therapy receive it in a timely fashion.

Over 60% of the women who suffered a fragility fracture had a BMI that would classify them as being either overweight or obese. While a low BMI (<18.5 kg/m2) has been shown to significantly increase the risk of osteoporotic fracture [36], it should also be recognised from this study that three in five women who suffered a fragility fracture are overweight or obese according to their BMI. This may be similar to what has been observed with BMD assessment in that it is well-supported that a lower BMD is associated with a higher fracture risk, but the majority of fragility fractures occurs in those who would not be classified at high risk to fracture (i.e. >−2.5 t score) [37]. This is, to some extent, a reflection on the size of the marginal risk population compared to the relatively smaller high-risk populations, but may not be entirely so.

An interesting finding from the univariate analyses was that of vitamin D and calcium supplementation with respect to initiating treatment. The results showed that women who were administering vitamin D and calcium at the time of fracture were more likely to attain a treatment for osteoporosis within 8 months of suffering the fracture. This may be explained by the patients' greater awareness of osteoporosis if they were taking vitamin D and calcium and/or their physicians' greater awareness of osteoporosis and its prevention/treatment. However, in the multivariate analyses, only the use of vitamin D was significantly associated with treatment initiation in the 8 months following the fragility fracture.

The most consistent finding in this investigation was that of increasing probability of treatment if a woman had received a DXA BMD test. The BMD test was a significant predictor of treatment if performed either before or after the fracture with those done after the fracture demonstrating a higher trend for treatment than those before. Within the same vein, those with a worse BMD result were found to have a higher probability of being treated within the 8 months following their fragility fracture. While these findings are not surprising, they are cause for at least a little concern. It appears that physicians (and patients) are choosing to treat osteoporosis based on a surrogate measure of bone integrity (BMD) rather than the clinical event that conclusively proves that the bones are insufficient to withstand normal loading events (fragility fracture). Based on the findings of this study and those in the literature, it would be prudent to suggest that those who suffer a fragility fracture should be diagnosed as osteoporotic, regardless of their BMD. However, it should be noted that no currently available anti-fracture therapy has been assessed in a phase III trial where the primary inclusion criteria was that of a previous fragility fracture, without reference to BMD. This fact may contribute to the reluctance of physicians to prescribe anti-fracture therapies when confronted with a fragility fracture in patients with BMD measures above that of osteoporotic. Encouragingly, post hoc analyses have demonstrated the efficacy of several anti-fracture therapies in preventing fragility fractures in osteopenic women [3840].

Similar to the findings of this investigation, a retrospective database study previously completed in Quebec reported that, after a fragility fracture, significant predictors of osteoporosis treatment included age, social status and prior DXA BMD testing [41]. However, different from the findings reported in this study, the probability of anti-fracture treatment decreased with increasing age after 75 years of age, with no difference in treatment rates between those aged 65–69 and 70–74 years. The differences with respect to treatment between the cohorts might be explained by changes in practice patterns since the data collected in this trial were from 2005 and later and the data from the other published trial from 1999 to 2000. It is possible that the differences lie in the more recent increased awareness of age as a risk factor for fragility fracture independent of BMD and thus a higher awareness to treat older individuals with a fragility fracture.

Limitations for this investigation included self-reporting of much of the data and a lack of information regarding vertebral fractures. However, non-vertebral fractures represent approximately 75% of all osteoporotic fractures.

To summarise, this investigation has demonstrated that much of the efforts to educate physicians on the primary factors associated with osteoporosis have been heard and well-received—women who have suffered a fragility fracture have a higher probability of being treated within 8 months if they are above 60 years of age, if they have suffered a fracture at an anatomical site generally considered to be one that is fractured in osteoporosis and if they have a low bone density as assessed by DXA. We have also established that only approximately one in five women after the age of 50 years who suffer a fragility fracture will receive pharmacological treatment within 8 months following a fragility fracture. Therefore, our educational strategies should be broadened from the current diagnosis of osteoporosis based on BMD to also further include the diagnosis of osteoporosis based on the single most clinical event associated with this disease: fragility fracture. It is time for change.

Acknowledgments

We gratefully acknowledge the contributions of the ROCQ Programme staff, particularly programme coordinators Lucie Vaillancourt and Nathalie Migneault and administrative assistant Julie Parrot. We also acknowledge the contributions of the regional coordinators and research assistants: Sylvie Bélanger, Geneviève Corneau, Isabel Lajeunesse, Pierre-Antoine Landry, Lise Lemire, Anne-Marie Louis XVI, Julie Simard and Lyse Roy. Finally, we thank the regional directors, Pierre Dagenais, Kim Latendresse, Pierre Major, Frédéric Morin, Suzanne Morin and Josée Villeneuve, for their support during the implementation of the programme and their critical scientific advice. We also thank past members of the ROCQ executive, Louise Lafortune, Christine Chin, Luc Sauriol and Andy McClenaghan, for their insightful guidance. Lastly, we appreciate all CaMos investigators for allowing us to utilise pertinent sections of the CaMos questionnaires for ROCQ. The ROCQ Programme was funded by Merck Frosst Canada, Procter and Gamble Pharmaceuticals, Sanofi-Aventis Group, Eli Lilly Canada and Novartis Pharmaceuticals Canada. None of the funding sources had a role in the collection, analysis or interpretation of the data or in the decision to publish this article.

Conflicts of interest

Drs. Bessette, Brown, Davison and Ste-Marie have consulted for, held research grants and/or received honoraria from companies that market anti-fracture therapies.

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2009