Skip to main content
SpringerLink
Log in

A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving

  • Short Communication
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

The post-fracture care gap has not narrowed in recent years. Following an initial improvement, rates of medication initiation have actually declined.

Introduction

The current study characterizes temporal changes in post-fracture bone mineral density (BMD) testing or osteoporosis treatment initiation from 1996/1997 to 2007/2008.

Methods

A population-based administrative data repository for Manitoba, Canada was accessed to identify non-traumatic fractures in individuals aged 50 years and older. Outcomes included BMD testing or dispensation of an osteoporosis medication in the 12 months following the fracture.

Results

Thirty thousand nine hundred and twenty (30,920) fracture events met the inclusion criteria; 15,670 affected major osteoporotic fracture sites. Based on either BMD testing or treatment initiation, intervention rates reached a maximum of only 15.5% in 2003/2004, compared with 6.3% in 1996/1997, and 13.2% in 2007/2008 (p-for-trend < 0.001). Post-fracture BMD testing increased from 0.7% in 1996/1997 to 8.9% 2007/2008 (p-for-trend < 0.001). Osteoporosis medication use increased from 6.1% in 1996/1997 to 12.3% in 2001/2002 and then progressively declined to 5.9% by 2007/2008 (p-for-trend = 0.025). Similar trends were observed when only major osteoporotic fractures were included. The initiation of BMD testing or medication varied according to age, gender, geographic region, and income.

Conclusion

Despite increased attention to gaps in osteoporosis management post-fracture in the last 10 years, the situation has not improved: in 2007/20008, fewer than 20% of untreated individuals with a low-trauma fracture received intervention. Novel strategies are required to disseminate and implement best practices at the point of care to reduce the risk of recurrent fractures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

References

  1. Kanis JA, WHO Study Group (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 4(6):368–381

    Article  PubMed  CAS  Google Scholar 

  2. Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19(4):385–397

    Article  PubMed  CAS  Google Scholar 

  3. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S et al (2010) Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 182(17):1864–1873

    Article  PubMed  Google Scholar 

  4. MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V, Suttorp M et al (2008) Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med 148(3):197–213

    PubMed  Google Scholar 

  5. Nevitt MC, Cummings SR, Stone KL, Palermo L, Black DM, Bauer DC et al (2005) Risk factors for a first-incident radiographic vertebral fracture in women > or = 65 years of age: the study of osteoporotic fractures. J Bone Miner Res 20(1):131–140

    Article  PubMed  Google Scholar 

  6. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P et al (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35(2):375–382

    Article  PubMed  CAS  Google Scholar 

  7. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35(5):293–305

    Article  PubMed  CAS  Google Scholar 

  8. Papaioannou A, Giangregorio L, Kvern B, Boulos P, Ioannidis G, Adachi JD (2004) The osteoporosis care gap in Canada. BMC Musculoskelet Disord 5:11

    Article  PubMed  CAS  Google Scholar 

  9. Ulahannan TJ, Lavelle LA (1997) Is systematic osteoporosis prevention and detection possible in a district hospital? J Clin Eff 2(2):43–46

    Google Scholar 

  10. Papaioannou A, Kennedy CC, Ioannidis G, Gao Y, Sawka AM, Goltzman D et al (2008) The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study. Osteoporos Int 19(4):581–587

    Article  PubMed  CAS  Google Scholar 

  11. Gardner MJ, Flik KR, Mooar P, Lane JM (2002) Improvement in the undertreatment of osteoporosis following hip fracture. J Bone Joint Surg Am 84-A(8):1342–1348

    PubMed  Google Scholar 

  12. Metge CJ, Leslie WD, Manness LJ, Yogendran M, Yuen CK, Kvern B (2008) Postfracture care for older women: gaps between optimal care and actual care. Can Fam Physician 54(9):1270–1276

    PubMed  Google Scholar 

  13. Bessette L, Ste-Marie LG, Jean S, Davison KS, Beaulieu M, Baranci M et al (2008) The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporos Int 19(1):79–86

    Article  PubMed  CAS  Google Scholar 

  14. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. [Review] [55 refs]. Osteoporos Int 15(10):767–778

    Article  PubMed  CAS  Google Scholar 

  15. Harrington JT, Broy SB, Derosa AM, Licata AA, Shewmon DA (2002) Hip fracture patients are not treated for osteoporosis: a call to action. Arthritis Rheum 47:651–654

    Article  PubMed  Google Scholar 

  16. Kaufman JD, Bolander ME, Bunta AD, Edwards BJ, Fitzpatrick LA, Simonelli C (2003) Barriers and solutions to osteoporosis care in patients with a hip fracture. J Bone Joint Surg Am 85A(9):1837–1843

    Google Scholar 

  17. Siris ES, Bilezikian JP, Rubin MR, Black DM, Bockman RS, Bone HG et al (2003) Pins and plaster aren't enough: a call for the evaluation and treatment of patients with osteoporotic fractures. J Clin Endocrinol Metab 88(8):3482–3486

    Article  PubMed  CAS  Google Scholar 

  18. Charalambous CP, Kumar S, Tryfonides M, Rajkumar P, Hirst P (2002) Management of osteoporosis in an orthopaedic department: audit improves practice. Int J Clin Pract 56(8):620–621

    PubMed  CAS  Google Scholar 

  19. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R (2002) An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int 13(6):450–455

    Article  PubMed  CAS  Google Scholar 

  20. Content G, Hajela V, Lucas B (2003) Osteoporosis screening and education following distal radial fracture: an expanding role for fracture clinic nurses. J Orthop Nurs 7(3):137–140

    Article  Google Scholar 

  21. Cuddihy MT, Amadio PC, Gabriel SE, Pankratz VS, Kurland RL, Melton LJ III (2004) A prospective clinical practice intervention to improve osteoporosis management following distal forearm fracture. Osteoporos Int 15(9):695–700

    Article  PubMed  Google Scholar 

  22. Davis JC, Guy P, Ashe MC, Liu-Ambrose T, Khan K (2007) HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. J Gerontol A Biol Sci Med Sci 62(8):888–891

    Article  PubMed  Google Scholar 

  23. Hawker G, Rideout R, Ricupero M, Jaglal S, Bogoch E (2003) The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int 14:171–178

    Article  PubMed  Google Scholar 

  24. Majumdar SR, Rowe BH, Folk D, Johnson JA, Holroyd BH, Morrish DW et al (2004) A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture.[see comment]. Ann Intern Med 141(5):366–373

    PubMed  Google Scholar 

  25. Leslie WD, Metge C (2003) Establishing a regional bone density program: lessons from the Manitoba experience. J Clin Densitom 6(3):275–282

    Article  PubMed  Google Scholar 

  26. Leslie WD, Caetano PA, Macwilliam LR, Finlayson GS (2005) Construction and validation of a population-based bone densitometry database. J Clin Densitom 8(1):25–30

    Article  PubMed  Google Scholar 

  27. Roos LL, Mustard CA, Nicol JP, McLerran DF, Malenka DJ, Young TK et al (1993) Registries and administrative data: organization and accuracy. Med Care 31(3):201–212

    Article  PubMed  CAS  Google Scholar 

  28. Roos LL, Walld RK, Romano PS, Roberecki S (1996) Short-term mortality after repair of hip fracture. Do Manitoba elderly do worse? Med Care 34(4):310–326

    Article  PubMed  CAS  Google Scholar 

  29. Metge C, Black C, Peterson S, Kozyrskyj AL (1999) The population's use of pharmaceuticals. Med Care 37(6 Suppl):JS42–JS59

    Article  PubMed  CAS  Google Scholar 

  30. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML et al (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 288(3):321–333

    Article  PubMed  CAS  Google Scholar 

  31. Leslie WD, Morin S, Lix LM (2010) A before-and-after study of fracture risk reporting and osteoporosis treatment initiation. Ann Intern Med 153(9):580–586

    PubMed  Google Scholar 

  32. Brown JP, Josse RG (2002) Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167(10 Suppl):S1–S34

    PubMed  Google Scholar 

  33. Bass E, French DD, Bradham DD, Rubenstein LZ (2007) Risk-adjusted mortality rates of elderly veterans with hip fractures. Ann Epidemiol 17(7):514–519

    Article  PubMed  Google Scholar 

  34. Ioannidis G, Papaioannou A, Hopman WM, Akhtar-Danesh N, Anastassiades T, Pickard L et al (2009) Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ 181(5):265–271

    Article  PubMed  Google Scholar 

  35. Curtis JR, McClure LA, Delzell E, Howard VJ, Orwoll E, Saag KG et al (2009) Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med 24(8):956–962

    Article  PubMed  Google Scholar 

  36. Demeter S, Leslie WD, Lix L, MacWilliam L, Finlayson GS, Reed M (2007) The effect of socioeconomic status on bone density testing in a public health-care system. Osteoporos Int 18(2):153–158

    Article  PubMed  CAS  Google Scholar 

  37. Little EA, Eccles MP (2010) A systematic review of the effectiveness of interventions to improve post-fracture investigation and management of patients at risk of osteoporosis. Implement Sci 5:80

    Article  PubMed  Google Scholar 

  38. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A (2008) A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am 90(6):1197–1205

    Article  PubMed  Google Scholar 

  39. Fraser LA, Langsetmo L, Berger C, Ioannidis G, Goltzman D, Adachi JD et al (2010) Fracture prediction and calibration of a Canadian FRAX(R) tool: a population-based report from CaMos. Osteoporos Int 22(3):829–837

    Article  PubMed  Google Scholar 

  40. Leslie WD, Sadatsafavi M, Lix LM, Azimaee M, Morin S, Metge CJ et al (2010) Secular decreases in fracture rates 1986–2006 for Manitoba. Canada: a population-based analysis. Osteoporos Int. doi:10.1007/s00198-010-1470-4

    Google Scholar 

  41. Jaglal SB, Weller I, Mamdani M, Hawker G, Kreder H, Jaakkimainen L et al (2005) Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res 20(6):898–905

    Article  PubMed  Google Scholar 

  42. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB (2009) Incidence and mortality of hip fractures in the United States. JAMA 302(14):1573–1579

    Article  PubMed  CAS  Google Scholar 

  43. Fisher A, Martin J, Srikusalanukul W, Davis M (2010) Bisphosphonate use and hip fracture epidemiology: ecologic proof from the contrary. Clin Interv Aging 5:355–362

    Article  PubMed  Google Scholar 

  44. Melton LJ III, Kanis JA, Johnell O (2005) Potential impact of osteoporosis treatment on hip fracture trends. J Bone Miner Res 20(6):895–897

    Article  PubMed  Google Scholar 

  45. Leslie WD, Tsang JF, Caetano PA, Lix LM (2007) Effectiveness of bone density measurement for predicting osteoporotic fractures in clinical practice. J Clin Endocrinol Metab 92(1):77–81

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository under HIPC project # 2008/2009-16. The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, or other data providers is intended or should be inferred.

Funded through a research grant from Amgen Canada Ltd. The funding source had no access to the data prior to publication, no input into the writing of the manuscript, and no input in the decision to publish the results.

Conflicts of interest

William Leslie: Research grants: Merck Frosst Canada, Amgen Pharmaceuticals Canada, Genzyme Canada. Research honoraria and educational grants: Sanofi-Aventis, Procter and Gamble Pharmaceuticals Canada. Novartis. Advisory boards: Genzyme Canada, Novartis, and Amgen Pharmaceuticals Canada.

Colleen Metge: Research grant: Amgen Pharmaceuticals Canada

Lisa Lix: Research grant: Amgen Pharmaceuticals Canada

Suzanne Morin: Consultant to: Procter and Gamble, sanofi-aventis, Amgen, Novartis. Speaker bureau: Procter and Gamble, sanofi-aventis, Amgen, Novartis. Research grant: Amgen Pharmaceuticals Canada

Patricia Caetano: Research grant: Amgen Pharmaceuticals Canada

Lora Giangregorio, Marina Yogendran, and Mahmoud Azimaee: None

Author information

Authors and Affiliations

  1. Department of Medicine, University of Manitoba, (C5121) 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada

    W. D. Leslie, M. Yogendran, M. Azimaee, C. Metge & P. Caetano

  2. University of Waterloo, Toronto, ON, Canada

    L. M. Giangregorio

  3. McGill University, Montreal, QC, Canada

    S. Morin

  4. University of Saskatchewan, Saskatoon, SK, Canada

    L. M. Lix

Authors
  1. W. D. Leslie
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L. M. Giangregorio
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Yogendran
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. Azimaee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. Morin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. C. Metge
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. Caetano
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. L. M. Lix
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to W. D. Leslie.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Leslie, W.D., Giangregorio, L.M., Yogendran, M. et al. A population-based analysis of the post-fracture care gap 1996–2008: the situation is not improving. Osteoporos Int 23, 1623–1629 (2012). https://doi.org/10.1007/s00198-011-1630-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-011-1630-1

Keywords

Search

Navigation