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Osteoporosis International

, Volume 15, Issue 10, pp 767–778 | Cite as

Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review

  • V. Elliot-Gibson
  • E. R. Bogoch
  • S. A. Jamal
  • D. E. Beaton
Review

Abstract

Fragility fractures are a strong indicator of underlying osteoporosis (OP). With the risk of future fracture being increased 1.5- to 9.5-fold following a fragility fracture, the diagnosis and treatment of OP in men and women with fragility fractures provides the opportunity to prevent future fragility fractures. This review describes the current status of practice in investigation and diagnosis of OP in men and women with fragility fractures, the rates and types of postfracture treatment in patients with fragility fractures and OP, interventions undertaken in this population, and the barriers to OP identification and treatment. A literature search performed in Medline, Healthstar, CINAHL, EMBASE, PreMedline, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 37 studies on OP diagnosis, treatment, and interventions. The studies varied in design methodology, study facilities, types of fractures, and pharmacological treatments. Some studies revealed that no patients with fragility fractures received investigation or treatment for underlying OP. Investigation of OP by bone mineral density was low: 14 of 16 studies reported investigation of less than 32% of patients. Investigation by bone mineral density resulted in high rates of OP diagnosis (35–100%), but only moderate use of calcium and vitamin D (8–62%, median 18%) and bisphosphoates (0.5–38%) in patients investigated postfracture. Studies on barriers to OP identification and treatment focused on various groups of health practitioners. Barriers included the cost of therapies, time and cost of resources for diagnosis, concerns about medications, and the lack of clarity regarding the responsibility to undertake this care.

Keywords

Diagnosis Fragility fracture Osteoporosis Risk factor Treatment 

Notes

Acknowledgements

The authors thank Dagmar Gross for assistance with data review and preparation of the manuscript. Dr Jamal is supported by a Clinician Scientist Award, and Dr Beaton is supported by a New Investigators Award from the Canadian Institute of Health Research. Ms Elliot-Gibson is supported by an unrestricted research grant from Merck Frosst Canada Ltd.

References

  1. 1.
    Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S (2003) Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: a meta-analysis. J Bone Joint Surg 85A:1936–1943Google Scholar
  2. 2.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739PubMedGoogle Scholar
  3. 3.
    Schroder HM, Petersen KK, Erlandsen M (1993) Occurrence and incidence of the second hip fracture. Clin Orthop 289:166–169PubMedGoogle Scholar
  4. 4.
    Clarke M, Oxman AD (eds) (2002) Cochrane reviewers’ handbook 4.1.5. Cochrane Libr 2 [updated April 2002]Google Scholar
  5. 5.
    Al-Allaf AW, Pal B, Reid N (1998) An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment. Clin Exp Rheumatol 16:451–453PubMedGoogle Scholar
  6. 6.
    Bellantonio S, Fortinsky R, Prestwood K (2001) How well are community-living women treated for osteoporosis after hip fracture? J Am Geriatr Soc 49:1197–1204CrossRefPubMedGoogle Scholar
  7. 7.
    Davison CW, Merrilees MJ, Wilkinson TJ, McKie JS, Sainsbury R, Gilchrist NL (2001) Hip fracture mortality and morbidity: can we do better? N Z Med J 114:329–332PubMedGoogle Scholar
  8. 8.
    Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR (2000) Recognition of vertebral fracture in a clinical setting. Osteoporos Int 11:577–582CrossRefPubMedGoogle Scholar
  9. 9.
    Gehlbach SH, Fournier M, Bigelow C (2002) Recognition of osteoporosis by primary care physicians. Am J Public Health 92:271–273PubMedGoogle Scholar
  10. 10.
    Harrington JT, Broy SB, Derose AM, Licata AA, Shewmon DA (2002) Hip fracture patients are not treated for osteoporosis: a call to action. Arthritis Rheum 47:651–654CrossRefPubMedGoogle Scholar
  11. 11.
    Khan SA, de Geus C, Holroyd B, Russell AS (2001) Osteoporosis follow-up after wrist fractures following minor trauma. Arch Inter Med 161:1309–1312CrossRefGoogle Scholar
  12. 12.
    Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH (2002) Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med 162:2217–2222CrossRefPubMedGoogle Scholar
  13. 13.
    Masud T, Jordan D, Hosking DJ (2001) Distal forearm fracture history in an older community-dwelling population: the Nottingham Community Osteoporosis (NOCOS) study. Age Ageing 30:255–258CrossRefPubMedGoogle Scholar
  14. 14.
    Pal B (1999) Questionnaire survey of advice given to patients with fractures. BMJ 318:500–501PubMedGoogle Scholar
  15. 15.
    Smith MD, Ross W, Ahern MJ (2001) Missing a therapeutic window of opportunity: an audit of patients attending a tertiary teaching hospital with potentially osteoporotic hip and wrist fractures. J Rheumatol 28:2504–2508PubMedGoogle Scholar
  16. 16.
    Castel H, Bonneh DY, Sherf M, Liel Y (2001) Awareness of osteoporosis and compliance with management guidelines in patients with newly diagnosed low-impact fractures. Osteoporos Int 12:559–564CrossRefPubMedGoogle Scholar
  17. 17.
    Colón-Emeric C, Yballe L, Sloane R, Pieper CF, Lyles KW (2000) Expert physician recommendations and current practice patterns for evaluating and treating men with osteoporotic hip fracture. J Am Geriatr Soc 48:1261–1263PubMedGoogle Scholar
  18. 18.
    Cuddihy M-T, Gabriel SE, Crowson CS et al (2002) Osteoporosis intervention following distal forearm fractures: a missed opportunity? Arch Intern Med 162:421–426CrossRefPubMedGoogle Scholar
  19. 19.
    Follin SL, Black JN, McDermott MT (2003) Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy 23:190–198CrossRefPubMedGoogle Scholar
  20. 20.
    Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA (2000) Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg 82A:1063–1070Google Scholar
  21. 21.
    Gardner MJ, Flik KR, Mooar P, Lane JM (2002) Improvement in the undertreatment of osteoporosis following hip fracture. J Bone Joint Surg 84A:1342–1348Google Scholar
  22. 22.
    Hajcsar EE, Hawker G, Bogoch ER (2000) Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ 163:819–822PubMedGoogle Scholar
  23. 23.
    Juby AG, De Geus-Wenceslau CM (2002) Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporos Int 13:205–210CrossRefPubMedGoogle Scholar
  24. 24.
    Kamel HK, Hussain MS, Tariq S, Perry HM III, Morley JE (2000) Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med 109:325–328CrossRefGoogle Scholar
  25. 25.
    Miller M, Crotty M, Whitehead C, Daniels L, Finucane P (2001) Nutritional assessment and intervention in patients admitted with a femoral neck fracture: a chronicle of missed opportunities. Aust J Nutr Diet 58:86–91Google Scholar
  26. 26.
    Papaioannou A, Wiktorowicz M, Adachi JD et al (2000) Mortality, independence in living and re-fracture, one year following hip fracture in Canadians. J Soc Obstet Gynaecol Can 22:581–597Google Scholar
  27. 27.
    Riley RL, Cames ML, Gudmundsson A, Elliott ME (2002) Outcomes and secondary prevention strategies for male hip fractures. Ann Pharmacother 36:17–23CrossRefPubMedGoogle Scholar
  28. 28.
    Simonelli C, Chen Y-T, Morancey J, Lewis AF, Abbott TA III (2003) Evaluation and management of osteoporosis following hospitalization for low-impact fracture. J Gen Intern Med 18:17–22CrossRefPubMedGoogle Scholar
  29. 29.
    Torgerson DJ, Dolan P (1998) Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis 57:378–379PubMedGoogle Scholar
  30. 30.
    Ulahannan TJ, Lavelle LA (1997) Is systematic osteoporosis prevention and detection possible in a district hospital? J Clin Eff 2:43–46Google Scholar
  31. 31.
    Rothberg AD, Matshidze AD (2000) Perimenopausal wrist fracture: an opportunity for prevention and management of osteoporosis. S Afr Med J 90:1121–1124PubMedGoogle Scholar
  32. 32.
    Tuck SP, Raj N, Summers GD (2002) Is distal forearm fracture in men due to osteoporosis? Osteoporos Int 13:630–636CrossRefPubMedGoogle Scholar
  33. 33.
    Onder G, Pedone C, Gambassi G, Landi F, Cesari M, Bernabel R (2001) Treatment of osteoporosis among older adults discharged from hospital in Italy. Eur J Clin Pharmacol 57:599–604CrossRefPubMedGoogle Scholar
  34. 34.
    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 56:620–621PubMedGoogle Scholar
  35. 35.
    Chevalley T, Hoffmeyer P, Bonjour J-P, Rizzoli R (2002) An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int 13:450–455CrossRefPubMedGoogle Scholar
  36. 36.
    Diamond T, Lindenberg M (2002) Osteoporosis detection in the community: are patients adequately managed? Aust Fam Physician 31:751–752PubMedGoogle Scholar
  37. 37.
    Hawker G, Ridout 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 14:171–178PubMedGoogle Scholar
  38. 38.
    McKercher HG, Crilly RG, Kloseck M (2000) Osteoporosis management in long-term care: survey of Ontario physicians. Can Fam Physician 46:2228–2235PubMedGoogle Scholar
  39. 39.
    Pal B, Morris J, Mudda B (1998) The management of osteoporosis-related fractures: a survey of orthopaedic surgeons’ practice. Clin Exp Rheumatol 16:61–62PubMedGoogle Scholar
  40. 40.
    Sheehan J, Mohamed F, Reilly M, Perry IJ (2000) Secondary prevention following fractured neck of femur: a survey of orthopaedic surgeons practice. Ir Med J 93:105–107PubMedGoogle Scholar
  41. 41.
    Simonelli C, Killeen K, Mehle S, Swanson L (2002) Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons. Mayo Clin Proc 77:334–338PubMedGoogle Scholar
  42. 42.
    Kirk RE (1995) Experimental design: procedures for the behavioral sciences, 3rd edn. Brooks/Cole, Pacific Grove, CA, pp 7–12Google Scholar
  43. 43.
    WHO (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis. World Health Organization, Geneva, p 59Google Scholar
  44. 44.
    Wilson RK, Stas V, Ridout R, Mahomed N, Gross A, Cheung AM (2002) Knowledge of osteoporosis in a fracture population. ASBMR, San Antonio, TX (Poster #M297)Google Scholar
  45. 45.
    Brown JP, Josse RG (2002) Scientific Advisory Council of the Osteoporosis Society of Canada: 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ167:1–34Google Scholar
  46. 46.
    NIH (2000) Consensus guidelines: osteoporosis prevention, diagnosis, and therapy. NIH Consens Statement 17(1):1–45Google Scholar
  47. 47.
    Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D (1997) Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporos Int 7:390–340PubMedGoogle Scholar
  48. 48.
    WHO (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO Study Group. WHO Technical Report Series, No. 843. World Health Organization, GenevaGoogle Scholar
  49. 49.
    Badurszki JE, Dimai HP, Dimic A et al (2003) New Europe consensus on osteoporosis 2003. In: Lakotos P, Christiansen C, Marton I (eds) Balatonfured, HungaryGoogle Scholar
  50. 50.
    NOF (1999) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington, DCGoogle Scholar
  51. 51.
    NOF (2002) Physician’s guide to prevention and treatment of osteoporosis: update on medications. National Osteoporosis Foundation, Washington, DCGoogle Scholar
  52. 52.
    Seeley DG, Browner WS, Nevitt MC, Genant HK, Scott JC, Cummings SR (1991) Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group. Ann Intern Med 115:837–842PubMedGoogle Scholar
  53. 53.
    Sanders KM, Pasco JA, Ugoni AM et al (1998) The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. J Bone Miner Res 13:1337–1342PubMedGoogle Scholar
  54. 54.
    Marsh D, Simpson H, Wallace A (2003) The care of fragility fracture patients. British Orthopaedic Association, LondonGoogle Scholar
  55. 55.
    Johnell O, Kannus P, Obrant KJ, Jarvinen M, Parkkan J (2001) Management of the patient after an osteoporotic fracture: guidelines for orthopedic surgeons. Consensus conference on treatment of osteoporosis for orthopedic surgeons, Nordic Orthopedic Federation, Tampere, Finland, 2000. Acta Orthop Scand 72:325–330CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  • V. Elliot-Gibson
    • 1
  • E. R. Bogoch
    • 1
    • 2
    • 4
    • 5
  • S. A. Jamal
    • 3
    • 4
  • D. E. Beaton
    • 1
    • 4
  1. 1.Mobility Program, St. Michael’s HospitalUniversity of TorontoTorontoCanada
  2. 2.Department of Surgery, St. Michael’s HospitalUniversity of TorontoTorontoCanada
  3. 3.Department of Medicine, St. Michael’s HospitalUniversity of TorontoTorontoCanada
  4. 4.Faculty of MedicineUniversity of TorontoTorontoCanada
  5. 5.St. Michael’s HospitalTorontoCanada

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