Osteoporosis International

, Volume 26, Issue 2, pp 543–551 | Cite as

Predictors of re-fracture amongst patients managed within a secondary fracture prevention program: a 7-year prospective study

Original Article



This 7-year prospective observational study determined the predictors of re-fracture amongst 234 patients managed within a Secondary Fracture Prevention programme. Poor compliance, multiple co-morbidities, corticosteroid therapy, low hip bone mineral density (BMD) or low body weight were all significantly associated with re-fracture in patients commenced on long-term anti-resorptive therapy.


Risk factors for osteoporotic fracture amongst treatment-naïve patients are well established. In contrast, predictors of re-fracture in patients optimally managed within a Secondary Fracture Prevention (SFP) programme are ill-defined.


This prospective observational study included 234 subjects with incident osteoporotic fractures managed long-term by the Concord SFP programme. Using Cox proportional hazards models, predictors of re-fracture were analysed separately for patients commenced on specific pharmacotherapy (group 1, N = 171) and subjects receiving calcium and/or vitamin D supplements only (group 2, N = 63). Relevant anthropometric, clinical and technical data were documented at each visit. Compliance and persistence were analysed as time-varying covariates.


During a mean follow-up of 5.2 (range 3.5–7.3) years, 20.9 % of all subjects re-fractured (26.3 % in group 1, 6.3 % in group 2). Multivariate predictors of re-fracture in group 1 were significant co-morbidity (HR 2.04 if >3, 95 % CI 1.10–3.79, p = 0.024), corticosteroid use (HR 1.75, 95 % CI 1.12–2.73, p = 0.013) and total hip BMD (HR 1.36 per 0.1 g/cm2 decrease, 95 % CI 1.08–1.70, p = 0.008). In contrast, gender, prevalent fractures and lumbar spine BMD were not associated with re-fracture. Amongst patients with complete compliance data, a medication possession ratio of ≤ 50 % (HR 3.36, 95 % CI 1.32–8.53, p = 0.011) and low body weight (HR 1.04 per 1-kg decrease, 95 % CI 1.003–1.08, p = 0.032) were significantly associated with re-fracture.


Amongst patients managed within a dedicated SFP programme, poor compliance, multiple co-morbidities, corticosteroid therapy, low hip BMD or low body weight are all associated with increased risk of re-fracture. This subgroup of patients therefore require intensive management including strategies to improve compliance.


Anti-resorptive Compliance Osteoporosis Persistence Re-fracture predictors Secondary fracture prevention programme 



We thank Caroline Sullivan, Kathy Wu, Anna Lih, Paul Lee, Veena Jayadev, Rohit Rajagopal, Damien Smith, Belinda Poon, Chris Muir, Bev White, Lynley Robinson and Klaus Sommer and his team for their invaluable contributions to data collection and entry.

Ethics approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

Conflicts of interest



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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2014

Authors and Affiliations

  1. 1.Bone Research Program, ANZAC Research InstituteThe University of SydneySydneyAustralia
  2. 2.Department of Endocrinology and MetabolismConcord HospitalConcordAustralia
  3. 3.Pharmacoepidemiology and Pharmaceutical Policy Research Group, Faculty of PharmacyThe University of SydneySydneyAustralia

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