Facilitated bone mineral density testing versus hospital‐based case management to improve osteoporosis treatment for hip fracture patients: Additional results from a randomized trial

Objective

We previously demonstrated that a case manager intervention improved osteoporosis (OP) treatment within 6 months of hip fracture compared with usual care. The second phase of the randomized trial compared a less intensive intervention, facilitated bone mineral density (BMD) testing, with usual care and the case manager intervention.

Methods

We initially randomized 220 hip fracture patients to either an OP case manager intervention or usual care. After completing the original trial at 6 months postfracture, usual care patients were reallocated to facilitated BMD testing; BMD tests were arranged and results sent to primary care physicians. Main outcomes (bisphosphonate treatment, BMD tests, receipt of appropriate care) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care.

Results

Compared with usual care, facilitated BMD testing increased testing from 29% to 68% (P < 0.001), bisphosphonate use from 22% to 38% (P < 0.001), and receipt of appropriate care from 26% to 45% (P < 0.001). The more intensive (70 versus 30 minutes) and expensive ($56 versus $24 Canadian per patient) OP case manager intervention led to significantly higher bisphosphonate use (54% versus 38%; P = 0.03), receipt of appropriate care (71% versus 45%; P < 0.001), and more BMD testing (80% versus 68%; P = 0.06) than usual care followed by facilitated BMD testing.

Conclusion

Compared with usual care, 2 different inexpensive interventions resulted in significant increases in appropriate management of OP after hip fracture. The magnitude of improvements achieved was directly related to the intensity of the interventions.     

HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial

OBJECTIVE: We aimed to determine whether a novel Patient Empowerment and Physician Alerting (PEPA) intervention would improve the proportion of seniors who were investigated and treated for osteoporosis after hip fracture. METHODS: We undertook a 6-month randomized controlled trial (RCT) in 48 women and men >/= 60 years old who had suffered a hip fracture and were admitted to a tertiary-care university hospital. The primary outcome measure was the proportion of participants offered one or more osteoporosis-specific 'best practices' measured using the Diagnosis and Management Questionnaire (DMQ). Participant responses were validated in part by physician report. RESULTS: In the PEPA intervention group, 19 (68%) were offered one or more components of best practice care compared with 7 (35%) in the 'usual care' group (p <.05). In the PEPA group, 15 (54%) (p <.01) were prescribed bisphosphonate therapy, 8 (29%) (p <.01) had a bone mineral density scan, 11 (39%) were prescribed calcium and vitamin D (p =.32), and 9 (32%) (p <.01) were prescribed exercise. In the usual care group, 0 (0%) were prescribed bisphosphonate therapy, a bone mineral density assessment, or exercise and 6 (30%) were prescribed calcium and vitamin D. CONCLUSIONS: This simple, inexpensive PEPA intervention resulted in far superior clinical management than did usual care in a population at high risk of future hip fracture.     

Interventions to increase osteoporosis treatment in patients with 'incidentally' detected vertebral fractures

BackgroundMost vertebral compression fractures are not recognized or treated. We conducted a controlled trial in older patients with vertebral fractures incidentally reported on chest radiographs, comparing usual care with osteoporosis interventions directed at physicians (opinion-leader-endorsed evidence summaries and reminders) or physicians+patients (adding activation with leaflets and telephone counseling).MethodsPatients aged >60 years who were discharged home from emergency departments and who had vertebral fractures reported but were not treated for osteoporosis were allocated to usual care (control) or physician intervention using alternate-week time series. After 3 months, untreated controls were re-allocated to physician+patient intervention. Allocation was concealed, outcomes ascertainment blinded, and analyses intent-to-treat. Primary outcome was starting osteoporosis treatment within 3 months.ResultsThere were 1315 consecutive patients screened, and 240 allocated to control (n = 123) or physician intervention (n = 117). Groups were similar at baseline (average age 74 years, 45% female, 58% previous fractures). Compared with controls, physician interventions significantly (all P <.001) increased osteoporosis treatment (20 [17%] vs 2 [2%]), bone mineral density testing (51 [44%] vs 5 [4%]), and bone mineral density testing or treatment (57 [49%] vs 7 [6%]). Three months after controls were re-allocated to physician+patient interventions, 22% had started treatment and 65% had bone mineral density testing or treatment (P <.001 vs controls). Physician+patient interventions increased bone mineral density testing or treatment an additional 16% compared with physician interventions (P = .01).ConclusionsAn opinion-leader-based intervention targeting physicians substantially improved rates of bone mineral density testing and osteoporosis treatment in patients with incidental vertebral fractures, compared with usual care. Even better osteoporosis management was achieved by adding patient activation to physician interventions [NCT00388908].     

Risedronate sodium therapy for prevention of hip fracture in men 65 years or older after stroke

BACKGROUND: There is a high incidence of hip fractures in patients after hemiplegic stroke. Bone mineral density is decreased on the hemiplegic side in patients after stroke, correlating with the immobilization-induced bone resorption, the degree of paralysis, and hypovitaminosis D. The purpose of this study is to evaluate the effectiveness of risedronate sodium, an inhibitor of bone resorption, on osteoporosis and the risk of hip fractures in men 65 years or older after stroke. METHODS: We conducted an 18-month randomized double-blind trial. Of 280 male patients 65 years or older who were poststroke, 140 received a daily dose of 2.5 mg risedronate sodium and the other 140 received placebo. Incidence of hip fractures in the 2 groups was compared. RESULTS: Ten patients sustained hip fractures in the placebo group, and 2 hip fractures occurred in the risedronate group. The relative risk of a hip fracture was 0.19 (95% confidence interval, 0.04-0.89). The number of patients needing the treatment was 16 (95% confidence interval, 9-32). Bone mineral density increased by 2.5% in the risedronate group and decreased by 3.5% in the placebo group (P<.001). Urinary deoxypyridinoline, a bone resorption marker, decreased by 58.7% in the risedronate group and by 37.2% in the placebo group. CONCLUSION: Treatment with risedronate increases bone mineral density and reduces hip fractures in elderly men who are poststroke.     

Role of bisphosphonates and calcitonin in the prevention and treatment of osteoporosis

Bisphosphonates have been shown to increase bone mineral density in patients with established osteoporosis as well as those with osteopenia. The evidence conclusively shows a reduction in fracture rates in patients on the more potent nitrogen containing bisphosphonates. Indeed, significant vertebral fracture rate reduction has been demonstrated after only 1 year of therapy. Alendronate, a second-generation bisphosphonate, and risedronate, a third-generation bisphosphonate, are first line medications for the treatment of osteoporosis given their efficacy in preventing both vertebral and non-vertebral fractures. There is evidence that vertebral fractures may be prevented by intermittent cyclic therapy with etidronate. All three have been shown to increase bone mineral density in the spine, with alendronate and risedronate producing significant increases in hip bone density. Calcitonin has demonstrated the ability to reduce vertebral fracture rates with minimal changes in bone density. Calcitonin is also beneficial in reducing the bone pain associated with fractures.     

Use of corticosteroids and bone‐active medications in clinical practice

Aim: To assess the quality of care of patients beginning corticosteroid therapy with respect to bone protection. Methods: Practicing rheumatologists in Australia were approached countrywide to recruit patients beginning corticosteroid therapy under their care. Use of bone‐active medications in the ensuing year was recorded prospectively. Baseline and follow‐up bone mineral density and fracture data were collected. Results: Ninety‐two patients (64% female) were enrolled by 18 rheumatologists. Seven patients reported a medical history of osteoporosis and 14 had already sustained a low‐trauma fracture. The median corticosteroid dose at commencement of therapy was 20 mg of prednisone. Bone‐active medications were commenced in 47% of patients within 3 months of commencing steroid therapy. These included calcium supplements (33%), vitamin D supplements (21%), hormone replacement therapy (11%), selective estrogen receptor antagonists (5%) and bisphosphonates (15%). Calcium and vitamin D supplementation usually accompanied bisphosphonate therapy. Median change in bone mineral density at the lumbar spine was ?0.20 SD units over 12 months (range: ?1.16–0.70, P = 0.007), and at the hip ?0.10 SD units over 12 months (range ?1.66–0.93, P = 0.24). There were 21 new fractures in 13 patients over the study period, with a vertebral fracture incidence of 0.16 per patient year. Of those patients taking bisphosphonate therapy, two had incident low‐trauma fractures but there was no significant change in bone mineral density at the hip or spine. Conclusions: Rheumatologists in Australia appear informed about the need for bone‐active medications in patients who are commencing steroid therapy. However there remains room for improved awareness, as is seen by the low use of bisphosphonates.     

Strategies for the prevention of hip fracture

Hip fractures are associated with 10% to 20% excess mortality in the first year and cause functional disability in most survivors. An estimated 17% of white women in the United States will sustain a hip fracture after the age of 50 years. Despite the availability of evidence-based guidelines for hip fracture prevention, routine screening and preventive measures have not been incorporated into standard primary care practice. Many physicians lack adequate knowledge to initiate bone mineral density testing and treatment with preventive medications to decrease the incidence of osteoporosis and fractures. Furthermore, patients are less likely to request information about bone health than about diseases for which systematic screening and prevention protocols have been established. This review describes preventive measures to decrease hip fracture in postmenopausal women, including screening by bone mineral density testing, risk factor assessment, and chemoprevention. Existing guidelines are summarized, and dilemmas regarding their implementation are discussed.     

Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital

Background: Patients with fragility fractures secondary to osteoporosis are at risk of recurrent fracture. Osteoporosis is often underrecognized and undertreated. We looked at the levels of awareness, investigation and treatment of patients with fracture. Methods: The study group included patients admitted to a tertiary teaching hospital. Postal surveys were sent to female patients over 60 years of age who had been identified in the hospital database as having International Classification of Diseases‐10 codes for fracture and discharged between June 1997 and January 2002. The questionnaire had specific questions on the histories of the fractures, the risk factors, the awareness of osteoporosis, bone mineral density testing and the treatment for osteoporosis. Results: Of 1584 surveys posted, 366 valid questionnaires were returned. The median age of respondents was 81 years with a range of 60–99 years. Fifty‐nine per cent reported one fracture, 41% two or more fractures and 65% reported a hip fracture. Forty‐eight per cent of patients were aware that they had osteoporosis and 35% reported having a bone density performed. Thirty‐seven per cent reported being on treatment for osteoporosis on discharge, with the majority being on treatment with calcium (34%). Conclusion: This postal survey of a high‐risk patient group discharged from a tertiary hospital confirm the findings from other population‐based and hospital‐based studies that a significant proportion of patients at risk of further fracture are not investigated or offered specific treatment for osteoporosis. Lack of awareness of underlying osteoporosis by both treating clinicians and patients is likely to be a major contributing factor.     

The prevention of hip fracture with risedronate and ergocalciferol plus calcium supplementation in elderly women with Alzheimer disease: a randomized controlled trial

BACKGROUND: A high incidence of fractures, particularly of the hip, represents an important problem in patients with Alzheimer disease (AD), who are prone to falls and have osteoporosis. We previously found that deficiency of 25-hydroxyvitamin D and compensatory hyperparathyroidism cause reduced bone mineral density in female patients with AD. We address the possibility that treatment with risedronate sodium and ergocalciferol plus calcium supplementation may reduce the incidence of nonvertebral fractures in elderly women with AD. METHODS: A total of 500 elderly women with AD were randomly assigned to daily treatment with 2.5 mg of risedronate sodium or a placebo, combined with 1000 IU of ergocalciferol and 1200 mg of elementary calcium, and followed up for 18 months. RESULTS: At baseline, patients of both groups showed 25-hydroxyvitamin D deficiency with compensatory hyperparathyroidism. During the study period, bone mineral density in the risedronate group increased by 4.1% and decreased by 0.9% in the control group. Vertebral fractures occurred in 29 patients (24 hip fractures) in the control group and 8 patients (5 hip fractures) in the risedronate group. The relative risk in the risedronate group compared with the control group was 0.28 (95% confidence interval, 0.13-0.59). CONCLUSIONS: Elderly patients with AD hypovitaminosis D are at increased risk for hip fracture. Treatment with risedronate and ergocalciferol may be safe and effective in reducing the risk of a fracture in elderly patients with AD.     

Undertreatment of osteoporosis in men with hip fracture

BACKGROUND: Women are not aggressively treated for osteoporosis after hip fracture; the treatment status of men with hip fracture has not been extensively studied. OBJECTIVE: To evaluate the outcome and treatment status of men with hip fracture. METHODS: Data from medical records were obtained for 363 patients (110 men and 253 women) aged 50 years and older with atraumatic (low-energy) hip fracture who were admitted to St Luke's Episcopal Hospital between January 1, 1996, and December 31, 2000. Surveys were mailed to surviving patients. Main outcome variables were osteoporosis treatments (antiresorptive or calcium and vitamin D) at hospital discharge, current osteoporosis treatments at 1- to 5-year follow-up, bone mineral density testing, mortality, current disability, and living arrangements (home or institution). RESULTS: The mean age for men was 80 years vs 81 years for women. Most fractures (89% for men and 93% for women) resulted from falls from a standing height. At hospital discharge, 4.5% of men (n = 5) had treatment of any kind for osteoporosis, compared with 27% of women (n = 69) (P<.001). The 12-month mortality was 32% in men, compared with 17% in women (P =.003). Surveys were usable from 168 (87%) of 194 survivors. At 1- to 5-year follow-up, 27% (12/44) of men were taking treatment of any kind for osteoporosis, compared with 71% (88/124) of women (P<.001). Of those treated, 67% (8/12) of men and 32% (28/88) of women were taking calcium and vitamin D only. At 1- to 5-year follow-up, 11% of men had a bone mineral density measurement, compared with 27% of women. After hospital discharge, the number of men and women who required wheelchairs, walkers, and canes and who lived in institutions increased significantly. CONCLUSIONS: The burden of hip fracture is illustrated by the high incidence of postfracture disability and the high mortality rate in both men and women. Nevertheless, few men receive antiresorptive treatment.     

The role of zoledronic acid in the management of osteoporosis

Bisphosphonates are the current standard of care for treatment of osteoporosis. However, oral bisphosphonates are associated with complicated dosing regimens because of poor absorption and have the potential for upper gastrointestinal (GI) tract irritation, resulting in poor adherence and persistence. Zoledronic acid (ZOL) 5 mg, a once-yearly intravenous bisphosphonate, is approved for treatment and prevention of postmenopausal osteoporosis, increasing bone mass in men with osteoporosis, and treatment and prevention of glucocorticoid-induced osteoporosis. Because it is administered as an infusion, ZOL ensures adherence and persistence over the entire 12-month dosing interval and bypasses the GI absorption/irritation problems associated with oral bisphosphonates. The objective of this study was to review the safety and efficacy of 5 mg ZOL and its potential for improving patient compliance. Published reports dating back to 2001 were reviewed, with emphasis on osteoporosis treatment. In the HORIZON-Pivotal Fracture Trial, annual infusions of 5 mg ZOL produced significant reductions in risk of morphometric vertebral fractures (70%) and hip fractures (41%) vs placebo over 3 years in postmenopausal women with osteoporosis. In the HORIZON-Recurrent Fracture Trial, an annual infusion of 5 mg ZOL after repair of a recent low-trauma hip fracture was associated with significant reductions in risk for new clinical fractures (35%) vs placebo. In men with osteoporosis, an annual treatment of ZOL over 2 years increased lumbar spine bone mineral density (BMD) by 6% compared with baseline. In patients starting or continuing treatment with chronic glucocorticoids, ZOL resulted in significantly greater increases in lumbar spine BMD over 1 year than an oral bisphosphonate. In postmenopausal women with osteopenia, a single infusion of ZOL over a 2-year period produced significantly greater gains in lumbar spine and hip BMD than placebo. ZOL is generally safe and well tolerated. Five milligrams of ZOL has the potential to improve compliance with osteoporosis therapy and, consequently, to reduce fracture risk in clinical practice.     

Treating osteoporosis to prevent fractures: current concepts and future developments

Antiresorptive drugs, such as the bisphosphonates and the RANKL inhibitor denosumab, are currently the most widely used osteoporosis medications. These drugs increase bone mineral density (BMD) and reduce the risk of vertebral (by 40–70%), nonvertebral (by 25–40%) and hip fractures (by 40–53%) in postmenopausal women with osteoporosis. Due to the risk of rare side‐effects, the use of bisphosphonates has been limited to up to 10 years with oral bisphosphonates and 6 years with intravenous zoledronic acid. Despite their well‐proven efficacy and safety, few women at high risk of fracture are started on treatment. Case finding strategies, such as fracture risk‐based screening in primary care using the fracture risk assessment tool (FRAX) and Fracture Liaison Services, have proved effective in increasing treatment rates and reducing fracture rates. Recently, anabolic therapy with teriparatide was demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture. Treatment with the sclerostin antibody romosozumab increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis. For patients with severe osteoporosis and high fracture risk, bisphosphonates alone are unlikely to be able to provide long‐term protection against fracture and restore BMD. For those patients, sequential treatment, starting with a bone‐building drug (e.g. teriparatide), followed by an antiresorptive, will likely provide better long‐term fracture prevention and should be the golden standard of future osteoporosis treatment.     

Steroid induced osteoporosis: prevention and treatment

PURPOSE: Corticosteroid induced osteoporosis (CIO) is the most frequent complication of long-term corticosteroid therapy, and the most frequent cause of secondary osteoporosis. New data from biological, epidemiological and therapeutic studies provide basis for optimal management of this bone disease. MAIN POINTS: Corticosteroids are responsible for both quantitative and qualitative deleterious effects on bone, through their effect on bone cells, mainly on osteoblasts (with both a decrease in osteoblast activity and an increase in apoptosis). Epidemiological studies have shown an increased risk of fractures related to CIO, even for low doses, and during the first 6 months of treatment. Relative risk is 1.3 and 2.6 for peripheral and vertebral fractures respectively. Bone mineral density, measured by dual-energy X-ray absorptiometry, is decreased at spine and hip; the risk of fracture is higher in CIO as compared to post-menopausal osteoporosis, for a similar bone density. Prevention of CIO needs the use of the minimal efficacious dose, and treatment of calcium, vitamin D and gonadal hormones insufficiencies. Patients at risk of fracture, as post-menopausal women with prevalent fractures, should receive a bisphosphonate. PERSPECTIVE: It may be possible to reduce the fracture risk in patients on long-term corticosteroid therapy.     

Raloxifene for older women: a review of the literature

Raloxifene is a non-steroidal selective estrogen-receptor modulator (SERM) which is used for prevention and treatment of postmenopausal osteoporosis. Raloxifene decreases the incidence of vertebral fractures by 30%–50% in postmenopausal women with osteoporosis but has not been shown to decrease the incidence of hip fractures or other non-vertebral fractures. At the present time, estrogen-replacement therapy and bisphosphonate treatment are the only medical treatments that are proven to prevent hip fractures with the exception of vitamin D and calcium replacement, which has been shown to prevent hip fractures in elderly individuals and nursing home residents. Raloxifene has been shown to have additive effects on bone turnover and bone mineral density (BMD) when used along with alendronate and teriparatide. Raloxifene could have a role in renal failure as it has been shown to increase BMD of the vertebra over 1 year of therapy. Raloxifene is as effective as tamoxifen in reducing the risk of invasive breast cancer. The increased incidence of venous thromboembolism is the main concern of raloxifene therapy and previous history of venous thromboembolism is a contraindication for use of raloxifene. Raloxifene has a role in treatment of vertebral osteoporosis in older women. The decision to use raloxifene should be based on evaluation of fracture risk and on potential other benefits than fracture reduction along with consideration of side effects.     

Osteoporosis disease management for fragility fracture patients: new understandings based on three years' experience with an osteoporosis care service

OBJECTIVE: To review the 3-year performance of an established osteoporosis care service and consider further improvements in an effort to reduce fragility fractures. METHODS: Osteoporosis care has been coordinated for all willing and able patients with orthopedic fragility fractures in our health system by a nurse and medical director since 2003, using a guideline-based care algorithm and task management software. Patients were followed by telephone for 2 years to monitor their status and optimize adherence to treatment. Demographics, management recommendations, clinical data, and adherence to treatment were reviewed for the 2003-2005 patient population. RESULTS: Of 1,019 patients with fragility fractures, 61% underwent osteoporosis evaluation and treatment. The remainder included 15% who refused to participate and 24% who were unable to participate for various logistical and health reasons. More patients age >80 years were unwilling or unable to participate. Bone densities (dual x-ray absorptiometry [DXA]) were normal, low, or osteoporotic in 24%, 55%, and 21% of patients, respectively, and 60% of the osteoporotic group had > or = 1 abnormal metabolic bone laboratory result. Only 17% of the total reported a previous fracture, and 47% had ever undergone DXA. Few experienced bone loss, a new fracture, or bisphosphonate intolerance during treatment. CONCLUSION: An osteoporosis care service has coordinated care for every willing and able fragility fracture patient with positive outcomes. In addition, the results suggest a high priority for earlier proactive diagnosis and intervention of the at-risk population if fractures are to be reduced.     

Sustained-release sodium fluoride in the treatment of the elderly with established osteoporosis

BACKGROUND: We ascertained the safety and efficacy of fluoride in augmenting spinal bone mass and reducing spinal fractures in older women with established osteoporosis. We compared a combination of sustained-release sodium fluoride, calcium citrate, and cholecalciferol (SR-NaF group) with calcium and cholecalciferol alone (control group). METHODS: Eighty-five ambulatory women aged 65 years or older with 1 or more nontraumatic vertebral compression fractures were enrolled in a 42-month randomized, double-blind, placebo-controlled trial. Primary outcome measures were vertebral fracture rate, bone mass, and safety. RESULTS: The vertebral fracture rate determined by means of computer assistance in the SR-NaF group was significantly lower than that in the control group (relative risk [RR], 0.32; 95% confidence interval [CI], 0.14-0.73; P =.007). Results of visual adjudicated inspection also confirmed a significant reduction in fracture rate (RR, 0.40; 95% CI, 0.17-0.95; P =.04). Bone mineral density in L2 through L4 increased significantly from baseline in the SR-NaF group by 5.4% (95% CI, 2.7%-8.2%; P<.001), and by 3.2% in the control group (95% CI, 0.8%-5.6%; P =.01). The between-group differences in bone mineral density were not significant. The femoral neck and total hip bone mineral density remained stable in the SR-NaF group and was not significantly different from that of the control group. There were no significant differences in adverse effects between groups. CONCLUSION: The SR-NaF group significantly decreased the risk for vertebral fractures and increased spinal bone mass without reducing bone mass at the femoral neck and total hip.     

Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures: a gap in evidence-based practice guideline implementation

BACKGROUND: Osteoporosis evaluation and treatment guidelines state that, because of the high risk for future fractures, a fracture in an older individual warrants initiation of pharmacological treatment or bone mineral density (BMD) measurement followed by treatment according to BMD. We compared current practice with these guidelines. METHODS: We used the electronic data systems of a health maintenance organization to collect fracture, BMD measurement, and pharmacy data for women aged 50 to 89 years and men aged 65 to 89 years who sustained a study-defined fracture during 1998 or 1999. We determined those who had BMD measurement or pharmacological treatment for osteoporosis (bisphosphonate or estrogen) during the 2 years. We compared the evaluation and treatment data with evidence-based clinical guidelines (for women) or expert consensus (for men). RESULTS: Of 70 513 members in the eligible age groups, 2804 persons sustained study-defined fractures. Overall, only 4.6% of those with fractures had treatment initiated after the fracture. Women sustained 80.7% of the study-defined fractures; 8.4% had BMD measurement and 42.4% received any treatment during the 2 years. Bone mineral density measurement and treatment frequency decrease significantly with age in women. In men, 1.5% had BMD measurement and 2.8% received any treatment. Approximately 51% (51.2%) of women and 95.5% of men in our study population were not evaluated or treated in accord with guideline or expert recommendations. CONCLUSIONS: Evaluation and treatment rates for osteoporosis in older individuals with fractures fall far below national recommendations, especially for men. Intervention strategies should be developed and evaluated to prevent refracture in older individuals with fractures.     

Hip fracture patients are not treated for osteoporosis: a call to action

OBJECTIVE: To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis. METHODS: Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment. RESULTS: DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate. CONCLUSION: Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.     

Bone mineral density thresholds for pharmacological intervention to prevent fractures

BACKGROUND: Treatment intervention thresholds for prevention of osteoporotic fractures can be derived from reports from the World Health Organization (diagnostic criteria) and National Osteoporosis Foundation (treatment criteria). It is not known how well these thresholds work to identify women who will fracture and are therefore candidates for treatment interventions. We used data from the National Osteoporosis Risk Assessment (NORA) to examine the effect of different treatment thresholds on fracture incidence and numbers of women with fractures within the year following bone mineral density measurement. METHODS: The study comprised 149 524 white postmenopausal women aged 50 to 104 years (mean age, 64.5 years). At baseline, bone mineral density was assessed by peripheral bone densitometry at the heel, finger, or forearm. New fractures during the next 12 months were self-reported. RESULTS: New fractures were reported by 2259 women, including 393 hip fractures; only 6.4% had baseline T scores of -2.5 or less (World Health Organization definition for osteoporosis). Although fracture rates were highest in these women, they experienced only 18% of the osteoporotic fractures and 26% of the hip fractures. By National Osteoporosis Foundation treatment guidelines, 22.6% of the women had T scores of 2.0 or less, or -1.5 or less with 1 or more clinical risk factors. Fracture rates were lower, but 45% of osteoporotic fractures and 53% of hip fractures occurred in these women. CONCLUSIONS: Using peripheral measurement devices, 82% of postmenopausal women with fractures had T scores better than -2.5. A strategy to reduce overall fracture incidence will likely require lifestyle changes and a targeted effort to identify and develop treatment protocols for women with less severe low bone mass who are nonetheless at increased risk for future fractures.