In women aged 50 years or more who experienced a fracture, 81% suffered a fragility fracture. Six to eight months after fragility fracture, 79% had either not been investigated for osteoporosis or prescribed anti-fracture therapy. Despite fragility fractures being common in this population osteoporosis is under-diagnosed and under-treated.
The objective of this study was to evaluate the diagnostic and treatment rates for osteoporosis six months following fragility fracture.
This prospective cohort study was set in the general community from the Province of Quebec, Canada. Women at least 50 years of age who suffered a fracture were recruited during their initial visit to the hospital and had their fracture type classified as either fragility or traumatic. Six-to-eight months after fragility fracture, women were again contacted to evaluate the diagnostic and treatment rates of osteoporosis.
Of the 2,075 women recruited over a 25 month period 1,688 (81%) sustained a fragility fracture and 387 (19%) sustained a traumatic fracture. Nine hundred and three participants with a fragility fracture were again contacted six-to-eight months after fracture. For the 739 women not on treatment on the recruitment day, only 15.4% initiated pharmacological therapy in the six-to-eight-month period following fracture and 79.0% had either not been investigated for osteoporosis or prescribed anti-fracture treatment.
The proportion of fragility fractures to total fractures is higher than previously reported. Despite the availability of diagnostic modalities, effective treatments, and adequate health care assessments, there is a substantial care gap in the management of osteoporosis.
BACKGROUND: The majority of people with osteoporosis are never evaluated even though effective treatments are available. The County Council of Värmland in Sweden has implemented an osteoporosis management model that has been shown to be effective in promoting awareness and providing care for osteoporosis patients. Discussions among a prevention group on osteoporosis in the county council were opened in 1997. The county of Värmland covers a large area, and the distances from the peripheral parts to the main city are approximately 300 km and cumbersome for the inhabitants. The importance of having an osteoporosis service that could reach the county inhabitants in a convenient way was therefore recognized. METHODS: Three thousand four hundred patients were evaluated between March 2001 and December 2003. Guidelines for patient selection for bone density testing and treatment guidelines were formulated. Promoting awareness was an important prerequisite for the model to function. This was accomplished by having the measurement devices where the patients showed up and by regular education of the primary care doctors. RESULTS AND CONCLUSIONS: A multidisciplinary team was established and consisted of primary care doctors, orthopaedic surgeons, internists, physiotherapists, a patient organization member, a county health care representative and nurses. Team members met every third month and agreed upon clinical guidelines for implementing the system. The presented osteoporosis management system is not a screening approach as all patients had risk factors for osteoporosis before they were suggested for bone density testing. This study shows that providing a comprehensive package of measures makes it possible to establish an effective osteoporosis management system with limited economical resources.
The majority of frail elderly who live in long-term care (LTC) are not treated for osteoporosis despite their high risk for fragility fractures. Clinical Practice Guidelines for the diagnosis and management of osteoporosis provide guidance for the management of individuals 50 years and older at risk for fractures, however, they cannot benefit LTC residents if physicians perceive barriers to their application. Our objectives are to explore current practices to fracture risk assessment by LTC physicians and describe barriers to applying the recently published Osteoporosis Canada practice guidelines for fracture assessment and prevention in LTC.
A cross-sectional survey was conducted with the Ontario Long-Term Care Physicians Association using an online questionnaire. The survey included questions that addressed members' attitudes, knowledge, and behaviour with respect to fracture risk assessment in LTC. Closed-ended responses were analyzed using descriptive statistics and thematic framework analysis for open-ended responses.
We contacted 347 LTC physicians; 25% submitted completed surveys (81% men, mean age 60 (Standard Deviation [SD] 11) years, average 32 [SD 11] years in practice). Of the surveyed physicians, 87% considered prevention of fragility fractures to be important, but a minority (34%) reported using validated fracture risk assessment tools, while 33% did not use any. Clinical risk factors recommended by the OC guidelines for assessing fracture risk considered applicable included; glucocorticoid use (99%), fall history (93%), age (92%), and fracture history (91%). Recommended clinical measurements considered applicable included: weight (84%), thyroid-stimulating hormone (78%) and creatinine (73%) measurements, height (61%), and Get-Up-and-Go test (60%). Perceived barriers to assessing fracture risk included difficulty acquiring necessary information, lack of access to tests (bone mineral density, x-rays) or obtaining medical history; resource constraints, and a sentiment that assessing fracture risk is futile in this population because of short life expectancy and polypharmacy.
Perceived barriers to fracture risk assessment and osteoporosis management in LTC have not changed recently, contributing in part to the ongoing care gap in osteoporosis management. Our findings highlight the importance to adapt guidelines to be applicable to the LTC environment, and to develop partnerships with stakeholders to facilitate their use in clinical practice.
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Osteoporosis Canada's 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada focus on the clinical impact of fragility fractures, and on the assessment and management of women and men at high risk for fragility fracture. These guidelines now integrate a 10-year absolute fracture risk prediction into an overall management approach by using validated risk assessment tools. There currently is a large gap between optimal practices and those that are now being provided to Canadians with osteoporosis. These guidelines are part of a concerted effort to close this gap. Key changes from the 2002 guidelines of interest and relevance to radiologists are highlighted in this report.
To survey physicians in Ontario regarding their approach to diagnosis and treatment of osteoporosis among residents of long-term care facilities.
Mailed questionnaire covering physician demographics; current clinical practice relating to osteoporosis; and perceived barriers to prevention, diagnosis, and treatment of the disease.
Long-term care facilities in Ontario.
Medical directors of long-term care facilities.
Demographic variables; physician attitudes; and practices concerning awareness, diagnosis, and treatment of osteoporosis.
Respondents returned 275 of 490 questionnaires, for a response rate of 56.1%. Most respondents (92.4%) were family physicians; 28.7% were caring for more than 100 patients in long-term care. Most (85.8%) saw from one to 10 hip fractures yearly in their practices. Although 49.6% of respondents estimated the prevalence of osteoporosis to be 40% to 80% among their long-term care patients, 45.5% said that they did not routinely assess their patients for the disease, and 26.8% do not routinely treat it. Half (50.9%) of physicians would treat patients at high risk based on clinical history; 47.9% if patients had a vertebral compression fracture on plain x-ray examination; 43.8% if patients were highly functional; 42.0% if osteoporosis were confirmed with bone mineral densitometry; and 30.0% if patients had a recent fracture. Perceived barriers to initiating treatment included cost of therapy, patient or family reluctance to accept therapy, and time or cost of diagnosis.
Although physicians are aware that patients in long-term care facilities are at high risk for osteoporosis and hip fractures, the disease remains underdiagnosed and undertreated.