Fragility fracture and osteoporosis investigation
Background: A fragility fracture is a sentinel event in osteoporosis and should prompt a family physician to investigate. However, previous research has shown that in both Canada and the United States investigation rates following a fragility fracture are generally 20% or less. A study was conducted to investigate potential physician barriers to osteoporosis management following a fragility fracture in British Columbia.
Methods: A questionnaire concerning the management of osteoporosis following a fragility fracture was sent to 517 family physicians and orthopaedic surgeons in Prince George, BC, and Victoria, BC.
Results: A total of 144 questionnaires were returned, for a response rate of 29%. Respondents consistently reported that osteoporosis should be managed by family physicians. Physicians did not report a lack of knowledge about osteoporosis investigation following a fragility fracture.
Conclusions: Given the demonstrated gap between recommendations and service delivery, a change in practice patterns is needed by all health professionals to improve secondary prevention of osteoporosis. Patients with fractures might be referred for densitometry on admission to the emergency department, and might also be offered information on supplements (calcium and vitamin D) and exercises for bone health. Patients and physicians could receive written reminders from fracture clinics to ensure that osteoporosis assessment is part of follow-up care.
A survey of BC physicians’ investigates why many patients with low-trauma fractures are not being investigated for bone loss, even though this is needed after a fragility fracture for secondary prevention of osteoporosis.
Osteoporosis is a condition of generalized skeletal fragility in which fractures occur with minimal trauma. More Canadian women die from the complications of osteoporosis than from breast and ovarian cancer combined. Over 1.4 million Canadians have osteoporosis, including 25% of women and 12% of men older than 50 years. In addition, Canadian health care costs for osteoporosis exceed $1.3 billion annually.
People who sustain a low-trauma fracture (falling from a standing height or less) have about twice the normal risk for subsequent fracture and an up to seven times greater risk of suffering a vertebral fracture, which is associated with a 28% risk of mortality.  Thus, the Osteoporosis Society of Canada (OSC) guidelines emphasize that low-trauma fractures should not merely be treated orthopaedically[5-7] but should prompt a family physician workup to determine possible causes of osteoporosis and appropriate management.
Although a low-trauma fracture provides a golden opportunity for secondary prevention of osteoporosis, studies in Ontario and Alberta both found low rates of intervention following these sentinel events.[8,9] A recent study by Hajcsar and colleagues found that more than 80% of people older than 50 who sustained a low-trauma fracture (and thus, by definition, had osteoporosis) were not told they had osteoporosis. Even fewer received adequate therapy, highlighting a gap between OSC guideline recommendations and actual clinical practice. More recently, Andrale and colleagues, in a review of the largest series of wrist fractures to date, found only 23% of at-risk patients were treated for osteoporosis, while Feldstein and colleague reported from a retrospective review of a large database that only 9.8% of the women and 2.9% of the men were screened for osteoporosis. Here in British Columbia, a prospective controlled trial looking at osteoporosis investigation after a distal radius fragility fracture found that only 23% of patients reported being investigated. Yet Cumming suggests that screening for these sentinel fractures would reduce hip fractures by 9%. Given how common and important this problem is, there have been few controlled studies testing interventions to address this gap in care. The study discussed below was initiated to investigate physician knowledge and self-reported clinical responses to fragility fractures in urban and rural communities of British Columbia.
A questionnaire was designed to ascertain physicians’ self-reported practice patterns for care of patients at risk of osteoporosis and to highlight barriers to osteoporosis intervention. The two-page five-question survey was approved by the University of British Columbia ethics review committee and mailed to 501 family physicians (FPs) and 16 orthopaedic surgeons (OSs) in Prince George, BC, and Victoria, BC. Names were obtained from the 2002–2003 Medical Directory of the College of Physicians and Surgeons of British Columbia. Questionnaire recipients were selected from College members identified as practising either family medicine or orthopaedic surgery. Questionnaires for the orthopaedic surgeons were printed on different colored paper to distinguish between participant specialties without compromising anonymity. A cover letter with instructions accompanied each survey. A return envelope was included and respondents were given the option of faxing the questionnaire back. Respondents were asked to provide information about their gender and type of practice, but information about age was not requested. All responses received within 30 days were included for analysis. All completed questionnaires were analyzed for frequency of responses and reported as the number of responses received plus percentages where appropriate.
Of the 517 questionnaires mailed, 141 were completed and returned. The 141 respondents included 103 family physicians (34 female, 64 male, 5 not disclosed) and 6 orthopaedic surgeons (6 male).
Respondents were asked about physician responsibility in question 1: “Who do you believe should address osteoporosis management in patients over 50 years of age with a low-trauma fracture (e.g., fall from a standing height or less)?” Overall, 76% of respondents believed that the family physician is the best practitioner to manage osteoporosis-related issues. The remaining 24% believed in a shared responsibility involving the FP and OS. No respondents believed that the orthopaedic surgeon alone should address osteoporosis management. These results in support of FP-managed osteoporosis are consistent with results from eastern Canada and the US.[14,15] The family physician is seen as a natural choice to manage osteoporosis because she or he is likely to maintain a long-term relationship with the patient and can initiate and coordinate osteoporosis medication prescription, diet, and exercise or lifestyle modifications.
Respondents were asked about the management of osteoporosis in more detail in questions 2 to 5 (Table). While previous studies have shown that physicians do not investigate routinely for osteoporosis after a fragility fracture,[8-11] in their responses to question 2, 85% of physicians say they would investigate 50- to 60-year-olds for osteoporosis after a low-impact fracture. And in their responses to questions 3 and 4, 65% of physicians reported that “Nothing” was stopping them from investigating for osteoporosis and that there were no barriers to investigation. When asked how to increase the diagnosis of osteoporosis in question 5, 66% of physicians advocated routine referral for dual-energy X-ray absorptiometry (DXA).
Results from the current study suggest that the secondary prevention of osteoporosis is hindered by a gap in service delivery or practice behaviors rather than by a lack of physician knowledge. Although family practitioners are ideally placed to manage osteoporosis, perhaps other health care professionals can be involved. Cohen and colleague suggest an office system approach to changing behavior based on Prochaska and DiClemente’s work in the model of change. Targeting the behavior of physicians and their office staff, other health care providers, and patients is one additive way to change behavior that could result in an increase in secondary intervention. For example, a successful intervention might involve the use of specific physician and patient reminders to follow up after a fragility fracture. In a recent study, a written reminder given to the patient at a fracture clinic and faxed to the family physician had a substantial impact on practice pattern. This simple intervention initiated osteoporosis investigation as part of post-fracture care, and led to 92% of individuals being assessed for osteoporosis compared with 23% in the usual care group.
Although a fragility fracture provides an important opportunity for secondary prevention of osteoporosis, most patients are not being investigated.
There are several novel care pathways that warrant testing in future studies. For example, referrals for densitometry could be generated on admission to the emergency department as part of hospital care plans (in centres where DXA is available) and results could be sent directly to the FP for follow-up. Concurrently, patients with fragility fractures could routinely be prescribed calcium, Vitamin D, and appropriate exercises. (Although this may be occurring in clinical practice at present, our data suggest that this is not the case.) As educating patients is a vital component of health care management, future research could test whether locating pamphlets in radiology offices, emergency departments, and physician offices might alert patients and prompt them to ask their FPs for a bone health assessment. Future research could also test whether other health care professionals such as physical therapists and occupational therapists (who see many potential osteoporosis patients routinely for therapy following a fragility fracture) might successfully provide education on exercise and bone health, and refer patients back to their FPs for osteoporosis assessment and management if necessary. Lastly, patients with distal radius fragility fractures could be targeted for secondary prevention with the help of written reminders from the fracture clinic to the FP and the patient.
Table. Responses to osteoporosis management questions 2 to 5.
|Question 2: Of the following, who would you investigate for osteoporosis after a low-trauma fracture?||Question 4: What do you believe are barriers to investigating a patient for osteoporosis after a low-trauma fracture?|
|Responses||All physicians (N=141)
(N=141) Frequency (%)
|> 60 years of age||134 (95)||Nothing||91 (65)|
|Obvious secondary cause of osteoporosis||124 (88)||Medical Services Plan not paying for DXA||33 (23)|
|Women||123 (87)||Other||9 (6)|
|50- to 60-year-olds||120 (85)||Time constraints||8 (6)|
|Men||114 (81)||Responsibility of the specialist||2 (1)|
|Frail elderly||107 (76)||My patients have more pressing issues||5 (4)|
|Independently dwelling senior||102 (72)||No effective treatment||1 (1)|
|Nursing home resident||73 (51)||Question 5: What do you see as an effective way of increasing the diagnosis and management of osteoporosis in a population at risk for the disease?|
|< 50 years||0|
|Question 3: What would prevent you from using dual-energy X-ray absorptiometry (DXA) to investigate a patient older than 50 years of age with a low-trauma fracture?||Responses||All physicians (N=141)
|Responses||All physicians (N=141)
|Wider coverage by Medical Services Plan for drugs which have been proven effective||98 (70)|
|Nothing||91 (65)||Routine referral for DXA > 50 years with a low-impact fracture||93 (66)|
|Can treat without DXA result||29 (21)||Wider Medical Services Plan reimbursement of DXA||71 (50)|
|Do not have access to DXA||13 (9)||More patient education (e.g., handouts) at the primary care level for distribution||63 (45)|
|Other||8 (6)||"User-friendly" treatment guidelines for physicians (e.g., laminated cards, algorithms)||53 (38)|
|Unsure of what diagnostic tests are available||5 (4)||Separate hospital program to address needs||36 (26)|
|Unsure of what treatment is available||3 (2)||None||8 (6)|
|Difficulty in interpreting results of DXA||4 (3)||Other
|Do not think current medications are effective||0 (0)|
This article has been peer reviewed.
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Ms Ashe is a PhD candidate in the Department of Experimental Medicine at the University of British Columbia. She is also associated with the Bone Health Research Group in the Departments of Orthopaedics and Family Practice at UBC. Dr Khan is an assistant professor at UBC in Family Practice and a consultant in the Osteoporosis Clinic at the BC Women's Health Centre. Dr Guy is an orthopaedic surgeon and an assistant professor at UBC in Orthopaedic Trauma. Dr Janssen is an assistant professor at UBC in Health Care and Epidemiology. Dr McKay is an associate professor at UBC in the Departments of Orthopaedics and Family Practice.
M.C. Ashe, MSc, K.M. Khan, MD, PhD, P. Guy, MD, Patricia Janssen, PhD, H.A. McKay, PhD. Fragility fracture and osteoporosis investigation. BCMJ, Vol. 46, No. 10, December, 2004, Page(s) 506-509 - Clinical Articles.
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