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Osteoporosis Treatment After Hip Fracture May Prevent Nonvertebral Fractures

July 23, 2018

By Will Boggs MD

NEW YORK (Reuters Health) - The use of osteoporosis medication after hip fracture, recommended by most guidelines, is associated with a reduction in subsequent nonvertebral fractures, according to a database study.

"Osteoporotic fractures remain a major public health burden," Dr. Rishi J. Desai from Brigham and Women's Hospital, Harvard Medical School, Boston, told Reuters Health by email. "Fortunately, effective, low-cost treatment options are available that can help manage risk in high-risk patients. However, it is critical to address the clinical inertia leading to dismal prescribing rates noted in this study and many previous studies."

Dr. Desai and colleagues used data from Truven MarketScan commercial claims to evaluate trends and initiation of osteoporosis treatments after hip fracture and the association of treatment initiation with the risk of subsequent osteoporotic fractures, compared with no use.

Their analysis controlled for four potential instrumental variables (calendar year, specialist access, geographic variation and prescribing patterns, and hospital preference), as well as demographic characteristics and healthcare use factors.

Among more than 97,000 patients age 50 and older who were not taking osteoporosis medications at the time of hip fracture hospitalization, only 6.9% initiated treatment with an osteoporosis medication within 180 days.

Moreover, the rate of osteoporosis medication initiation declined continuously between 2004 (9.8%) and 2015 (3.3%), according to the July 20th JAMA Network Open online report.

The incidence of fracture during follow-up was 5.34 per 100 person-years among osteoporosis medication initiators, compared with 6.50 per 100 person-years among nonusers.

In unadjusted models, initiation of osteoporosis medication was associated with 1.2 fewer fracture events per 100 person-years, but this difference increased to 4.2 fewer fracture events per 100 person-years after adjustment for instrumental variables (especially hospital preference).

"We have long known that osteoporosis screening rates and treatment rates are low in general, but our results are intriguing in part because it focuses on a high-risk population of hip fracture patients, all of whom should be considered for osteoporosis treatment, according to National Osteoporosis Foundation recommendations," Dr. Desai said. "Even in these patients, we saw a monotonic decline in treatment initiation, with the rates dropping to around 3% in 2015. Such low use of evidence based treatments, many of which are available at a low cost as generics, can lead to increase in preventable fracture cases in frail, elderly individuals."

"Collaborative care models such as fracture liaison services, which can coordinate post-fracture care in these patients who are likely under the care of multiple clinicians, may be important," he said.

"Undertreatment of patients following hip fracture is an important age-related health disparity that must be addressed by both health systems and individual clinicians," writes Dr. Douglas E. Bauer from University of California, San Francisco, in an editorial.

"To reverse these trends, we need to actively screen selected patients for osteoporosis risk factors, and in particular, use information technology to identify those who have had a hip or other osteoporotic fracture," he said. "Once identified, patients who have had a previous fracture can be counseled about fall prevention strategies and effective drug therapy to avoid additional fractures."

"Regular monitoring of postfracture treatment rates, at both the health care system and individual levels, will provide feedback and allow benchmarking," Dr. Bauer added.

Dr. Jeffrey C. Munson from Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, who has evaluated patterns of prescription drug use before and after fragility fracture, told Reuters Health by email, "Unfortunately, we do not understand how to consistently modify physician prescribing behavior. In this instance, the authors showed that prescribing practices are heavily influenced by the hospital in which they occur, which suggests interventions may need to be directed at the institutional level."

"Furthermore," he said, "the authors have shown that high-performing institutions can be identified. These institutions could serve as models to determine how they have achieved success, and what techniques may be transferred to other institutions where prescribing is less common. These techniques might include protocols or order sets for hip fracture patients, a checklist for medication reconciliation, or best-practice alerts embedded in the electronic medical record."

"It is unrealistic to expect that treatment rates could be, or even should be, 100% in this population, but it is implausible that the optimal treatment rate is less than 5%," Dr. Munson said. "This suggests there is a very real gap in the quality of current prescribing practices. We need to better understand why this gap exists, and how to close it."

Dr. Sian Yik Lim from Hawaii Pacific Health, Bone, and Joint Center, Straub Clinic, Honolulu, also recently found low rates of osteoporosis treatment after hospitalization for hip fracture. He told Reuters Health by email, "I think this study confirms recent observations that osteoporosis treatment rates after hip fracture is decreasing. It also provides strong evidence of the importance of osteoporosis treatment after fracture."

"Recently inpatient fracture liaison services have received a lot of attention," he said. "Fracture care is complicated; therefore, we need to coordinate care better to help patients get osteoporosis care that they need. The best evidence seems to point to fracture liaison services."


JAMA Network Open 2018.

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