Fracture Related Issues
Screening and Treatment of Osteoporosis After Hip Fracture: Comparison of Sex and Race

https://doi.org/10.1016/j.jocd.2014.01.009Get rights and content

Abstract

Most patients with osteoporosis (OP) are untreated and remain so even after hip fracture. Outcomes after osteoporotic hip fractures are worse among men and non-Caucasians compared with Caucasian women. We hypothesized that screening and treatment of OP after hip fracture remains low in men and non-Caucasian women. We identified all patients aged 65 yr or older with a primary diagnosis of hip fracture (ICD9-DM code 820.xx) discharged from an urban public hospital between January 1, 2000 and December 31, 2010. Patients with active malignancy (1 yr before or after the fracture) and Paget's disease were excluded. Also, patients were excluded if they had less than 2 encounters for post-event care at the hospital. Patient charts were reviewed to obtain information on demographics, post-fracture OP screening status (dual-energy X-ray absorptiometry [DXA] ordered or resulted), OP treatment status (prescription for oral bisphosphonates, raloxifene, zoledronic acid, calcitonin, or teriparatide), and referral to rheumatology clinic. Data were captured using Research Electronic Data Capture. Differences in frequency of patients who had been evaluated by DXA and/or prescribed antiosteoporotic therapy after hip fractures overall and stratified by sex and race were evaluated using Chi-squared tests. The study was approved by our hospital institutional review board. There were a total of 596 patients discharged with a primary diagnosis of hip fracture during the study period. After exclusions, 417 patients remained and were included in the analyses. The median age was 80 yr (range: 65–95), 113 (27%) were men, and 243 were White women (57.9%). Overall, 10.3% of the patients were ordered DXA after their hospital discharge, 5.4% of men and 12.1% of women (p = 0.05). A total of 19% received treatment for OP, and women were nearly 3 times more likely to receive treatment than men (23.2% vs 8%, p = 0.004). The rates of DXA, treatment, and referral to rheumatology did not differ by race. The frequency of OP screening using DXA scan and the initiation of OP treatment was low in all patients after fragility fractures of hip. Women were more likely than men to receive DXA and significantly more likely to receive OP treatment. Although representative of only 1 hospital, these data suggest that more attention should be paid to possible OP among elderly patients hospitalized for hip fracture, and especially among men.

Introduction

With an aging population, osteoporosis (OP) and OP-related fractures are an important public health problem.

Hip fracture is the most serious consequence of OP with high morbidity and mortality associated with it (1). The 1-yr mortality rate after hip fracture has been estimated to be between 8.4% and 36% (2).

In addition to disability, the economic cost of hip fractures has become significant. An estimated $13 billion is spent each year in care for hip fractures in the United States. There is also the cost of post-fracture care. It has been recently found that 58% of the patients with hip fracture require long-term nursing facility care (3). A frequently recognized consequence of hip fracture is increased risk of recurrent fractures. The risk of future clinical fractures is about 10% (4), and the risk of recurrent hip fracture is about 15% in 4 yr (5).

The OP, the primary cause of low-impact hip fractures in the elderly, is rarely cited as an associated or secondary diagnosis in hospital admissions for such fractures (6). There is increasing body of evidence that antiresorptive therapy along with calcium and vitamin D reduces the risk of new hip fractures and recurrent hip fracture, as well as death from all causes (7). Also, the National Osteoporosis Foundation (NOF) recommends that all patients with fragility fractures of the hip should be treated for OP.

The aim of our study was to assess the rates of OP screening and treatment in Medicare for eligible patients after hip fracture. Similar studies in the past have documented poor rates of screening and treatment, however, with newer guidelines for treatment after hip fracture 8, 9, 10 as well as increased availability and lower cost of OP treatment; this study provides a more recent analysis of the current situation. The goal was to evaluate physician adherence to recommendations for both screening and treatment of OP after hip fracture in our hospital setting. We also wanted to determine if screening or treatment varied by patient race or gender. We hypothesized that screening and treatment rates of OP after hip fracture remain low overall and might vary by gender and race.

Section snippets

Study Population

The study was done at an academic-based, county hospital in the Midwestern United States. The study protocol was approved by the Institutional Review Board of MetroHealth Medical Center. The hospital inpatient database was used to identify all patients aged 65 yr or older admitted to our institution between January 1, 2000 and December 31, 2010 and discharged with a primary ICD-9-CM diagnosis of hip fracture. If patients were readmitted within a 1-yr period, they were only included as a single

Results

Using the inpatient database, we identified a total of 596 patients who were discharged with a diagnosis of hip fracture between 2000 and 2010. Of the 596 patients, 417 met the study inclusion criteria and were included in the analysis (Fig. 1). The demographics for the study population are shown in Table 1. The median age of study subjects was 80 yr (range: 65–95), median age for women and men were 80.6 and 76.9 yr, respectively (p = 0.015). Of the population, 73% were female and 80% were white.

Discussion

Our study demonstrates that rates of OP screening and treatment after hip fracture remain low for both men and women in our hospital population. This finding is consistent with previous studies showing only 20% of patients with fractures received appropriate screening and adequate treatment for OP (12). Trends have shown improvement in screening of OP in the last decade; however, treatment elsewhere is still inadequate (13). In our population, 23.7% received any screening or treatment after

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