23% Non-vertebral
45-55% Hip
Despite the increasing prevalence of osteoporosis and expected increase in fragility fracture rate, there appears to be an overall poor adherence to osteoporosis screening and treatment protocols. Studies have found that <25% of patients for whom osteoporosis screening is recommended receive such screening [ 61 ]. A 2019 study demonstrated that in patients 50 year or older who presented to the emergency department with a vertebral fragility fracture, only 27% were receiving medical therapy for osteoporosis prior to their fracture [ 7 ]. While our knowledge of screening guidelines and adherence to their recommendations certainly lacks, as does our post-fragility fracture care of bone health. Studies demonstrate an almost 200% increased risk of subsequent fragility fracture and an almost 300% increased risk of hip fracture following a vertebral fragility fracture [ 62 ]. In 2016, Oertel et al evaluated osteoporosis management in 1375 geriatric patients following fragility fractures and found only 21% of patients were previously tested for bone mineral density or received osteoporosis treatment [ 63 ]. Similarly, another study found that one year after fragility fracture, over 90% of patients failed to receive a bone density scan or start empiric treatment for osteoporosis [ 7 ]. Ultimately, 38% of patients in this study went on to develop a second osteoporotic fracture within 2 years of their initial fragility fracture [ 7 ]. These results highlight the fact that we are slow to diagnose and treat osteoporosis before fragility fractures occur. Even more concerning, they demonstrate a generalized lack of understanding about the need for testing and treatment following fragility fractures in order to prevent future fractures.
Beyond the lack of understanding about the need for testing and treatment for osteoporosis, there are also significant patient factors to consider, especially non-compliance. While there are a variety of reasons for poor patient compliance, it has previously been shown that patient adherence to treatment correlates with decreased fragility fracture risk as well as improvement in BMD [ 64 ]. Therefore, it is incredibly important to discuss areas of patient concern including their understanding of the diagnosis and treatment plan, as well as the potential consequences of untreated osteoporosis as well as the side effects of medications. While clinicians believe >67% of their patients are taking their prescribed osteoporosis medications, only 40% of patients are picking those medications and it is likely that even fewer are actually taking these medications as prescribed [ 65 ]. From a patient stand-point, the major reasons for non-compliance include side effect profile of medications, lack of education/awareness of benefits of treatment, as well as dosing/administration inconveniences [ 65 ]. It is our recommendation that practitioners treating osteoporosis have an in-depth discussion with their patient regarding the side effect profile of the medications they prescribe. They should also stress the significant morbidity/mortality associated with untreated osteoporosis and the benefits of treatment.
Initially implemented in the UK, a Fracture Liaison Service (FLS) is a coordinator based, post fracture model of care designed to close the gap between sentinel fragility fracture and secondary fracture [ 66 ]. The aim is to create a structured pathway to improve identification, evaluation, and implementation of appropriate treatment in patients at risk of a secondary fragility fracture. A successful FLS program generally consists of a core of three individuals. These include a physician leader, FLS coordinator, and nurse navigator. Outside the core, significant multispecialty assistance is necessary and includes orthopedic surgery, rheumatology, endocrinology, primary care, and nursing support [ 67 ]. The International Osteoporosis Foundation (IOF) launched their “Capture the Fracture” program in 2012 and provided guidance on development of FLS programs globally [ 68 ]. When comparing institutions with FLS programs in place versus non-FLS institutions, an approximate 30% reduction in any re-fracture and 40% reduction in major re-fractures have been reported [ 69 ]. Gupta et al described their institution’s unique FLS program supplemented with EMR based alerts. These alerts helped identify at-risk patients who were admitted to the hospital or evaluated in the emergency department. After implementation for 12 months, the authors reported their ability to identify “captured missed opportunities” in 73.1% of previously undiagnosed and 77.1% of previously untreated osteoporosis patients [ 70 ]. Although success of FLS may vary, key factors that influence effectiveness include a multidisciplinary involvement, dedicated case managers, regular assessment and follow up, multifaceted interventions, and patient education [ 71 ]. The authors of this paper recommend that an FLS be developed at each institution in order to improve diagnosis and treatment of individuals suffering from osteoporosis.
In 2004, The US Surgeon General report warned that in 2020, the prevalence of osteoporosis and low bone mass is expected to increase to 1 in 2 Americans over age 50. We have made significant progress in understanding the genetic etiology of osteoporosis and development of treatments [ 72 ]. As our understanding of this diseased has improved, a greater number of pharmacotherapy options have become available for treatment.
While we continue to make great strides in the understanding of the disease and development of treatment modalities, there is continued need for improvement in screening and implementation of treatment. Many age-appropriate patients do not receive screening or counselling on osteoporosis. Furthermore, patients with known fragility fractures do not consistently receive the osteoporosis care and treatment they most certainly need. With more than 53 million people in the US alone affected by this disease, a thorough understanding of the basis, screening, diagnosis and treatment of osteoporosis is vital for all practitioners.
Dr. Swanson would like to acknowledge her funding (K23 AR070275, R03 AR074509)
COMMENTS
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