Postfracture care for older women: Gaps between optimal care and actual care

There is a serious gap in the care of patients with fractures characteristic of osteoporosis. Osteoporosis is increasingly being recognized as an important public health problem because of its age-related increase in prevalence and the morbidity, mortality, and economic consequences associated with it. Yet many family physicians appear to be unaware of the magnitude of this problem and the importance of identifying people at high risk for appropriate intervention, and of the process of diagnosis and management of the disease.1,2 Researchers currently estimate that 30% to 50% of women will experience fractures characteristic of osteoporosis during their lives.3 Women’s lifetime risk of hip fractures is greater than the sum of their lifetime risk of having breast, endometrial, or ovarian cancer.4 The rate of premature death (at younger than 75 years) and substantially increased morbidity among patients with osteoporosis make it a particularly compelling public health problem. Women who have sustained major osteoporotic fractures have a 2-fold increase in age-adjusted risk of mortality.3 Hip fractures are the cause of up to 40% of fall-related hospitalizations among those 65 years old and older,5 and 40% of all nursing home admissions occur as a result of fractures among people older than 65 years.6 These morbidity and mortality rates are especially distressing given that effective prevention and treatment strategies are available for those at highest risk of osteoporotic fractures—that is, people needing secondary prevention because they have already experienced spine, hip, or other fractures characteristic of osteoporosis. Appropriate intervention can be very effective. Pharmacologic therapy has been shown to reduce risk of fracture by 30% to 60% in women at high risk. Additional nonpharmacologic intervention with calcium and vitamin D supplementation,7 exercise,8 smoking cessation, and fall prevention9 can further contribute to preventing fractures. Serious gaps between what could be done for postfracture patients and what is done in actual practice have been observed. A recent meta-analysis of 37 studies of diagnosis and treatment of osteoporosis and intervention for those who have sustained fragility fractures revealed that, in some studies, none of the fracture patients was investigated or treated for underlying osteoporosis.1 Studies have demonstrated that all patients, including those older than 75 years, can benefit from treatment, and yet older women have been least likely to receive bone mineral density (BMD) testing or appropriate treatment for osteoporosis.10,11 This gap in the care of fracture patients should be less evident in a publicly funded health care system such as Canada’s. Bone mineral density testing as a medically necessary diagnostic procedure does not require payment from patients, and drug benefit programs are available to most Canadian residents 65 years old and older. As a prelude to developing interventions to improve diagnosis and treatment of osteoporosis, we examined the rates of investigation and treatment of osteoporosis among older women in an entire Canadian province during the first year after they had had fractures.