Elderly patients who fracture a hip often do not receive osteoporosis treatment afterward to prevent subsequent fractures, according to a new study.
Researchers performed a cohort study using data from a U.S. commercial insurance claims database to examine rates of osteoporosis treatment initiation and estimate risk for subsequent nonvertebral fractures in patients ages 50 years and older who had fractured a hip and had not been receiving osteoporosis medications. Data were included from Jan. 1, 2004, to Sept. 30, 2015. Each initiation of therapy, defined as dispensing of an osteoporosis medication (alendronate, ibandronate, risedronate, and zoledronic acid; teriparatide; and denosumab) within 180 days of a hospitalization for hip fracture, was matched with 10 episodes in which therapy was not prescribed and followed for nonvertebral fracture until exposure to medication changed or until a censoring event occurred. The researchers also looked at four potential instrumental variables: calendar year of cohort entry, access to a subspecialist, geographic variation in prescribing patterns, and hospital treatment preference. The study's primary outcome was time to event of a composite nonvertebral osteoporotic fracture of the humerus, radius, ulna, hip, or pelvis. Study results were published online July 20 by JAMA Network Open.
Overall, 97,169 patients (66.0% women) were included, with a mean age of 80.2 years. Among these, 6,743 (6.9%) began osteoporosis treatment within 180 days of hip fracture. Rates of osteoporosis medication initiation declined continuously over the study period, from 9.8% (95% CI, 9.0% to 10.6%) in 2004 to 3.3% (95% CI, 2.9% to 3.8%) in 2015. Two hundred three nonvertebral fractures occurred over 3,798 person-years of follow-up in patients who received osteoporosis medication versus 1,737 nonvertebral fractures over 26,688 person-years of follow-up in those who did not. The incidence rate of fracture was 5.34 per 100 person-years and 6.50 per 100 person-years, respectively. When instrumental variable analysis was performed with hospital preference in an additive hazard model, the suggested rate difference was 4.2 subsequent fractures (95% CI, 1.1 to 7.3 events) per 100 person-years associated with initiation of osteoporosis treatment versus no treatment. In analyses of effectiveness, hospital preference was more strongly associated with osteoporosis treatment than calendar year, subspecialist access, or geographic variation in prescribing patterns.
The study did not look at duration of treatment and fracture risk or compare the effectiveness of different classes of osteoporosis medications, among other limitations, the authors noted. However, they wrote that they found a continuous rate of decline in initiation of osteoporosis treatment after hip fracture from 2004 to 2015, as well as a clinically meaningful reduction in rate of subsequent nonvertebral fracture in patients who did initiate treatment versus those who did not, “suggesting that improving prescriber adherence to prescribing guidelines and patient adherence to prescribed regimen may result in notable public health benefit.” They called for interventions to increase awareness among patients and physicians and promote innovative collaborative care models.
An accompanying commentary called the observed treatment rates “dismal” and a “shocking failure to provide adequate care to a high-risk population.” The reasons for lack of treatment are multifactorial, the commentary author said, including patient and family preferences, multimorbidity, insurance problems, drug contraindications, gaps in clinician knowledge, and clinical inertia. Potential solutions include actively screening selected patients for osteoporosis risk factors and using information technology to identify patients who have had an 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,” the commentary author wrote. “Regular monitoring of postfracture treatment rates, at both the health care system and individual levels, will provide feedback and allow benchmarking.”