4th November 2011, Volume 124 Number 1345

Katherine Bloomfield, Joe Singh

Osteoporosis is a costly disease with the total health cost of osteoporosis in New Zealand estimated to be over $1.5 billion per anum.1 It is very common with 1 in 3 women and 1 in 5 men over the age of 50 years thought to eventually experience an osteoporotic fracture.2–4 A prior fragility fracture is one of the most robust predictors of future fragility fractures; the presence of a vertebral fracture predicts both further vertebral and non vertebral fractures with up to 19% sustaining a further vertebral fracture within 1 year.5

In women, vertebral fractures are strong predictors of incident hip fractures, with the risk increasing with the number of vertebral deformities.6 In older patients, functional impairment with vertebral fractures can be similar to that following a hip fracture, with significant pain and/or impairment in activities of daily living.7–10 Several previous studies suggest vertebral fractures are associated with increased mortality similar to that seen following neck of femur fractures.11–13

International data has shown osteoporotic fractures are both underdiagnosed and undertreated.14–17Approximately only 30% of vertebral fractures come to clinical attention and only 2–10% require hospitalisation.18 Over recent years work has been focused on appropriate secondary prevention of neck of femur (NOF) fractures, and the introduction of orthogeriatric services across many New Zealand (NZ) District Health Boards (DHBs) has improved the management of NOF fractures.19 We are aware however, that in their current form, many orthogeriatric services may not interact directly with patients with other fragility fractures such as vertebral or Colles’ fractures.

Secondary prevention of patients with osteoporosis has level one evidence of support. The aim of this study was to investigate whether a treatment gap between best practice and actual clinical practice existed in our DHB.

Methods

We performed a retrospective chart review of patients admitted to Waitamata District Health Board, Auckland, NZ from July 2006 to June 2007. Electronic discharge summaries were reviewed and patients with evidence of vertebral fracture as either a primary or secondary discharge diagnosis were identified. Patients over the age of 65 and admitted to any service across the DHB were reviewed. Patients were excluded if fracture was secondary to malignancy. Demographic data, details of vertebral fracture, history of prior fractures, and medications (calcium and vitamin D supplementation, other osteoporotic medicines and steroids) at time of admission and discharge were collected. Discharge medications are reported in this article. Note was also made of any readmissions during the audit period for evidence of any further fractures or medication changes to osteoporosis regime.

Results

Demographic information—In total 163 patients with a primary or secondary diagnosis of vertebral fracture were identified. Nine patients were excluded due to bone metastases or multiple myeloma, leaving 154 patients. The mean age was 81.5 years with 101 (65.6%) women (see Table 1 and Figure 1 for further details).

Table 1. Patient and fracture characteristics
Total population
154
Women
Total
Mean age
Range
101 (65.6%)
83.2 years
66 – 97 years
Men
Total
Mean age
Range
53 (34.4%)
79.8 years
67 – 93 years
Service of admission
General medicine
Older people’s health
General surgery
Orthopaedics
Emergency medicine
117 (76%)
19 (12%)
2 (1%)
10 (6%)
6 (4%)
Additional non-vertebral fracture
Total
Neck of femur
Pelvic
Other Lower limb
Colles’
Other upper limb
Chest wall
54 patients(35%)
24 fractures
14 fractures
6 fractures
4 fractures
10 fractures
15 fractures
More than one vertebral fracture
New/primary diagnosis vertebral fracture
Corticosteroids
Readmission with subsequent fracture
101 (66%)
28 (18%)
31 (20%)
8 (5%)

Patients were predominantly admitted through the General Medical service (76%), with 12% admitted through Older Peoples health services and the remaining 12% through the Emergency Department, orthopaedics or general surgery.

As shown in Table 1, two-thirds of patients had more than one documented vertebral fracture and over one-third had a history of additional non-vertebral fractures. Ninety-one percent of vertebral fractures were either thoracic or lumbar, 6% cervical and with 4% not documented in hospital records.

Figure 1. Age distribution

Bllomfield-1

Treatment rates in the overall group—One-third of patients (51) were documented as being treated with a combination of calcium, vitamin D and some form of bisphosphonate (Table 2).

Table 2. Treatment rates in overall patients and subgroups
Variables
Ca/VitD/BP combination
none
BP
Ca
Vit D
Total group
51 (33%)
42 (27%)
73 (47%)
93 (60%)
83 (54%)
Additional non vertebral fracture
25 (46%)
11(20%)
31 (57%)
37 (69%)
34 (63%)
New/primary diagnosis
9 (32%)
6 (21%)
15 (54%)
19 (68%)
15 (54%)
Corticosteroids
16 (52%)
5 (16%)
19 (61%)
25 (81%)
23 (74%)
Ca=calcium supplementation, VitD=Vitamin D supplementation, BP=bisphosphonate.

Seventy-three patients (47%) were treated with a bisphosphonate alone. In comparison 42 patients (27%) were on no treatment for osteoporosis (vitamin/mineral supplementation or antiresorptive treatment). No patients were prescribed other forms of osteoporotic treatment, such as hormone replacement therapy.

There was a statistically insignificant trend that patients treated with all three modalities were more likely to be women. Conversely there was a significant likelihood that patients receiving no medications for osteoporosis were more likely to be male (p<0.05). The age range for the 42 patients not on any treatment for osteoporosis is similar to the spread in the total population (Figure 2).

Figure 2. Age distribution in patients on no treatment

Bllomfield-2

Three out of the 42 patients on no treatment were discharged to a private hospital setting with the remaining discharged home or to rest home level of care. Thirty two of these 42 patients (76%) were seen through the general medical service with the remaining patients admitted and discharged through orthopaedics (7 patients), general surgery (2 patients) and the emergency department (1 patient).

When looked at as a percentage of patients admitted through each service with a vertebral fracture, this represents 27% general medical admissions, 70% of orthopaedic admissions, 100% of general surgical admissions and 17% of emergency department admissions with vertebral fracture.

Treatment rates in subgroups—Previous non-vertebral fractures: Over one third of patients (54, 35%) had documentation of a total of 73 prior non-vertebral fracture in addition to documented vertebral fracture (Table 1). These were predominantly neck of femur, pelvic and chest wall fractures. Nine patients had documentation of more than two prior non vertebral fractures. In this subgroup of 54 patients 46% were on calcium, vitamin D and bisphosphonate treatment, and 20% were receiving none of these medications. Over half of the patients (57%) were receiving bisphosphonate treatment (Table 2).

New diagnosis of vertebral fracture: 28 (18%) patients were admitted with a new diagnosis of vertebral fracture, with 23 (15%) of these being the primary reason for admission to hospital, and the remaining 5 being older fractures identified on chest X-ray films. These patients were again predominantly admitted through the general medical service (22/28). At time of discharge 6 of these patients (21%) were not on any form of treatment, where as 9 (32%) were on full combination treatment, and 15 (54%) were documented to be receiving bisphosphonates (Table 2).

Treatment with corticosteroids31 patients (20%) were documented as being treated with corticosteroids. The main indication for steroid treatment was chronic obstructive pulmonary disease (21 patients) and the age range in this group was similar to the overall group with a range of 66 to 94 years of age. In this subgroup of 31 patients 5 patients (16%) were on no treatment, with 16 patients (52%) on full combination treatment and 19 (62%) receiving bisphosphonates (Table 2).

Discussion

To our knowledge this is the first published audit on the secondary prevention of vertebral fractures in a large general hospital in NZ. The recommended practice in NZ at the time of this audit for patients with known vertebral fractures included adequate calcium intake of 1–1.5 g per day, adequate vitamin D supplementation of 800–1000 IU per day and use of antiresorptive medications, of which bisphosphonates are first line treatment.20

Patients in this audit were, as expected, predominantly women and of an old age, however the younger-old were still well represented in numbers. Overall the group had a high fracture burden as evidenced by multiple vertebral and non vertebral fractures. Results clearly show inadequate rates of treatment for this important condition with 53% of patients not prescribed bisphosphonate treatment. Unfortunately there was no documentation of why patients were not receiving bisphosphonates, such as contraindications or adverse effects in any of these patients, or of patients referred to endocrine or geriatrician lead osteoporosis clinics which are available at this DHB.

It is possible that some patients receive adequate calcium and vitamin D from dietary and other sources without requiring supplementation, however given the age range of this population this is likely to be the case in only a very small number of patients, if any. In which case adequate documentation of calcium intake or vitamin D levels should have been recorded by physicians in order to highlight these issues had been addressed and considered. This was not the case in any patients. It is also possible that treatment with calcium or vitamin D supplementation may not have been included in discharge papers despite the patient actually taking them.

This study was conducted before the safety of calcium supplementation was questioned. Given the intermittent nature of treatment with bisphosphonates, it is also possible that this was occasionally not properly documented, which may mean treatment rates are underestimated in this study. However we believe a treatment gap still exists for vertebral fracture secondary prevention.

Although rates of treatment were improved in the subgroups studied compared to the overall group, particularly in patients prescribed corticosteroids, we are still failing many of these patients. The rates of secondary prevention in our study are somewhat better than similar reports from Australia. Teede et al published results from a multisite study of minimal trauma fractures presenting to emergency departments in 2003 to 2005 which also demonstrated poor use of calcium, vitamin D and bisphosphonates.21

Interestingly male patients were significantly more likely to receive no secondary prevention than female patients There is likely a perception that osteoporosis is a disease of old women, however as clearly has been demonstrated both younger and male patients are afflicted with this disease. This is particularly concerning, especially when considering the increased mortality rates seen in men compared to women after hip fractures (one year mortality rates of up to 38% in men compared to up to 28% in women)11-13. This is an issue that we believe needs further education.

We also looked at possible influences on lack of treatment such as age, frailty and service of admission. All medical treatments should be individualised, with medicines prescribed when a positive risk/benefit ratio exists. Therefore in some cases very old patients or those with a perceived short survival span would not necessarily benefit from treatment. Given the spread of age across this subgroup of patients however, we do not believe age influenced prescribing in these cases. This is in contrast to a previous study were older patients were less likely to receive adequate treatment22. We used discharge destination as a surrogate marker of frailty in this audit. Again, we do not believe perceived frailty was a significant influence.

Although most patients were seen through the general medical services, a patient seen through one of the surgical services was less likely to receive appropriate medical treatment. Surgical colleagues may feel uncomfortable prescribing these medications and should be given appropriate referral points of contact to address this issue. Changes to the way orthogeriatrics is delivered at WDHB may help capture the small number of patients that are admitted under orthopaedics with vertebral fractures. Unfortunately however, the greatest patient numbers were seen through the general medical service.

This service at WDHB is a busy acute service and it is likely that most cases of secondary prevention were neglected due to significant service demands. We remain disappointed however, as we believe that secondary prevention of osteoporosis is as important as secondary prevention of other diseases and we suspect patients with ischaemic heart disease have greater rates of appropriate treatment in the same DHB. In other words greater awareness and education is necessary to improve secondary prevention of osteoporosis across the DHB.

Great strides have been made over recent years in improving the rates of osteoporosis treatment post hip fractures with the instigation of orthogeriatric services across many District Health Boards in NZ. Local unpublished audits in the Auckland region have demonstrated improved rates of secondary prevention in neck of femur fractures over recent years. However a large group of patients with other fragility fractures may clearly be missed by these services depending on how they are structured.

Given the cost of osteoporosis both financially to the health service and in terms of morbidity and mortality, we need to educate medical staff about the importance of all osteoporotic fractures and the readily available secondary prevention measures that do actually make a difference.

In addition, DHBs need to consider other avenues to capture this large group of patients. At Waitemata DHB, the position of a multiservice osteoporosis/fracture liaison nurse may help to improve the gap between best practice and actual clinical practice at our DHB.

Summary

Osteoporosis is a common medical condition affecting many New Zealand older adults. Vertebral fractures are a common manifestation of osteoporosis and strongly predict future fractures. Medications proven to help prevent further fractures are available, yet this audit shows many patients with prior fractures presenting to Waitemata District Health Board were not adequately treated. This appeared particularly so for men with prior fractures.

Abstract

Aim

International data suggests osteoporotic vertebral fractures are undertreated. The aim of this audit was to identify treatment gaps in patients with known vertebral fractures at Waitemata District Health Board (WDHB).

Method

Retrospective review of patients admitted to WDHB from July 2006 to June 2007. Inclusion criteria were age over 65 years, admission to any service with a primary or secondary diagnosis of vertebral fracture. Exclusion criteria were fractures related to malignancy. Demographic data, details of vertebral fracture, and history of prior fractures were documented. Osteoporotic medications at admission and discharge were collected.

Results

We analysed 154 patients. The mean age was 81.5 years and 101 (66%) were women. At discharge, 42 (27%) of patients were on no treatment and 51 (33%) were treated with calcium, vitamin D and a bisphosphonate. Men were significantly more likely to be on no treatment (p<0.05). Lack of treatment did not appear to be associated with age or frailty. Subgroups studied included patients with prior non-vertebral fractures, primary diagnosis of vertebral fracture and patients on corticosteroids with rates of no treatment of 20%, 21% and 16% respectively.

Conclusion

Secondary treatment of vertebral fractures in patients admitted to WDHB is suboptimal. Men were particularly affected.

Author Information

Katherine Bloomfield, Freemasons’ Senior Lecturer and Geriatrician, Department of Geriatric Medicine, University of Auckland and Waitemata District Health Board, Auckland; Joe Singh, Geriatrician, Department of Geriatric Medicine, Waitemata District Health Board, Auckland

Correspondence

Katherine Bloomfield, Department of Geriatric Medicine, University of Auckland and Waitemata District Health Board, 120 Shakespeare Road, PO Box 93 503 Takapuna, North Shore 0740, Auckland, New Zealand. Fax: +64 (0)9 4427166

Correspondence Email

Katherine.bloomfield@waitematadhb.govt.nz

Competing Interests

None.

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