Osteoporosis has been called a “silent epidemic” because it is largely asymptomatic and its prevalence is progressively increasing1. However, when osteoporosis is symptomatic, presenting as a fragility fracture, it is neither recognized nor treated in more than half of such patients2-6.
Because of the poor treatment record and studies showing that treatment prevents recurrent fractures, the fragility fracture has been called a “missed opportunity” for treating osteoporosis7,8. From a public health perspective, the prevalence of hip fracture is expected to double or triple between the years 1990 and 2020 in the United States, largely because of the aging of the population, if current suboptimal treatment patterns continue9. To avert a crisis in health care, the President of the United States designated the years 2002 to 2011 the “Decade of the Bone and Joint,” and the United States Congress requested a report from the Surgeon General on bone health and osteoporosis, which was released in November 200410. That report advised that a fracture should trigger “tertiary prevention” strategies, including evaluation for “secondary causes of bone loss” and evaluation for “drug therapy” including bisphosphonates and anabolic agents10. In addition, the report recommended that the health-care team be multidisciplinary, including medical specialists and subspecialists.
We describe a clinical intervention initiative, an osteoporosis consultation team, to facilitate osteoporosis evaluation and treatment for patients during their inpatient treatment for a fragility fracture.
Materials and Methods
Osteoporosis Consultation Team
An agreement was established between the Orthopaedic and Endocrinology departments at the University of Maryland Hospital and the Baltimore Veterans Administration Hospital whereby orthopaedic surgeons who admitted patients with a fragility fracture would voluntarily request an “osteoporosis consultation” by the inpatient endocrinology team (fellows and faculty). The purpose of the osteoporosis consultation was to evaluate patients for secondary causes of osteoporosis and to initiate treatment as deemed appropriate. The request for an osteoporosis consultation was initiated by the treating orthopaedic resident or faculty physician. The intent was for all patients with a fragility fracture to be seen by the inpatient osteoporosis consultation team. Permission was obtained from the institutional review board at the University of Maryland School of Medicine to review the medical records of all patients with a fragility fracture and to use the information for this study. Written, informed consent was obtained to use clinical data for research and publication from participants in the intervention cohort who were seen by our osteoporosis consultation team.
A fragility fracture was defined as a fracture in an adult resulting from a fall from a standing height. To look for secondary causes of osteoporosis, the osteoporosis consultation team obtained the following laboratory studies: liver function tests and levels of calcium, albumin, 25-hydroxyvitamin D, intact parathyroid hormone, and thyroid-stimulating hormone in all patients and a total serum testosterone level in men. All patients were verbally instructed to get a dual x-ray absorptiometry bone-mineral density study after discharge. For logistical reasons, twelve patients received the initial osteoporosis consultation in the outpatient osteoporosis clinic, after discharge from the hospital.
The treatment recommendations written in the charts of the patients and communicated verbally by the osteoporosis consultation team to the orthopaedic service were 500 mg of calcium carbonate to be taken orally three times a day and 800 units of vitamin D3 to be taken orally every day for all patients (after determining that the serum calcium was not elevated). After our initial review at twelve months revealed that all patients had low levels of 25-hydroxyvitamin D (<50 nmol/L or <20 ng/mL), a pharmacologic dose of vitamin D2 (50,000 units orally) was subsequently prescribed once, followed by a daily dose of 800 units of vitamin D3. For all patients, unless it was contraindicated, bisphosphonate treatment was also recommended. Most often, a weekly dose of 70 mg of alendronate or 35 mg of risedronate was recommended; for three patients who had severe gastrointestinal disorders, 30 mg of pamidronate or 4 mg of zoledronic acid11 was given intravenously after establishing that vitamin-D deficiency was not present (i.e., the level of 25-hydroxyvitamin D was >50 nmol/L). Treatment initiation was confirmed by a retrospective review of the medication administration record in the electronic patient records after discharge.
Verbal recommendations were made to each patient to return for a follow-up evaluation in the University of Maryland Osteoporosis Clinic after discharge. In addition, all patients were subsequently telephoned by the osteoporosis consultation team to assess their progress every three months in the first year after discharge and then annually. In the first year, patient information was entered into the “Stop Osteoporosis” program2. After the first year, telephone calls were made with use of a simple Excel spreadsheet (Microsoft, Redmond, Washington) into which the results of the calls could be directly entered. During telephone calls, the patients were reminded that the osteoporosis consultation team had seen them during their hospitalization and were asked whether they were taking a prescription osteoporosis medication, how much calcium and vitamin D they were taking, and whether they had had a bone density test.
Assessment of the Efficacy of Intervention
Ascertainment of Patients with a Fragility Fracture
The osteoporosis consultation team intended to see all inpatients with a fragility fracture. To determine the percentage of such patients who were actually seen by the osteoporosis consultation team, we identified all patients with a low-energy hip fracture who were seen at the two medical facilities during the time-period of November 2001 to December 2003, by searching the billing records using the International Classification of Diseases, Ninth Revision (ICD-9) codes12 for hip fracture and the Clinical Procedural Terminology (CPT) codes13 for hip fracture repair or femoral endoprosthesis for fracture. We did not attempt to identify all patients with a fragility fracture seen during this time because of the large volume of such patients treated at our level-I trauma center. The number of patients with a hip fracture is comparatively low at our facilities, at least partially because of our location in an inner city community with a predominantly black population. The total number of patients with a fragility fracture of the hip identified by our search was fifty-nine, and twenty-eight (47%) of them were seen by our osteoporosis consultation team while thirty-one were not seen. The thirty-one patients who were not seen by the osteoporosis consultation team are referred to as the “nonintervention cohort.” A retrospective review of the medical records demonstrated that these patients were not seen by the inpatient osteoporosis consultation team because the initiating consultation request was not made. Data extracted from the electronic patient record included age, gender, ethnicity, and recommendations written in the chart for calcium, vitamin D, and osteoporosis prescription medications as well as recommendations for a dual x-ray absorptiometry scan and for outpatient osteoporosis evaluation. The medication administration record was reviewed to assess whether the recommended medication had been administered. After discharge, we attempted to contact all thirty-one patients in the nonintervention cohort to assess their current osteoporosis treatment. These calls were made at a mean of thirty-nine months (range, two to four years) after discharge, at the time of data analysis.
The means, standard deviation, and Student t test (unpaired, same expected variance) were calculated with Excel 2000 software (Microsoft) with use of standard techniques. A p value of < 0.05 was considered to be significant.
The study population included a total of eighty-four patients who were treated from November 2001 through December 2003; fifty-three patients were in the “intervention cohort” and thirty-one patients were in the “nonintervention cohort.” This overall group consisted of fifty-nine patients with a fragility fracture of the hip (twenty-eight were in the intervention cohort and thirty-one, in the nonintervention cohort) and twenty-five patients with a fragility fracture in another bone (all of them were in the intervention cohort). The fifty-three patients in the intervention cohort had a fracture of the hip (twenty-eight patients), tibia and/or fibula (seven), thoracic or lumbar spine (seven), distal aspect of the femur (four), pelvis (three), ankle (two), and proximal aspect of the humerus (two). The thirty-one patients in the nonintervention group all had hip fractures. The gender, age, and ethnicity of the fifty-three patients in the intervention cohort and the thirty-one patients with a hip fracture in the nonintervention cohort were included in this analysis (Table I). Of the fifty-nine patients with a hip fracture in the study population, twenty-eight (47%) were seen by the osteoporosis consultation team and thirty-one were not.
In the intervention cohort, the mean age (and standard deviation) was 66.7 ± 17.1 years for the men and 71.0 ± 15.1 for the women (p = 0.37). A comparison of the intervention and nonintervention cohorts demonstrated a trend for more advanced age in the nonintervention group; however, with the numbers studied, no significant differences were detected with respect to age, gender, or ethnicity (p = 0.25, 0.17, and 0.63, respectively).
Seven (8%) of the eighty-four patients died during the hospitalization for the fracture, and all seven had had a hip fracture. Four of them had been in the intervention cohort and three, in the nonintervention cohort. Most had died from pneumonia or respiratory failure. Six of the seven patients who died were men.
Laboratory results for the intervention and nonintervention cohorts are shown in Table II. Vitamin-D (25-hydroxyvitamin-D) levels were measured in forty-one of the fifty-three patients in the intervention cohort but in none of the thirty-one patients in the nonintervention cohort. Vitamin-D deficiency (25-hydroxyvitamin of <50 nmol/L [20 ng/mL]) was found in thirty-five (85%) of the forty-one patients, with undetectable levels in seven (17%) of the forty-one. Secondary causes of osteoporosis other than vitamin-D deficiency were identified in eighteen (34%) of the fifty-three intervention patients, and they included hypogonadism (nine male patients), chronic glucocorticoid therapy (five patients), excessive doses of thyroid hormone replacement (two), anticonvulsant medication (two), and known osteogenesis imperfecta, primary hyperparathyroidism, previous gastric bypass surgery, and hemochromatosis (diagnosed as a result of our evaluation) in one patient each. Only one patient (who had osteogenesis imperfecta) in the intervention cohort was diagnosed as having osteoporosis prior to admission.
Dual X-Ray Absorptiometry Results
A verbal recommendation for a dual x-ray absorptiometry scan after discharge was documented in the electronic patient records for all patients in the intervention cohort. No documentation for a dual x-ray absorptiometry scan was found for any patients in the nonintervention cohort. Of the forty-one patients in the intervention cohort who were available for follow-up, twenty-seven (66%) had a dual x-ray absorptiometry scan done after discharge from the hospital. The mean T scores (and standard deviation) were –1.05 ± 1.69 for the lumbar spine, –2.08 ± 1.57 for the total hip, and –2.46 ± 1.20 for the femoral neck.
Treatment Initiated on Inpatients
As shown in Table III, documentation was found in the electronic patient record of recommendations for calcium and vitamin-D treatment for all intervention cohort patients but for only two of the thirty-one nonintervention cohort patients. A review of the medication administration component of the electronic patient record and outpatient charts showed that forty (75%) of fifty-three patients in the intervention cohort were actually started on calcium and vitamin-D treatment during hospitalization compared with one (3%) of the thirty-one patients in the nonintervention cohort (p = 0.0005). A bisphosphonate was recommended for forty-one (77%) of the fifty-three patients in the intervention cohort and was actually started in twenty-eight (68%) of them. A bisphosphonate was recommended for only one patient in the nonintervention cohort compared with the intervention cohort; the difference was significant (p < 0.0001).
Follow-up After Hospital Discharge
Of the fifty-three patients in the intervention cohort who were seen by the osteoporosis consultation team, follow-up information was available by telephone for forty-one (77%) (Table IV). Of the forty-one patients, seven had died since discharge from the hospital, leaving thirty-four who were alive and available for follow-up on osteoporosis treatment. Twenty-seven (79%) of the thirty-four living patients reported taking calcium and vitamin D, and twenty-two (65%) reported taking a bisphosphonate. Three patients received an intravenous bisphosphonate while in the hospital: two received zoledronic acid (4 mg) and one received pamidronate (30 mg).
In the nonintervention cohort, patients were contacted by telephone only once, two to four years after hospitalization. Follow-up information was available for twelve of the thirty-one patients in the nonintervention cohort (Table IV). Nine patients had died (three died during the hospitalization for the hip fracture and six died following discharge), leaving six living patients available for follow-up information on osteoporosis treatment. None of these six patients was receiving a bisphosphonate, and only one was receiving calcium and vitamin-D treatment. Five of the six patients were interested in receiving educational information on osteoporosis treatment.
Discharge Summary Review
Discharge summaries from the admission for the fragility fracture were reviewed for all patients in the intervention and nonintervention cohorts. Statements indicating that the patient may have osteoporosis or osteopenia, that an osteoporosis (or endocrinology) consultation had been obtained, or references to any recommendations given (such as medications, a dual x-ray absorptiometry scan, or follow-up) were found in a minority of the summaries (see Table V). No mention of any of the above was made in nearly half of the discharge summaries in the intervention cohort and in twenty-nine (94%) of the thirty-one summaries in the nonintervention cohort.
Hospitalization following a fragility fracture represents an important strategic opportunity to evaluate such patients for osteoporosis, identify secondary causes of osteoporosis, and begin treatment with appropriate medications. In the approach described in the present study, endocrinologists constituted a consultation team designed for this purpose. However, rheumatologists or specially trained internists should be able to provide this service as well.
Our clinical initiative was less effective in improving overall osteoporosis treatment for inpatients with a fragility fracture than we had hoped. Our experience shows that reliance on the treating orthopaedist to initiate an appropriate osteoporosis consultation was not effective for reaching all patients with a fragility fracture. Nonetheless, for the patients seen by the osteoporosis consultation team (specifically, twenty-eight (47%) of the fifty-nine patients with a hip fracture), this intervention was effective in improving their osteoporosis care. Of the patients seen by the osteoporosis consultation team, 75% were started on calcium and vitamin D and 68% were started on a bisphosphonate. Equally important, more than two-thirds of the patients available for follow-up remained on the prescribed osteoporosis therapy at a mean of eighteen months after discharge. In contrast, in the nonintervention cohort, only 6% were started on calcium and vitamin D and 3% on a bisphosphonate, similar to the 0% to 13% reported by other investigators1,5,7.
Our evaluation for secondary causes of osteoporosis in the intervention cohort revealed that vitamin-D deficiency (a 25-hydroxyvitamin-D level of <50 nmol/L) was ubiquitous, as has been reported by others14-16. Although vitamin-D deficiency is generally accepted to be present when the 25-hydroxyvitamin-D level is <50 nmol/L, the best reduction in fracture rates from calcium and vitamin-D administration occurs when the 25-hydroxyvitamin-D level is 100 nmol/L17 and none of our patients had levels this high. The consistency in vitamin-D deficiency noted after the first year of this intervention subsequently led to our decision to give a loading dose of 50,000 IU of vitamin D2 to all patients, followed by a daily dose of 800 IU of vitamin D3 after documenting eucalcemia, without waiting for 25-hydroxyvitamin-D results. Additional secondary causes of osteoporosis were identified in eighteen of the fifty-three patients tested; this included five patients on chronic glucocorticoid therapy and a thirty-two-year-old man with hemochromatosis, which was diagnosed as a direct result of the osteoporosis consultation. Therefore, this osteoporosis consultation program yielded important clinical information that directly helped patient care, and it was not merely an academic exercise.
One of the goals of this program was to broaden the perspective of the admitting orthopaedist, as well as the patient with a fragility fracture, from a narrow focus on the surgical treatment of the fracture to a broader “whole patient” focus to include evaluation and treatment of the osteoporosis that caused the fracture. In this regard, there has been considerable enthusiasm for this program on the part of the orthopaedic faculty and residents at our institution. However, despite this enthusiasm, an osteoporosis consultation was requested for less than half of the patients with a fragility fracture of the hip in this study, suggesting that a mechanism to initiate routine consultation might be more effective. We speculate that having a designated individual (perhaps a nurse or physician's assistant) to identify patients with a fragility fracture and to expedite consultation by the osteoporosis consultation team would improve the consultation rate.
We are aware of several other studies on intervention programs to improve the treatment of osteoporosis in inpatients with fragility fractures, which were done in Scotland18, Switzerland19, New Zealand20, and the United States21. Our program and results are similar to those described in a study from Northwestern University Hospital, where osteoporosis treatment was started on inpatients21. In another United States study, in which hip fracture patients were triaged to an osteoporosis clinic after discharge, twenty-two (59%) of thirty-seven patients were started on a bisphosphonate22, although no follow-up data on adherence were reported. In contrast, after educational information about osteoporosis and its role in causing fractures was provided to inpatients with a hip fracture, only 29% (ten) of thirty-four patients received medical therapy for osteoporosis by their primary care physicians after discharge23. In addition, after primary physicians were provided with bone density results and osteoporosis treatment recommendations for their patients with a hip fracture, only 13% of those patients received osteoporosis treatment24. Therefore, providing patients and primary physicians with information appears to be less effective in improving osteoporosis treatment for patients with a fragility fracture than direct inpatient intervention by an osteoporosis specialist team. In addition, we believe that patients may realize the importance of osteoporosis treatment in preventing future fractures when these medications are prescribed immediately after a fracture, and this may improve compliance with the treatment plan established on discharge.
We chose to include all patients with a fragility fracture in our clinical inpatient initiative, rather than restricting our program to patients with a hip fracture for several reasons. First of all, we believe that fractures that do not involve the hip and are severe enough to require hospitalization cause substantial morbidity. Secondly, given the fact that 68% of women and 56% of men with a hip fracture have sustained a previous fracture25, we believed that by targeting all inpatients with a fracture, some hip fractures might be prevented. Finally, treating all patients with a fragility fracture should improve our ability to reach more osteoporotic patients at risk of subsequent fracture.
The strengths of this report include the follow-up information obtained on patients after discharge and the confirmation of the ubiquitous nature of vitamin-D deficiency in this population. Although our inclusion of the nonintervention cohort served to illustrate that our program was ineffective in reaching all fracture patients as we had planned, it did allow us to demonstrate the efficacy of the osteoporosis consultation when successfully initiated in an inpatient population. Although the numbers are very small, our results do suggest substantial adherence to prescribed treatment. In addition, we showed that our osteoporosis consultation team approach is feasible for the university hospital setting, but sole dependence on the orthopaedic service to initiate a request for osteoporosis consultation resulted in reaching less than half of the patients with a hip fragility fracture who were appropriate for treatment. We believe that this program could be adapted to other settings, including the community hospital, by creating an osteoporosis consultation team among endocrinologists, rheumatologists, or internists in practice and forming a partnership with orthopaedists. However, in these other settings, our experience and experience of others26 suggest the need for some form of automatic consultation.
The limitations of this report include the relatively small number of patients. In addition, we relied on patient self-reports of medication adherence and did not have an independent method of verification for all patients. Another limitation is the shorter follow-up period for the intervention group, who were contacted at regular intervals after discharge compared with the nonintervention group who were contacted only once (at two to four years after discharge). Although our findings should be generalizable to other academic inner-city hospitals with patients similar to ours, we cannot be sure that they are applicable to other types of hospitals.
In conclusion, this study provides strong support for the need for a mechanism of automatic osteoporosis consultation for inpatients with a fragility fracture and suggests that if consultation were automatic, this approach could be effective in improving care in these patients. Continued effort is needed to increase awareness among orthopaedic surgeons of the need for osteoporosis specialty care for patients with a fragility fracture. ▪
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Medicine, Division of Endocrinology, Diabetes, and Nutrition and the Departments of Epidemiology and Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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