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Adult Hip Reconstruction Test 3: Perioperative Practices
Hand Test 1: Trauma about the Hand and Wrist
Trauma Test 1: Fractures of the Long Bones and Joints
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The Journal of Bone and Joint Surgery (American) 85:2294-2302 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Older Women with Fractures: Patients Falling Through the Cracks of Guideline-Recommended Osteoporosis Screening and Treatment

Adrianne C. Feldstein, MD, MS1, Gregory A. Nichols, PhD1, Patricia J. Elmer, PhD, MS1, David H. Smith, RPH, MHA, PhD1, Mikel Aickin, PhD1 and Michael Herson, MD2

1 Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227-1110. E-mail address for A.C. Feldstein: adrianne.c.feldstein{at}kpchr.org
2 Northwest Permanente, 500 N.E. Multnomah Street, Portland, OR 97232

Investigation performed at Kaiser Permanente Center for Health Research, Portland, Oregon

In support of their research or preparation of this manuscript, one or more of the authors received Grant 1 R03 HS13013-01k from the Agency for Health Care Quality and Research. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated (Kaiser Permanente Center for Health Research received three grants from Merck and Company for osteoporosis-related research. A.C.F. is primary investigator for two studies and coinvestigator for one study, and P.J.E. is primary investigator for one study and coinvestigator for two studies).

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: Many older patients with fractures are not managed in accordance with evidence-based clinical guidelines for osteoporosis. Guidelines recommend that these patients receive treatment for clinically apparent osteoporosis or have bone mineral density measurements followed by treatment when appropriate. This cohort study was conducted to further characterize the gap between guidelines and actual practice with regard to bone mineral density measurement and treatment of older women after a fracture. Our purpose was to aid in the design of more effective future interventions.

Methods: We identified female members of a not-for-profit group-model health maintenance organization who were fifty years of age or older and who had a diagnosis of a new fracture as defined in the study. We used administrative databases and the clinical electronic medical records to obtain data on demographics, diagnoses, drugs dispensed by the pharmacy, and the measurement of bone mineral density.

Results: The study population included 3812 women with an average age of 71.3 years. Fewer than 12% of the women had a diagnosis of osteoporosis prior to the index fracture; 10.7% had an increased risk for secondary osteoporosis and 38.8%, for falls because of a diagnosis or medication. It was found that 46.4% of the study population had been managed as specified by clinical guidelines. The patients who had been managed as specified by the guidelines were younger and less likely to have the risk factor of a weight of <127 lb (58 kg), a hip fracture, or a wrist fracture. They were also more likely to be taking steroids on a chronic basis and to have had a vertebral fracture. The percentage of women who had measurement of bone mineral density increased during the study period, from 1.3% in 1998 to 10.2% in 2001. Of the patients receiving treatment for osteoporosis, 73.6% adhered to the treatment regimen.

Conclusions: Adherence to guidelines for evaluation and treatment for osteoporosis after a patient sustained a fracture did not improve between 1998 and 2001 despite the promulgation of evidence-based guidelines. Methods to enhance education and facilitate processes of care will be necessary to reduce this gap. It may be fruitful to target high-risk subgroups for tailored interventions for prevention of refracture.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.


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