Older women with fractures: patients falling through the cracks of guideline-recommended osteoporosis screening and treatment.
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.
Feldstein
Adrianne C
AC
Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227-1110, USA. adrianne.c.feldstein@kpchr.org
Nichols
Gregory A
GA
Elmer
Patricia J
PJ
Smith
David H
DH
Aickin
Mikel
M
Herson
Michael
M
D015502:Absorptiometry, Photon; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D016009:Chi-Square Distribution; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis / Q000453:epidemiology*; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006279:Health Maintenance Organizations; D006801:Humans; D008403:Mass Screening / Q000592:standards* / Q000639:trends; D008875:Middle Aged; D009922:Oregon / Q000453:epidemiology; D015663:Osteoporosis, Postmenopausal / Q000175:diagnosis / Q000453:epidemiology*; D010818:Practice Patterns, Physicians'; D011336:Probability; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index