Download Low rates of treatment in postmenopausal women with a history of

QJM Advance Access published October 28, 2009
Q J Med
doi:10.1093/qjmed/hcp154
Low rates of treatment in postmenopausal women with a
history of low trauma fractures: results of audit in a
Fracture Liaison Service
M.O. PREMAOR1, L. PILBROW2, C. TONKIN2, M. ADAMS2, R.A. PARKER3 and
J. COMPSTON1
From the 1Department of Medicine, University of Cambridge, 2Metabolic Bone Unit, Cambridge
University Hospitals NHS Foundation Trust and 3Centre for Applied Medical Statistics, University of
Cambridge, Cambridge, UK
Received 13 August 2009 and in revised form 5 October 2009
Summary
Background: A past history of low trauma fracture is
a strong risk factor for future fractures in postmenopausal women and national guidance recommends
treatment in the majority of such women
Aim: To establish the prevalence of bone protective
therapy use in postmenopausal women with a history of low trauma fracture
Design and Methods: Clinical audit of 1641 postmenopausal women presenting with a low trauma
fracture to the Fracture Liaison Service at
Addenbrooke’s Hospital, Cambridge between
January 2006 and December 2007.
Results: A total of 526 (31%) women presenting with
a fracture had a past history of fracture, defined as a
low trauma fracture after the age of 45 years. The
wrist was the most common site of previous fracture,
followed by hip, hand or foot, lower leg and
humerus. Of these women, only 27.6% were receiving bone protective therapy with a bisphosphonate
(89%) or other medication. Calcium and vitamin D
supplements were received by 35.6%. The highest
rates of treatment were seen for spine and hip fracture (61.9 and 49.3%, respectively). Only 45.1% of
women aged 75 years and over with a previous history of fracture were receiving bone protective
therapy.
Conclusions: The results of our audit demonstrate
low rates of treatment in postmenopausal women
with a history of low trauma fracture. Better education of healthcare professionals, more consistent recording of fractures in primary care and the use of
clearly defined care pathways that involve patients
and their carers provide rational approaches to reducing this care gap.
Introduction
fracture is a strong risk factor for future fracture, an
effect that is to some extent independent of bone
mineral density (BMD).2 For example, the presence
of a prevalent vertebral fracture increases subsequent fracture risk 5-fold and a past history of any
low trauma fracture, 2–3-fold.3 These observations
provide a strong rationale for bone protective
therapy in older people who suffer low trauma
fractures.
Osteoporotic fractures are widely recognised as a
major cause of morbidity and mortality in the elderly
population, and impose huge economic costs on
health services. In recent years there have been
major advances in the treatment of osteoporosis
and a range of interventions is now available to
reduce fracture risk.1 A past history of low trauma
Address correspondence to M.O. PREMAOR, MD, PhD, Department of Medicine, University of Cambridge,
Cambridge, UK. email: [email protected]
! The Author 2009. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: [email protected]
Page 1 of 8
M.O. Premaor et al.
In the UK, there has been a number of government led or supported initiatives to improve the care
of patients who suffer low trauma fractures. These
include the National Service Framework for Older
People,4 guidance from the Royal College of
Physicians5–7 and from the National Institute of
Health and Clinical Excellence (NICE).8–10
However, a recent large audit in 172 Trusts in the
UK of patients with low trauma fractures indicated
that implementation of these various initiatives was
extremely poor.11 Thus only 20–35% of older
women presenting with a fracture were assessed
for risk factors for osteoporosis and in the age
group 65–74 years, in which NICE mandates that
areal BMD (BMDa) assessment by dual energy
X-ray absorptiometry (DXA) should be performed,
this was achieved in <20%. The results of this
audit again highlighted the low intervention rates
with pharmacotherapy following fracture, only
42% of individuals with hip fracture and 19% of
those with other fractures being treated with bone
protective therapy other than calcium and vitamin
D. In an audit of standards in primary care, evidence
of treatment was present in only 25% of women
aged 75 years or older with a recorded previous
fragility fracture.12 These data are consistent with
those reported in a systematic review of the management of osteoporosis between 1996 and 2005 in
the US, Canada, Europe, Australia and New
Zealand, which found that only a minority of
patients was receiving bone protective therapy following a low trauma fracture and that the rates of
clinical diagnosis of osteoporosis and BMD testing
did not improve significantly following the index
fracture.13
One model that seeks to address this care gap is
the Fracture Liaison Service (FLS), in which patients
with a low trauma fracture are assessed by a specialist nurse or other healthcare professional and,
where appropriate, referred for further investigation
and treatment.14,15 These services also provide a
structure in which the implementation of guidance
can be audited. The 2002 RCP guidance recommends that treatment with bone protective therapy
should be considered in all individuals aged 65
years or over who sustain a low trauma fracture.
NICE guidance, issued in 2005 and 2008, mandates
that women over the age of 75 years who present
with a low trauma fracture should receive treatment
without the need for prior estimation of BMD,
whereas younger postmenopausal women must be
shown to have osteoporosis (BMDa T-score < 2.5)
before they can receive bone protective therapy.
The main aim of this audit was to investigate the
proportion of postmenopausal women presenting
to the FLS with a low trauma fracture and a previous
history of fracture who were receiving bone protective therapy.
Materials and methods
The Fracture Liaison Service at Addenbrooke’s
Hospital in Cambridge was set up in 2005. It is situated in the Fracture Clinic where a specialist nurse
(LP) sees all postmenopausal women attending the
clinic with a recent low trauma fracture. Patients are
counselled about risk factors and, in keeping with
current NICE guidance, those aged <75 years are
referred for bone densitometry. The study was an
anonymous audit of a clinical service and informed
consent was therefore not required.
Information recorded included fracture site, previous history of a low trauma fracture since age 45
years, tobacco and alcohol use, medications, age
at menopause and past medical history. BMDa in
the lumbar spine (L1–L4) and proximal hip was measured in women aged <75 years within 4 weeks of
the fracture by DXA using a Hologic bone densitometer (Hologic QDR 4500A, Hologic Inc., Bedford
MA). The short term in vivo precision of measurement at these two sites is 1 and 1–2%, respectively.
Total hip BMDa T-scores were calculated using data
from the NHANES reference female population.
According to the WHO classification, osteoporosis was defined as a BMDa T-score in the lumbar
spine and/or total hip of < 2.5, osteopenia as a
T-score between 1 and 2.5 and normal BMDa
as a T-score > 1.16 If the T-score was < 2.5 at
one site, a diagnosis of osteoporosis was made
regardless of the T-score at the other site.
Osteopenia was diagnosed when at least one
T-score was between 1 and 2.5 and neither
T-score was < 2.5 and normal BMDa was diagnosed only in cases where the T-score was higher
than 1 at both sites.
Height and weight were measured at the time of
bone density measurement and the body mass index
(BMI) was calculated as weight (kg)/[height (m)2].
Fractures were considered to be low trauma fractures if they occurred spontaneously or from standing height or less. All incident fractures were verified
radiologically.
Statistics
The study statistics were mainly descriptive. The
prevalence of previous fracture, use of bone protective medication, use of calcium and vitamin D, fracture sites, and previous fracture were calculated.
The student t test was used to compare age, BMI
and T-score between women with or without a previous history of fracture. In addition, Fisher’s exact
Page 2 of 8
Low rates of treatment in postmenopausal women
Table 1 Characteristics of postmenopausal women presenting at the Fracture Liaison Service
between January 2006 and December 2007
Clinical data
Age (years)
BMI (kg/m2)
Previous history of fracture
On bone protective therapy
Bisphosphonates
Hormone replacement therapy
Strontium ranelate
Raloxifene
Calcium plus vitamin D supplementation
Current glucocorticoid use
Use of more than 14 units alcohol per week
Current smokers
Bone mineral density (DXA; mean SD)
Spine T-score
Total hip T-score
Fracture sites
Wrist
Lower leg
Humerus
Hand or foot
Hip
Spine
Other
test was used to evaluate the differences in use of
bone protective therapy, and calcium and vitamin D
in these two groups. This test was used also to evaluate differences in the prevalence of fracture sites in
women with and without fractures. Differences were
considered significant when the two-tailed P-value
was <0.05. The statistical analysis was performed
using the SPSSÕ statistics package for WindowsÕ
version 16.0.
Results
Data from 1641 postmenopausal women presenting
with a fragility fracture to the Fracture Liaison
Service between January 2006 and December
2007 were examined. Of these women, 1005 were
under the age of 75 years, of whom 801 (80%)
agreed to undergo bone densitometry. In the
remaining 20%, the patient either declined to have
bone densitometry or was unable to undergo the
examination for physical or logistical reasons.
Women who did not undergo BMDa measurement
did not differ significantly from those who did in
terms of age, fracture site, BMI, tobacco use or alcohol intake but were more likely to be taking
70.2 11.7 (n = 1641)
27.28 5.6 (n = 849)
526/1640 (32.1%)
280/1641 (17.1%)
232/1641 (14.1%)
31/1641 (1.9%)
16/1641 (1.0%)
1/1641 (0.1%)
365/1641 (22.2%)
24/1641 (1.5%)
26/1640 (1.6%)
80/1640 (4.9%)
1.22 1.4 (n = 804)
0.82 1.05 (n = 797)
628/1641 (38.3%)
276/1641 (16.8%)
225/1641 (13.7%)
218/1641 (13.3%)
158/1641 (9.6%)
2/1641 (0.1%)
134/1641 (8.2%)
glucocorticoids (3.6 vs. 0.6%; p < 0.003) and bone
active medications (29.7 vs. 7.2%; p < 0.0001).
Demographic details of all 1641 women, including the fracture sites, are shown in Table 1. The wrist
was the most common site of fracture, followed by
the lower leg, humerus and hand or foot.
Information about previous fracture history was
available in all but one woman. 526 (32.1%) of
the remaining 1640 women had a past history of
fracture. The mean (SD) spine T-score in women
undergoing bone densitometry was 1.22 (1.4)
and the mean total hip T-score was 0.82 (1.05).
Overall, when both spine and hip BMDa were considered, osteoporosis was present in 19.3%, osteopenia in 41.2% and normal BMDa in 39.4% of
women.
Table 2 shows that women with a past history of
fracture were significantly older than those without
fracture and had significantly lower BMDa both in
the hip and spine (p < 0.0001 and 0.02, respectively). Only 27.6% of women with a previous history of fracture were receiving bone protective
therapy, as compared to 12.1% of women without a known fracture history (p < 0.0001).
Bisphosphonates were the commonest form of treatment in both groups (89 and 76.3%, respectively),
followed by strontium ranelate (6.2 and 5.2%,
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M.O. Premaor et al.
Table 2 Demographic details in women with or without a previous history of fracture
Without previous fracture
Clinical data
Age (years)
BMI (kg/m2)
On bone protective therapy
Bisphosphonates
Strontium ranelate
Hormone replacement therapy
Raloxifene
Calcium plus vitamin D supplementation
BMD (DXA; mean SD)
Spine T-score
Total hip T-score
68.5 11.7
27.33 5.4
135/1114
103/135
7/135
25/135
0/135
178/1114
(n = 1114)
(n = 599)
(12.1%)
(76.3%)
(5.2%)
(18.5%)
(0%)
(16.0%)
1.16 1.35 (n = 607)
0.74 1.02 (n = 606)
With previous fracture
73.7 10.9
27.16 6.0
145/526
129/145
9/145
6/145
1/145
187/526
p-value
(n = 526)
(n = 250)
(27.6%)
(89%)
(6.2%)
(4.1%)
(0.7%)
(35.6%)
<0.0001
0.685
<0.0001
0.001
1.41 1.36 (n = 197)
1.08 1.09 (n = 191)
0.020
<0.0001
<0.0001
Table 3 Site of previous fracture
Fracture site
Wrist
Hip
Hand or foot
Lower leg
Humerus
Elbow
Ribs
Spine
Clavicle
Pelvis
Scapula
Nose
195
75
61
56
39
34
25
21
9
6
1
3
(37.1%)
(14.3%)
(11.6%)
(10.7%)
(7.4%)
(6.5%)
(4.8%)
(4.0%)
(1.7%)
(1.1%)
(0.2%)
(0.6%)
Table 4 Percentage of women with and without a history of fracture according to site of incident fracture
Site of incident fracture
Without previous fracture
With previous fracture
p-value
Wrist
Humerus
Hip
Lower leg
Hand or foot
Spine
Other
409/1114
152/1114
98/1114
199/1114
169/1114
2/1114
85/1114
219/526
73/526
60/526
76/526
49/526
0/526
49/526
0.057
0.938
0.106
0.089
0.001
0.999
0.247
(36.7%)
(13.6%)
(8.8%)
(17.9%)
(15.2%)
(0.2%)
(7.6%)
respectively). Information about the indication for
bone protective therapy in women without a history
of fracture was not recorded in the audit.
The site of previous fracture is shown in Table 3.
Wrist was most common, followed by hip, lower leg
and hand or foot. Table 4 compares the proportion
of women without and with a previous fracture
according to incident fracture site. Women presenting with a wrist fracture were more likely to have a
(41.7%)
(13.9%)
(11.4%)
(14.5%)
(9.4%)
(0%)
(9.4%)
previous fracture history (p = 0.057) whilst those
presenting with a hand or foot fracture were less
likely to have a previous history of fracture
(p = 0.001). No woman reported a previous history
of vertebral fracture.
Figure 1 shows the frequency of bone protective
therapy in women with a previous fracture according to fracture site. The highest rates of treatment
were seen for spine and hip fracture (61.9 and
Page 4 of 8
Low rates of treatment in postmenopausal women
Figure 1. Use of bone protective therapy in women with previous fracture by fracture site.
49.3%, respectively). The lowest rates were seen in
women with a previous history of lower leg and
hand or foot fracture (16.1 and 11.5%, respectively).
Women aged 75 years or older were more likely
to be receiving bone protective therapy and/or calcium and vitamin D supplements than women aged
<75 years. The rate of treatment with bone protective therapy in women aged >75 years was 45.1%
compared with 23.1% in women aged <75 years.
The corresponding figures for calcium and vitamin
D supplementation were 43.6 and 23.2%,
respectively.
Discussion
Our results confirm low rates of bone protective
therapy in postmenopausal women with a history
of low trauma fracture, only 27.6% of those with a
known past history of fracture in this audit receiving
treatment. The highest rates of treatment were seen
in women with previous spine or hip fracture, and
women aged 75 years or older were more likely to
be taking treatment than those aged <75 years. The
use of calcium and vitamin D supplements was
slightly higher but overall was reported by only
36.5% of women with previous fracture.
Overall, a previous history of fracture was
recorded in approximately one–third of women
presenting to the Fracture Clinic with a low trauma
fracture. A previous fracture history is a welldocumented risk factor for future fracture; this relationship is particularly strong for previous vertebral
fracture but is also seen for other fracture sites.2,3
Klotzbuecher et al. reported that overall, a previous
fracture was associated with an 2-fold increase in
the risk of subsequent fracture; however, in women
with a previous vertebral fracture the risk was
increased 4-fold.3 This effect is largely unchanged
after adjustment for BMDa, and little affected by
whether the previous fractures are classified as low
trauma or not.2
A range of options has been shown to be effective
in reducing low trauma fractures in postmenopausal
women including bisphosphonates (alendronate,
risedronate, ibandronate and zoledronate), strontium ranelate, raloxifene and parathyroid hormone
peptides.1 Their use in the prevention of fractures in
high-risk women is cost-effective and can reduce
vertebral fractures by up to 70%, non-vertebral fractures by up to 15–20% and hip fractures by up to
40%. Current guidelines in the UK are consistent in
recommending bone protective therapy in postmenopausal women aged >75 years who have sustained a low trauma fracture without the need for
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M.O. Premaor et al.
BMDa measurement, although there is a general
consensus that BMDa measurements should guide
treatment decisions in younger postmenopausal
women.5–10,17 European guidelines recommend
that all postmenopausal women with a previous
fracture can be considered for treatment without
the need for DXA18 whilst in the USA, DXA is
recommended before treatment in all postmenopausal women with a fracture.19 The majority of postmenopausal women with a low trauma fracture
have osteoporosis or osteopenia and on the basis
of their probability of future fracture would be considered as candidates for bone protective therapy.20–23
However, in other cases BMDa is normal and the
case for bone protective therapy is uncertain. In
this context it should be recognised that measurements of spine BMDa may be falsely elevated by the
presence of scoliosis and osteophytes; in addition,
increased risk of falling increases fracture risk independent of BMDa. Nevertheless, the rates of treatment reported in this audit are suboptimal; for
example, treatment would be considered appropriate in the vast majority of women with a previous
hip or spine fracture, yet only 49 and 61%, respectively, in our sample were treated. Similarly, in the
population of women aged over 75 years with a
previous low trauma fracture, less than one half
were receiving treatment. Our audit results are consistent with the low rates of treatment reported in
other studies and emphasise the missed opportunities to prevent further fractures in women who
are known to be high risk as a result of their previous
fracture history.
Consistent with other reports, we found that the
majority of postmenopausal women presenting with
a low trauma fracture did not have osteoporosis as
defined on the basis of BMDa20–23 and normal
BMDa (T-score > 1) was recorded in nearly 40%
of the women aged <75 years in whom it was measured. The WHO classification of osteoporosis as a
BMDa T-score < 2.5 was intended as an operational definition that identified women at highest
risk of fracture, but few postmenopausal women
have a BMDa in this range and numerically the
most fractures occur in women with a BMDa
T-score higher than 2.5. Using peripheral BMD
measurements Siris et al.20 reported that only 7.2%
of women who developed a fracture within 1 year of
BMDa measurement had a T-score below 2.5,
whilst 39.6% had a T-score between 1 and 2.5
and 53.2% had a T-score higher than 1. Schuit
et al.21 reported normal baseline femoral neck
BMDa in 12.6% of postmenopausal women with incident non-vertebral fractures during a mean follow-up
period of 6.8 years, osteopenia in 43.3% and osteoporosis in 44.1%. In the Study of Osteoporotic
Fractures (SOF), baseline total hip BMDa showed
osteoporosis in 46% of women who developed a
hip fracture during 5 years of follow-up, whereas
48% were osteopenic and 6% had normal
BMDa22. Pascoe et al.23 reported that only 26.9%
of fractures over a median follow-up period of
5.6 years occurred in women with osteoporosis as
defined by a baseline BMDa T-score > 2.5, whilst
56.5% occurred in women with osteopenia and
16.6% in women with normal BMDa. In clinical
trials the anti-fracture efficacy of bone protective
treatments has mostly been established in postmenopausal women with low BMDa, with or without
prevalent fractures. The results of these studies provide a strong rationale for treating postmenopausal
women who present with fracture and have low
BMDa; evidence from a number of sources supports
the efficacy of these interventions in women with
osteopenia as well as those with osteoporosis.24–29
Our study has several limitations. Vertebral fractures were under-represented in this audit, because
the majority do not come to medical attention30,31
and those that do may be referred to a specialist
metabolic bone clinic rather than a fracture clinic.
Only total hip, and not femoral neck BMDa was
recorded for the purposes of the audit, since only
total hip BMDa is routinely included in our DXA
reports to referring physicians. Hip fractures were
also under-represented, since they are not routinely
followed up in the fracture clinic. We were only
able to assess those women who attended the fracture clinic and do not know the characteristics of
those who failed to keep their appointment. Only
current medications were recorded, so it is possible
that some women recorded as not receiving bone
protective therapy had taken this in the past. We did
not record the date of previous fractures and it is
likely that some of these occurred before national
guidance for secondary prevention of fractures
became available in 1999. Nevertheless, the history
of a low trauma fracture after the age of 45 years
should have triggered further intervention and,
where appropriate, bone protective treatment following the availability of national guidance.
Finally, previous fractures were self-reported and
not verified radiologically.
A number of factors are likely to contribute to the
persisting care gap in the secondary prevention of
fracture13,32–37. The financial costs of diagnosis and
treatment may act as barriers, as may the lack of
availability of DXA in some parts of the UK,
although this has improved in recent years.
Second, bone disease is an ‘orphan’ speciality and
the care of patients with osteoporosis is
shared between primary care and a number of different specialities in secondary care including
Page 6 of 8
Low rates of treatment in postmenopausal women
rheumatology, endocrinology, gerontology and
orthopaedics. Third, there is often a lack of clarity
regarding the allocation of responsibility for prescribing treatment; funding pressures may be used
to deny adequate access to treatment, although the
cost-effectiveness of secondary prevention of fracture is well documented. Fourth, publicity about
perceived or real side effects of treatment, for example osteonecrosis of the jaw, may make both
patients and their doctor reluctant to initiate and
continue therapy. Finally, the patient is often
poorly informed about their disease and its treatment. Better education of healthcare professionals
involved in the management of osteoporosis, more
consistent recording of fractures in primary care and
the use of clearly defined care pathways that involve
and empower patients and their carers provide rational approaches to reducing the care gap. Fracture
Liaison Services and similar models have proven
value in improving the assessment of patients with
osteoporosis and should be more widely utilised to
target high-risk individuals for bone protective therapy.14,38–40 In addition use of the FRAXÕ risk algorithm to assess 10 year fracture probability41 and
guidelines that provide treatment advice based on
FRAXÕ outputs should facilitate the much needed
improvement in the management of postmenopausal women with low trauma fracture.
Funding
This study was supported by Cambridge Biomedical
Research Centre and National Institutes for Health
Research (NHIR). In addition, Melissa Premaor was
supported by Coordenação de Aperfeiçoamento de
Pessoal de Nı́vel Superior (CAPES Foundation),
Ministry of Education, Brazil.
6. Royal College of Physicians and Bone and Tooth Society of
Great Britain. Update on Pharmacological Interventions and
an Algorithm for Management. London, UK, Royal College of
Physicians, 2000. http://www.rcplondon.ac.uk
7. Royal College of Physicians. Glucocorticoid-induced osteoporosis. Guidelines on Prevention and Treatment. Bone and
Tooth Society of Great Britain, National Osteoporosis Society
and Royal College of Physicians. Royal College of
Physicians, London, UK, 2002.
8. National Institute for Health and Clinical Excellence.
Alendronate, etidronate, risedronate and raloxifene for the
secondary prevention of osteoporotic fragility fractures in
postmenopausal women. Final Appraisal Determination.
TAG87. London, NICE, 2005.
9. National Institute for Health and Clinical Excellence.
Alendronate, etidronate, risedronate, raloxifene, strontium
ranelate and teriparatide for the secondary prevention of
osteoporotic fragility fractures in postmenopausal women.
Final Appraisal Determination. TAG 161. London, NICE,
2008.
10. National Institute for Health and Clinical Excellence.
Alendronate, etidronate, risedronate, raloxifene, strontium
ranelate for the primary prevention of osteoporotic fragility
fractures in postmenopausal women. Final Appraisal
Determination. TAG 160. London, NICE, 2008.
11. National Clinical Audit of falls and bone health in older
people. Clinical Effectiveness and Evaluation Unit. London,
Royal College of Physicians, 2007.
12. Hippisley-Cox J, Bayly J, Potter J, Fenty J, Parker C.
QResearch. Evaluation of standards of care for osteoporosis
and falls in primary care. Final Report to the
Information Centre for Health and Social Care, 2007. http://
www.qresearch.org/public/publications.aspx
13. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N,
Adachi JD. Fragility fractures and the osteoporosis care
gap: an international phenomenon. Semin Arthritis Rheum
2006; 35:293–305.
14. McLellan AR, Gallacher SJ, Fraser M, McQuillan C. The
fracture liaison service: success of a programme for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 2003; 14:1028–34.
Conflict of interest: None declared.
15. British Orthopaedic Association. Care of the Patient
with Fragility Fracture. September 2007. http://
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