JBJS | Treatment of Osteoporosis: Are Physicians Missing an Opportunity?*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 8

Articles | August 01, 2000

Treatment of Osteoporosis: Are Physicians Missing an Opportunity?*†

Kevin B. Freedman, M.D., M.S.C.E.‡; Frederick S. Kaplan, M.D.‡; Warren B. Bilker, Ph.D.‡; Brian L. Strom, M.D., M.P.H.‡; Robert A. Lowe, M.D.‡, M.P.H.

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Investigation performed at University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were a grant from Merck and Company, Incorporated, West Point, Pennsylvania, and the Clinical Investigator Graduate Degree Program at the University of Pennsylvania School of Medicine.
†Winner of the American Orthopaedic Association/Zimmer Annual Travel Awards Competition for United States Orthopaedic Residents.
‡Department of Orthopaedic Surgery (K. B. F. and F. S. K.), Center for Clinical Epidemiology and Biostatistics (K. B. F., W. B. B., B. L. S., and R. A. L.), Department of Biostatistics and Epidemiology (K. B. F., W. B. B., B. L. S., and R. A. L.), Department of Emergency Medicine (R. A. L.), Leonard Davis Institute for Health Economics (R. A. L.), and Division of General Internal Medicine (F. S. K. and B. L. S.), University of Pennsylvania School of Medicine, 2 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. E-mail address for K. B. Freedman: kfreedma@mail.med.upenn.edu.

The Journal of Bone & Joint Surgery. 2000; 82:1063-1063

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Abstract

Background: Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius.

Methods: A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture.

Results: A search of the database identified 1162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001).

Conclusions: Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Osteoporosis affects 45 percent of women who are fifty years of age or older, resulting in a lifetime risk of 40 percent for fractures of the hip, vertebra, or distal part of the forearm³⁶. Treatment of osteoporosis with estrogen^7,16,18,19, bisphosphonates^{6,26,31,55,56,60}, or calcitonin^24,44,49,50 has been shown to increase bone-mineral density and to decrease the incidence of future fracture. Importantly, treatments resulting in small increases in bone-mineral density may reduce the risk of hip fracture by 50 percent compared with the risk for untreated postmenopausal women⁵¹.

Fracture of the distal part of the radius often represents a seminal event in patients at high risk for later hip fracture; this highlights the importance of treatment intervention in this high-risk group³⁴. Patients who have sustained a distal radial fracture have nearly twice the relative risk of a future hip fracture^23,34,45, and elderly women with a distal radial fracture have both site-specific and generalized decreased bone-mineral density when compared with young adults and age-matched controls^{12,13,20,33,35}. A recent study showed that 91 percent of 106 postmenopausal women who had sustained a distal radial fracture met the World Health Organization (WHO) diagnostic criteria for osteoporosis or osteopenia on a dual-energy x-ray absorptiometry (DEXA) scan¹³. Therefore, in the majority of cases, a distal radial fracture in a postmenopausal woman should alert the treating physician that osteoporosis is very likely to be present.

Despite the evidence in support of evaluating and treating older women for osteoporosis after they have sustained a low-energy fracture, a survey of fifty-six Danish orthopaedic surgery departments revealed that only 13 percent (seven) referred their patients with a low-energy fracture for a bone-density scan and only 11 percent (six) treated these patients for osteoporosis¹⁴. The present study was undertaken because of the concern that physicians in the United States may have similar rates of diagnosis and treatment of osteoporosis in patients with a low-energy fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius.

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Table I: Rate of Medical Treatment of Osteoporosis by Age*

*There was a significant trend for a decreasing rate of treatment with increasing patient age (p < 0.0001, chi-square test for trend).

Age (yrs.)	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
55-59	139	50	36.0 (28.0-44.5)
60-64	130	37	28.5 (20.9-37.0)
65-69	206	50	24.3 (18.6-30.7)
70-74	224	48	21.4 (16.2-27.4)
75-79	196	42	21.4 (15.9-27.8)
80-84	113	29	25.7 (17.9-34.7)
85-89	66	6	9.1 (3.4-18.7)
90-94	24	1	4.2 (0.1-21.1)
95 or older	64	3	4.7 (1.0-13.1)

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Table I: Rate of Medical Treatment of Osteoporosis by Age*

*There was a significant trend for a decreasing rate of treatment with increasing patient age (p < 0.0001, chi-square test for trend).

Age (yrs.)	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
55-59	139	50	36.0 (28.0-44.5)
60-64	130	37	28.5 (20.9-37.0)
65-69	206	50	24.3 (18.6-30.7)
70-74	224	48	21.4 (16.2-27.4)
75-79	196	42	21.4 (15.9-27.8)
80-84	113	29	25.7 (17.9-34.7)
85-89	66	6	9.1 (3.4-18.7)
90-94	24	1	4.2 (0.1-21.1)
95 or older	64	3	4.7 (1.0-13.1)

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Table II: Medical Treatment of Osteoporosis by Fracture Date*

*With the numbers available, there was no significant trend in the rate of treatment of osteoporosis across study years (p = 0.8006, chi-square test for trend).

Fracture Date by Year	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
July 1, 1994-June 30, 1995	550	124	22.5 (19.1-26.3)
July 1, 1995-June 30, 1996	316	73	23.1 (18.6-28.1)
July 1, 1996-June 30, 1997	296	69	23.3 (18.6-28.6)

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Table II: Medical Treatment of Osteoporosis by Fracture Date*

*With the numbers available, there was no significant trend in the rate of treatment of osteoporosis across study years (p = 0.8006, chi-square test for trend).

Fracture Date by Year	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
July 1, 1994-June 30, 1995	550	124	22.5 (19.1-26.3)
July 1, 1995-June 30, 1996	316	73	23.1 (18.6-28.1)
July 1, 1996-June 30, 1997	296	69	23.3 (18.6-28.6)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

The specific aim of the study was to determine the proportion of women fifty-five years of age or older with a distal radial fracture between July 1, 1994, and June 30, 1997, who had undergone subsequent diagnostic evaluation or treatment of osteoporosis. This was a retrospective cohort study performed with use of a large administrative database. Approval for the study was obtained from the institutional review board at our university.

Data Source: Clinical Care in America Managed Care Database

The Clinical Care in America (CCIA) Managed Care Database (Protocare Sciences, Herndon, Virginia), which includes a national cohort of patients enrolled with a private insurance carrier, was used for this study. This database contains private-health-care claims and enrollment data representing health-care services provided through health maintenance organizations (HMOs), preferred-provider organizations (PPOs), major employers (through Administrative Services), and Medicare coverage to more than three million members annually. The database includes insurers with a wide geographic distribution, with members residing predominantly in twenty-two states. Approximately 72 percent of the members of the Managed Care Database belong to commercial HMO or PPO plans. Seventeen percent of the membership of the Managed Care Database belong to a Medicare Risk plan, which provides HMO-based managed care to Medicare-eligible individuals, and 4 percent belong to a Medicare Supplement plan, an indemnity insurance policy that supplements Medicare benefits. The remaining 7 percent are enrolled in a variety of specialty and administrative-services-only products. Protocare Sciences assembled the data from third-party payers, subjecting it to a rigorous internal quality-assurance protocol for completeness and consistency before supplying it for analysis by the project team (personal communication, Amy Solis, Protocare Sciences). Databases from Protocare Sciences have been used for a variety of studies on adverse drug effects and on drug treatment^{39,47,54,57,58}.

Within the Managed Care Database, currently available billing data for each patient includes demographic information (age, state of residence, and marital status), inpatient and outpatient diagnoses (by International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code³), procedures (surgical, laboratory, and radiology, by Current Procedural Terminology code²), outpatient drugs (by National Drug Code), and physician visits.

Performance of this study with use of the CCIA Managed Care Database had several major advantages. The first was the size of the database, which includes data on more than three million individuals. Second, the database is population-based, permitting the calculation of incidence rates. Third, it includes a diverse sample of patients and physicians, from a wide geographic area. Fourth, it is complete, in the sense that it captures all medical care, including full pharmaceutical coverage, provided by private insurers. Finally, and most importantly, computerized claims data do not rely on patient recall or on interviewers to collect the data and therefore are not subject to recall or interview bias.

Selection of Study Subjects

All patients in the CCIA Managed Care Database who had sustained a distal radial fracture during the study period from July 1, 1994, to June 30, 1997, were enrolled in the study. The diagnosis was identified by ICD-9-CM code 813.4 or 813.5 and was confirmed with use of Current Procedural Terminology (CPT) codes appropriate for this specific injury (25600, 25605, 25611, 25620, 29065, 29075, 29085, 29105, and 29125). The confirming CPT code had to have been recorded within thirty days after the date of the fracture diagnosis. Only patients who had both an ICD-9-CM and a CPT code consistent with the diagnosis of an acute distal radial fracture were included in the final cohort.

Of these patients, only women fifty-five years of age or older at the time of the first wrist-fracture diagnosis were included. Women were selected because they are much more likely to have osteoporosis, and most of the evidence regarding the effectiveness of treatment of osteoporosis has been derived from studies of women. The minimum age of fifty-five was selected because the average age of menopause is fifty (range, forty-five to fifty-five^30,32), with 98.5 percent of women having experienced menopause by the age of fifty-five³⁰. The specific age of menopause for individual women in the database was not available.

We next screened for patients with continuous and complete health and drug-plan enrollment for at least six months after the diagnosis of the wrist fracture to capture all health-care claims, including those for prescriptions. All patients enrolled in a Medicare Supplement plan were excluded, since these patients could have an incomplete claim history if coverage were provided by their Medicare plan. The final screening identified 1162 eligible patients. Medical and pharmacy claims from January 1, 1991, through December 31, 1997, were available (ensuring a minimum of six months of follow-up) for all patients who met the final screening criteria. Since complete and continuous enrollment was guaranteed only for six months following the date of the fracture, the database may not have contained all health-care and drug claims made prior to the date of the fracture if a patient did not have continuous or complete enrollment during this period. All screening was performed by Protocare Sciences according to the specific algorithm detailed above. Data on the 1162 patients were transferred to us for analysis.

Outcome Variables

The index date (the date when follow-up was begun) for each subject was the initial date of the diagnosis of a distal radial fracture. The patient's record was then analyzed to determine whether either of two general outcomes - diagnostic evaluation or treatment of osteoporosis - occurred in the six-month period following the index date. To identify the patients who underwent diagnostic evaluation for osteoporosis, the patient record was searched for the CPT codes for any accepted radiographic measure of bone mineral density (76070, 76075, and 76076). To identify the patients who were treated for osteoporosis with medications, the patient record was searched for any of the target medications (estrogen, bisphosphonates, or calcitonin) approved by the Food and Drug Administration during the study period for the treatment of established osteoporosis. These medications were identified by National Drug Codes (NDCs) contained in the database.

The outcome of interest was simply whether the physician had prescribed any appropriate medication, thus demonstrating recognition and treatment of the underlying osteoporosis, rather than patient compliance with ongoing treatment. Therefore, compliance beyond a single filled prescription was not considered important for the purpose of this study. A follow-up period of six months was chosen because this interval is sufficient for both acute fracture-healing (six to eight weeks) and chronic disease management.

Statistical Analysis

The analysis described the frequency of the specific outcome of interest - namely, diagnostic evaluation or treatment of osteoporosis. Each specific outcome (bone-density scanning or treatment with estrogen, a bisphosphonate, or calcitonin) was analyzed individually. A combined analysis was also performed. The results of each outcome analysis are reported as a proportion, with an associated exact binomial 95 percent confidence interval. In order to evaluate the rate of treatment for osteoporosis by age and fracture date, a chi-square test for trend (Cochran-Armitage trend test⁴) was performed. Statistical analyses were performed with Intercooled Stata 6.0 (Stata; College Station, Texas) and StatXact 4.0 (Cytel Software; Cambridge, Massachusetts).

Results

Introduction | Materials and Methods | Results | Discussion | References

Patient Selection

After all screens had been performed, 1162 women who were fifty-five years of age or older, had an ICD-9-CM and a CPT code confirming a wrist fracture between July 1, 1994, and June 30, 1997, and had had continuous health and drug benefits for at least six months following the diagnosis of the wrist fracture were identified. Two hundred and sixty-nine patients (23.1 percent) were fifty-five to sixty-four years of age; 430 (37.0 percent), sixty-five to seventy-four years of age; 309 (26.6 percent), seventy-five to eighty-four years of age; ninety (7.7 percent), eighty-five to ninety-four years of age; and sixty-four (5.5 percent), ninety-five years of age or older.

The patients resided in thirty states in the United States.

Diagnosis of Osteoporosis

Of the 1162 patients, only thirty-three (2.8 percent [95 percent confidence interval, 2.0 to 4.0 percent]) underwent a bone-density scan within six months after the fracture. Of the thirty-three scans, six were computerized tomography bone-density studies and twenty-seven were central dual-energy x-ray absorptiometry (DEXA) scans.

Treatment of Osteoporosis

Of the 1162 patients, 266 (22.9 percent [95 percent confidence interval, 20.5 to 25.4 percent]) filled prescriptions for at least one of the medications approved for the treatment of established osteoporosis. Estrogen was prescribed for 232 patients; a bisphosphonate (alendronate), for forty patients; and calcitonin, for nineteen patients. More than one medication was prescribed for twenty-five patients. Of these, eleven had a change of medication (from estrogen to a bisphosphonate or from estrogen to calcitonin) at the time of the fracture. The other fourteen patients were treated with more than one medication concurrently.

Of the 232 patients who filled prescriptions for estrogen, ninety-nine had first been given a prescription for estrogen prior to the date of the wrist fracture. Of these ninety-nine patients, eleven were treated with a bisphosphonate or calcitonin following the fracture, indicating a change in treatment. Because the remaining eighty-eight patients had been given a prescription for estrogen prior to the fracture date, there is no indication that the estrogen was prescribed in response to the fracture. In addition, of the forty patients who filled prescriptions for alendronate, three had first been given a prescription for alendronate prior to the date of the fracture, and of the nineteen patients who filled prescriptions for calcitonin, two had been so treated prior to the date of the fracture. If the patients with medical treatment for osteoporosis prior to the date of the fracture are eliminated from the denominator for "eligible for treatment," then only 173 (16.2 percent [95 percent confidence interval, 14.0 to 18.5 percent]) of 1069 patients filled prescriptions for a medication for osteoporosis in response to the fracture.

Of the 1162 women with a distal radial fracture, 883 (76.0 percent [95 percent confidence interval, 73.4 to 78.4 percent]) received neither a bone-density scan nor medical treatment of osteoporosis.

Rate of Treatment of Osteoporosis by Patient Age

The rates of treatment by patient age at the time of the distal radial fracture, in five-year intervals, are presented in Table I. The chi-square test for trend was used to test for a trend in the rate of treatment of osteoporosis across age-groups. There was a significant trend for a decreasing rate of treatment with increasing patient age (p < 0.0001).

Rate of Treatment of Osteoporosis by Fracture Date

A yearly analysis was performed to determine if there was any change in the rate of treatment of osteoporosis over the three-year study period (Table II). The chi-square test for trend showed no significant trend in this rate (p = 0.8006), with the numbers available.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

In the United States alone, 1.5 million fractures, including 250,000 hip fractures, 700,000 vertebral fractures, and 250,000 distal radial fractures, occur each year as a result of osteoporosis⁵². These fractures, especially hip fractures, result in substantial morbidity and mortality for postmenopausal women^15,25,37. Recent advances in the medical treatment of established osteoporosis may decrease the incidence of osteoporotic fractures^{6,7,16,17,21,26,31}. The recommendations of the National Osteoporosis Foundation for the treatment of osteoporosis are widely available⁴² and are as follows:

1. Physicians should perform an evaluation for osteoporosis, using bone-density testing to confirm the diagnosis and to determine the disease severity, for all postmenopausal women who present with a fracture.

2. Physicians should advise all patients to obtain an adequate intake of dietary calcium (at least 1200 milligrams per day, including supplements if necessary) and vitamin D (400 to 800 international units per day for individuals at risk for deficiency).

3. Physicians should initiate therapy to reduce fracture risk in women with bone-mineral-density T-scores of less than -2 in the absence of risk factors and in women with T-scores of less than -1.5 if other risk factors are present (including a history of any adult fracture).

4. Women older than seventy years of age with multiple risk factors (especially those with previous fractures involving neither the hip nor the spine) are at high enough risk of fracture to justify the initiation of treatment without bone-density testing.

5. The Food and Drug Administration-approved pharmacological options for osteoporosis prevention or treatment, or both, are hormone replacement therapy, alendronate, raloxifene (for prevention), and calcitonin (for treatment)⁴².

Postmenopausal women who sustain a distal radial fracture are at high risk for osteoporosis and future fractures. Fracture of the distal part of the radius has classically been associated with low bone mass, and several studies have demonstrated that elderly women with a distal radial fracture have both site-specific and generalized decreased bone-mineral density when compared with young adults and age-matched controls^{12,13,20,33,35}. In more than 90 percent of cases, distal radial fracture alone is sufficient clinical evidence for the diagnosis of osteoporosis^{1,38,43,46,59,62}. In addition, the risk factors for women who have sustained a distal radial fracture are similar to those for women who have sustained a hip fracture; these include an older age and reduced bone mass. However, the incidence of distal radial fracture starts to rise approximately fifteen years earlier than that of hip fracture; thus, a distal radial fracture is a potential forecaster of a hip fracture^5,34. In fact, there is a substantial body of literature demonstrating an increased risk of future fracture, including hip fracture^{9,23,34,45,53}, following a fracture of the distal part of the radius. Cummings et al.⁹ found that patients with a previous wrist fracture had a relative risk of hip fracture of 1.9 (95 percent confidence interval, 1.4 to 2.7) compared with those without a previous wrist fracture. Similarly, in a cohort study with twenty-four years of follow-up, Mallmin et al.³⁴ demonstrated an increased risk of subsequent hip fracture for women with a distal radial fracture (relative hazard, 1.54 [95 percent confidence interval, 1.24 to 1.93]). These studies highlight the need for medical treatment of osteoporosis in postmenopausal women with a distal radial fracture. Despite this imperative, the present study demonstrated that only 24 percent of women fifty-five years of age or older who sustained a distal radial fracture underwent any confirmatory diagnostic testing or medical treatment for osteoporosis.

In the current study, the rate of treatment of osteoporosis was significantly lower with increasing patient age (p < 0.0001). One possible explanation for this trend is that physicians believe that it is too late to alter the natural history of osteoporosis at this late stage - that is, once a fragility fracture has occurred. We would emphasize, however, that several major points support treatment of these elderly patients. First, the risk of hip fracture increases with increasing patient age³⁶. Second, even small changes in bone density due to the treatment of osteoporosis can lead to substantial reduction in fracture risk⁵¹. Third, the increase in the risk of a subsequent hip fracture following a distal radial fracture is higher among women who are seventy years of age or older at the time of the wrist fracture than it is among those who are younger at the time of the wrist fracture⁴⁵.

The options for medical treatment changed substantially over the course of the study period. At the outset of the study in 1994, estrogen was the major pharmacological choice available for the treatment of osteoporosis. The decision to take hormone replacement is a difficult one for postmenopausal woman to make and involves many factors. Women who use hormone replacement therapy have a substantially decreased risk of coronary artery disease, osteoporosis, fracture, and death. However, they may also have an increased risk of breast cancer²⁹. Although data suggest that nearly all postmenopausal women will benefit from hormone replacement therapy, only 37.6 percent of women currently use it²⁹. Therefore, when analyzing the low rate of treatment of osteoporosis with estrogen in this study, one must consider the effect of patients' concerns and noncompliance in concert with physicians' recommendations. Thus, the physicians' performance with regard to recognizing and treating osteoporosis may have been better than reported, but the patients' fears and noncompliance with their recommendations may have prevented them from filling the prescriptions. If patient noncompliance were a significant confounder for the results, one would expect a higher rate of treatment once alendronate became available, in October 1995, for the treatment of osteoporosis. However, despite the availability of alendronate, there was no significant increase in the rate of treatment of osteoporosis in the latter periods of the study (p = 0.8006).

The small number of patients (2.8 percent) who underwent bone-density testing in the studied population is particularly worrisome. Although the National Osteoporosis Foundation guidelines do indicate that individuals older than seventy who have a fragility fracture can be treated for osteoporosis without the performance of a dual-energy x-ray absorptiometry (DEXA) scan, the current recommendation is to perform a DEXA scan at the start of treatment, in order to assess changes in bone-mineral density over the next one to two years⁴¹. If a patient does not respond adequately to a single-drug regimen, combination therapy can be started. Given the infrequent use of bone-density testing, we believe that DEXA scans were not being used adequately for diagnostic or treatment protocols in this study population.

Limitations of the Study

There are several potential limitations of this study. There is a potential for misclassification bias within all claims data that rely only on ICD-9-CM codes for diagnoses. The use of CPT codes to confirm the diagnosis of distal radial fracture in this study should have minimized the risk of diagnosis misclassification. Because the presence of a distal radial fracture was confirmed with both ICD-9-CM and CPT codes, the diagnosis should have been highly accurate even without confirmation with medical records⁴⁸. Undoubtedly, there may have been patients in the overall base cohort who sustained a distal radial fracture that was not identified by this method because of coding inaccuracies.

Another source of potential bias concerns patients who had a distal radial fracture and underwent diagnostic evaluation or drug treatment but were not billed for or covered by insurance. However, because the study was limited to patients with full medical and pharmaceutical benefits, the likelihood that the selected outcome events occurred but were not billed for is extremely low. Still, it is possible that a particular insurance plan did not pay for bone-density scans and any scans paid for purely "out of pocket" were not captured.

Since the database only includes information on prescriptions that are filled by patients, it is possible that prescriptions were dispensed by physicians but not filled by patients. Postmenopausal women may have fears regarding an increased risk of endometrial or breast cancer with estrogen replacement therapy, which could have affected their compliance with treatment. However, even in the extremely unlikely scenario of half of the patients given prescriptions having failed to fill them, more than 50 percent of women with a distal radial fracture would still have failed to receive treatment or testing for osteoporosis. Although the present study could not differentiate patients whose physicians did not give them prescriptions from patients who chose not to fill prescriptions, all of these patients ultimately went untreated for osteoporosis. Additional research will be needed to distinguish the contributions of these two components, but we speculate that both providers and patients need more education about the benefits of osteoporosis treatment.

An additional potential limitation is that the database that we used does not include information on over-the-counter medications. This limitation would, importantly, exclude calcium and vitamin D. There is evidence that calcium and vitamin D may increase bone-mineral density and decrease the risk of osteoporotic fracture in certain populations^8,11. However, these medications are not currently accepted as adequate treatment alone for established osteoporosis, and they should be used only as adjuvant measures^27,28,40.

One hundred and four patients were treated with a medication for osteoporosis both before and after the date of the wrist fracture. Of the ninety-nine patients for whom estrogen was prescribed, eleven had a change in the treatment regimen following the fracture. The other eighty-eight patients for whom estrogen was prescribed, as well as the three for whom a bisphosphonate was prescribed and the two for whom calcitonin was prescribed, may be more accurately considered "not treated" since there is no evidence that the treating physician made an attempt to change the treatment regimen. If these patients are not included in the calculations, only 16 percent of the patients were treated for osteoporosis. As we considered the patients who were already taking a medication for osteoporosis at the time of the wrist fracture as being treated, we may have overestimated the number of patients treated for osteoporosis. This overestimation strengthens the conclusions of the study.

Finally, our including only patients enrolled with a private insurance carrier may limit the generalizability of the results to patients with other types of insurance or to those who are uninsured. Given that all patients in the study had full health and drug benefits, it is probable that they were more likely to have undergone diagnostic testing or treatment than the general population. The results therefore may overestimate the adequacy of diagnostic evaluation or treatment of postmenopausal women who sustain a distal radial fracture; again, this limitation strengthens the conclusions of the study. Finally, the majority of the patients resided in only six states of the United States, and it is possible that there are practice differences in these states that cannot be generalized to the remainder of the country.

In conclusion, the key to the treatment of osteoporosis lies in prevention, with the major goal being the preservation of bone mass. Prevention of osteoporosis in asymptomatic women, however, requires screening with a bone-density scan, which may not be cost-effective. In women with established osteoporosis, treatment can increase bone mass and decrease the incidence of fractures^{6,7,16,18,19,24,26,31,44,49,50,55,56,60,61}. Diagnostic testing is probably unnecessary for patients who have already sustained a low-energy fracture; treatment of these patients should be initiated. Patients with osteoporotic fractures create a unique opportunity for treatment intervention. Failure to treat these patients for osteoporosis at the time of a wrist fracture represents a missed opportunity for intervention.

This study suggests that current physician practice is inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture. When physician compliance with treatment recommendations for chronic diseases was revealed to be inadequate in the past, physician education was shown to improve compliance^10,22. Since nearly all patients who sustain a distal radial fracture present to an orthopaedic surgeon for treatment, there is a unique opportunity for us to initiate treatment for osteoporosis in these patients. Medical treatment of these patients could have a profound public-health impact by decreasing the burden of future osteoporotic fractures.

References

Introduction | Materials and Methods | Results | Discussion | References

American Association of Clinical Endocrinologists: AACE clinical practice guidelines for the prevention and treatment of postmenopausal osteoporosis. J. Florida Med. Assn.,83: 552-566, 1996.83552 1996

American Medical Association: Current Procedural Terminology. Chicago, American Medical Association, 1998.

American Medical Association: International Classification of Diseases, Ninth Revision, Clinical Modification, vols. 1 and 2. Chicago, American Medical Association, 1998.

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Bauer, G. C. H.: Epidemiology of fracture in aged persons. A preliminary investigation in fracture etiology. Clin. Orthop.,17: 219-225, 1960.17219 1960

Black, D. M.; Cummings, S. R.; Karpf, D. B.; Cauley, J. A.; Thompson, D. E.; Nevitt, M. C.; Bauer, D. C.; Genant, H. K.; Haskell, W. L.; Marcus, R.; Ott, S. M.; Torner, J. C.; Quandt, S. A.; Reiss, T. F.; Ensrud, K. E.; and Fracture Intervention Trial Research Group: Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet,348: 1535-1541, 1996.3481535 1996 [PubMed]

Cauley, J. A.; Seeley, D. G.; Ensrud, K.; Ettinger, B.; Black, D.; and Cummings, S. R.: Estrogen replacement therapy and fractures in older women. Study of Osteoporotic Fractures Research Group. Ann. Intern. Med.,122: 9-16, 1995.1229 1995 [PubMed]

Chapuy, M. C.; Arlot, M. E.; Duboeuf, F.; Brun, J.; Crouzet, B.; Arnold, S.; Delmas, P. D.; and Meunier, P. J.: Vitamin D3 and calcium to prevent hip fractures in elderly women. New England J. Med.,327: 1637-1642, 1992.3271637 1992

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Table I: Rate of Medical Treatment of Osteoporosis by Age*

*There was a significant trend for a decreasing rate of treatment with increasing patient age (p < 0.0001, chi-square test for trend).

Age (yrs.)	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
55-59	139	50	36.0 (28.0-44.5)
60-64	130	37	28.5 (20.9-37.0)
65-69	206	50	24.3 (18.6-30.7)
70-74	224	48	21.4 (16.2-27.4)
75-79	196	42	21.4 (15.9-27.8)
80-84	113	29	25.7 (17.9-34.7)
85-89	66	6	9.1 (3.4-18.7)
90-94	24	1	4.2 (0.1-21.1)
95 or older	64	3	4.7 (1.0-13.1)

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Table I: Rate of Medical Treatment of Osteoporosis by Age*

*There was a significant trend for a decreasing rate of treatment with increasing patient age (p < 0.0001, chi-square test for trend).

Age (yrs.)	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
55-59	139	50	36.0 (28.0-44.5)
60-64	130	37	28.5 (20.9-37.0)
65-69	206	50	24.3 (18.6-30.7)
70-74	224	48	21.4 (16.2-27.4)
75-79	196	42	21.4 (15.9-27.8)
80-84	113	29	25.7 (17.9-34.7)
85-89	66	6	9.1 (3.4-18.7)
90-94	24	1	4.2 (0.1-21.1)
95 or older	64	3	4.7 (1.0-13.1)

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Table II: Medical Treatment of Osteoporosis by Fracture Date*

*With the numbers available, there was no significant trend in the rate of treatment of osteoporosis across study years (p = 0.8006, chi-square test for trend).

Fracture Date by Year	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
July 1, 1994-June 30, 1995	550	124	22.5 (19.1-26.3)
July 1, 1995-June 30, 1996	316	73	23.1 (18.6-28.1)
July 1, 1996-June 30, 1997	296	69	23.3 (18.6-28.6)

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Table II: Medical Treatment of Osteoporosis by Fracture Date*

*With the numbers available, there was no significant trend in the rate of treatment of osteoporosis across study years (p = 0.8006, chi-square test for trend).

Fracture Date by Year	No. of Patients with Fracture (N = 1162)	No. of Patients Treated (N = 266)	Percentage (95% Confidence Interval) of Patients Treated
July 1, 1994-June 30, 1995	550	124	22.5 (19.1-26.3)
July 1, 1995-June 30, 1996	316	73	23.1 (18.6-28.1)
July 1, 1996-June 30, 1997	296	69	23.3 (18.6-28.6)