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.