Improving osteoporosis care following hip fracture
Hip fractures commonly result in an inability to walk normally, and complications result in a 20 percent increase in mortality during the six months following the fracture. Osteoporosis, the major cause of hip fractures in older adults, can be prevented with pharmacologic agents; however, but many patients who would benefit from treatment are not identified. Reducing the number of hip fractures is a challenge because of the under-recognition of osteoporosis by physicians. Kaufman and associates encourage the development of programs that will increase recognition and management of osteoporosis among patients with hip fracture and describe two practice models.
In the first model, an orthopedic nurse practitioner provided bedside education to patients and their families about osteoporosis and sent the osteoporosis guidelines to the patients’ primary care physicians (see accompanying table). This intervention increased the number of patients whose calcium and vitamin D needs were addressed but did not significantly increase the use of osteoporosis medications. When the intervention was expanded to include in-hospital consultations and evaluations, a greater number of patients were given calcium, vitamin D, and a specific osteoporosis medication.
The second practice model included education of medical staff and full diagnostic testing while patients were in the hospital. Patients who were prescribed specific osteoporosis medications started treatment while they were hospitalized or after they were discharged. Recommendations were made for hip protectors, and home assessments were arranged. The primary care physician was informed about all test results and recommendations. There was a significant increase in osteoporosis evaluation and treatment with this model, but at 12 months there was a significant decline in the number of patients still taking a specific osteoporosis medication.
The authors conclude that patients presenting with hip fracture are at high risk for osteoporosis. Mandatory osteoporosis consultation would be useful for these patients. The physician treating the fracture should assume responsibility for management of possible osteoporosis or designate another physician who is capable of doing so and willing to provide this care.
Recommendations for Post-fracture Care in Patients with Osteoporosis
A total calcium intake of at least 1,200 mg a day
Adequate vitamin D intake (400 to 800 IU daily)
Avoidance of tobacco smoking and alcohol abuse
Home safety and fall precautions
All adults who present with vertebral or hip fracture are considered
to be candidates for osteoporosis evaluation and treatment.
Low-impact fractures at other sites also may be an indicator of
Bone mineral density (BMD) testing with dual energy x-ray
absorptiometry (to confirm the diagnosis of osteoporosis and
determine disease severity in appropriate patients 2 to 4 weeks
Some patients, i.e., those older than 75 years with multiple risk
factors for osteoporosis, are at sufficiently high risk for fracture
that treatment is warranted without BMD testing.
Approved osteoporosis therapies include estrogen, alendronate,
risedronate, raloxifene, and salmon calcitonin.
Adapted with permission from Kaufman JD, Bolander ME, Bunta AD, Edwards
BJ, Fitzpatrick LA, Simonelli C. Barriers and solutions to osteoporosis
care in patients with a hip fracture. J Bone Joint Surg 2003;85-A:1839.
RICHARD SADOVSKY, M.D.
Kaufman JD, et al. Barriers and solutions to osteoporosis care in patients with a hip fracture. J Bone Joint Surg September 2003;85-A:1837-43.
COPYRIGHT 2004 American Academy of Family Physicians
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