WASHINGTON — Three-fourths of patients hospitalized for a hip fracture do not receive an osteoporosis diagnosis before discharge, and the majority are not taking a bisphosphonate at discharge or 6 months after the injury, a study has shown.
The findings are dismaying, said Dr. Pardeep Bansal, because 24% of patients older than 50 years who sustain an osteoporotic hip fracture die within a year. “The 1-year mortality rate is higher than it is in some cancers, and even higher than it is after a heart attack,” said Dr. Bansal, chief resident at the Scranton-Temple Residency Program, Scranton, Pa. “But if you have a heart attack, no physician is going to let you leave the hospital without aspirin, a beta-blocker, and a statin. If you have a hip fracture, you're likely to be discharged without even the underlying diagnosis, much less the appropriate treatment.”
The two-part study began with a chart review of 191 patients who were admitted to a hospital with a hip fracture. Most (80%) were white females older than 70 years. At the time of discharge, 25% had been assigned a diagnosis of osteoporosis. Only 30% were taking calcium; patients who had been diagnosed with osteoporosis were significantly more likely to be taking both calcium and vitamin D than were patients without a diagnosis.
Furthermore, only 15% were taking a bisphosphonate at discharge, Dr Bansal said. Clinical contraindications did not appear to play a significant role in the lack of treatment: Only 2% of patients had a glomerular filtration rate of less than 30 mL/min per 1.73 m
Dr. Bansal then performed a telephone survey of the 105 patients who could be contacted; 33% of the original cohort had died since their fractures, and another 12% could not be found. All of the patients interviewed reported having seen their primary care physicians within 6 months of the fracture. Yet still, only 50% had received a diagnosis of osteoporosis, 50% were taking calcium, 40% were taking vitamin D, and only 28% were taking a bisphosphonate. “Another painful finding was that 14% of the group had experienced a subsequent fragility fracture.”
To help improve the rate of osteoporosis diagnosis at his hospital, Dr. Bansal and his colleagues have instituted a standardized protocol. “It's very simple,” he said. “Any patient who comes in with a fracture suggestive of osteoporosis is started on calcium, vitamin D, and a bisphosphonate before discharge. If they have a contraindication to a bisphosphonate, such as an allergy or a low GFR, then we call the family physician and discuss an alternative treatment.”
Treatment should not be delayed until a scan can be obtained, said Dr. Bansal, who presented the study at an international symposium sponsored by the National Osteoporosis Foundation. He had no conflicts of interest to declare.
'The 1-year mortality rate is higher than it is in some cancers, and even higher than it is after a heart attack.' DR. BANSAL