WASHINGTON — Three-fourths of patients hospitalized for a hip fracture do not receive an osteoporosis diagnosis before discharge, and most are not taking a bisphosphonate at discharge or 6 months after the injury, a small study showed.
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 admitted to a hospital with a hip fracture. Most (80%) were white females older than 70 years. At discharge, 25% had been assigned a diagnosis of osteoporosis. Only 30% were taking calcium.
Furthermore, only 15% were taking a bisphosphonate at discharge, Dr. Bansal said. Clinical contraindications did not appear to play a significant role: Only 2% of patients had a glomerular filtration rate of less than 30 mL/min per 1.73 m
A telephone survey revealed that 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 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,” he said.
To improve the rate of osteoporosis diagnosis at his hospital, Dr. Bansal and his colleagues instituted a standardized protocol. “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.”
Although a dual-energy x-ray absorptiometry scan is a helpful diagnostic tool, Dr. Bansal said treatment should not be delayed until a scan can be obtained. “You have to wait for the fracture to heal and then schedule that as an outpatient, and during that time the patient can be lost to follow-up. … Don't delay the treatment while waiting for the scan.”
Dr. Bansal presented the study in a poster session at an international symposium sponsored by the National Osteoporosis Foundation. He had no conflicts of interest to declare.
'If you have a hip fracture, you're likely to be discharged without even the underlying diagnosis.' DR. BANSAL