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. 1999 Jun 19;318(7199):1698.

Advice given to patients with fractures

Drug treatments that reduce fracture rate are underused after vertebral fractures

David J Torgerson 1,2, Paul Dolan 1,2
PMCID: PMC1116037  PMID: 10373187

Editor—We recently undertook a cost analysis of osteoporosis, which showed that the disease is probably more costly than earlier estimates quoted by Pal suggested.1 We estimated that the total annual cost of fractures in a United Kingdom population is around £940 million, with hip fractures costing roughly £12 000 each.2 More importantly, using data from the general practice research database, like Pal we found little evidence that patients who had sustained a fracture were being offered treatment.3 The table (taken from our paper) summarises our results.

In terms of evidenced based medicine the only population of patients that has been widely studied for secondary prevention is those who have sustained a vertebral fracture. Most, if not all, widely available treatments for the prevention of fractures have been shown to be effective at preventing new vertebral fractures in patients who have had one previously. Despite this, over three fifths of patients with a vertebral fracture diagnosed in primary care were not prescribed any drugs that reduce the fracture rate to prevent new vertebral fractures. Such patients are also at high risk of non-vertebral fractures.4 The priority in preventing fractures would seem to be to offer drug treatments that reduce the fracture rate to patients with existing vertebral fractures.

Table.

Number of patients receiving at least one prescription for drug that reduces fracture rate (HRT, calcium, vitamin D, bisphosphonate) in years before and after hip, wrist, or vertebral fracture (n=100)

Type of fracture
Hip Wrist Vertebral
Year before fracture (1994) 2 7 10
Year after fracture (1996) 4 5 39
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HRT=Hormone replacement therapy. 

References

  • 1.Pal B. Questionnaire survey of advice given to patients with fractures. BMJ. 1999;418:500–501. doi: 10.1136/bmj.318.7182.500. . (20 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Dolan P, Torgerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporosis Int. 1999;8:611–617. doi: 10.1007/s001980050107. [DOI] [PubMed] [Google Scholar]
  • 3.Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis. 1998;57:378–379. doi: 10.1136/ard.57.6.378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Burger H, van Daele PLA, Algra D, Hofman A, Grobbee DE, Schütte HE, et al. Vertebral deformities as predictors of non-vertebral fractures. BMJ. 1994;309:991–992. doi: 10.1136/bmj.309.6960.991. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1999 Jun 19;318(7199):1698.

Fragility fractures establish diagnosis of osteoporosis

Juliet Compston 1

Editor—Pal’s short article highlights the lack of appropriate advice received by many patients with osteoporotic fracture, particularly those with hip fracture.1-1 Although comprehensive recommendations for the care of patients with hip fracture exist,1-1,1-2 it seems that they are not always implemented and opportunities for secondary prevention are missed. Measures that are effective in protecting against hip fracture include calcium and vitamin D supplementation and the use of hip protectors,1-3,1-4 neither of which is routinely advised. In addition, many patients leave hospital without assessment of risk factors for falling, some of which, such as poor vision and environmental hazards, may be remediable.

The editorial accompanying Pal’s article advocates dual energy x ray absorptiometry in older patients with osteoporotic fracture, both to identify underlying osteoporosis and to provide a baseline for monitoring treatment.1-4 Although bone densitometry may sometimes be of value in confirming or refuting osteoporosis in individuals with a fracture, it is often unnecessary: the presence of a fragility fracture establishes a diagnosis of osteoporosis and is an independent risk factor for subsequent fracture.

A strong case can be made for treating patients with a fragility fracture, regardless of whether bone densitometry is available; this is particularly so for elderly patients with hip fracture, most of whom will satisfy the densitometric criteria for osteoporosis. Further justification for this approach is provided by the increasing evidence that safe and relatively short term interventions in elderly people can produce significant reductions in the fracture rate.1-3,1-4

The rationale for monitoring treatment can also be challenged. Response rates to antiresorptive treatment are generally reported as being greater than 90%. Against this background it is difficult to understand why monitoring should be regarded as essential, particularly since the time required accurately to detect non-response may be three years or more.

Finally, in view of the high prevalence of vitamin D deficiency in the elderly population, routine vitamin D supplementation would surely be a more cost effective approach to reducing hip fracture than measurement of serum 25-hydroxyvitamin D concentrations.1-5

References

  • 1-1.Pal R. Questionnaire survey of advice given to patients with fractures. BMJ. 1991;318:500–501. doi: 10.1136/bmj.318.7182.500. . (20 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Royal College of Physicians. Fractured neck of femur: prevention and management. Summary and recommendations of the report. J R Coll Phys Lond. 1995;23:8–12. [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Audit Commission. London: HMSO; 1995. United they stand: co-ordinating care for elderly patients with hip fractures. [Google Scholar]
  • 1-4.Doube A. Managing osteoporosis in older people with fractures. BMJ. 1999;318:477–478. doi: 10.1136/bmj.318.7182.477. . (20 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-5.Compston JE. Vitamin deficiency: time for action. BMJ. 1998;317:1466–1467. doi: 10.1136/bmj.317.7171.1466. . (28 November.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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