Trends in drug prescribing for osteoporosis following a hip fracture have changed dramatically over the last decade: The proportion of patients treated post fracture has increased, but fewer than one-third are ever prescribed drugs at all, according to a population-based study of nearly 16,000 fracture patients.
In an interview, lead author Suzanne M. Cadarette, Ph.D., said, “Many patients, following hip fracture, still do not receive adequate pharmacotherapy. While there have been some successful quality improvement interventions to address this gap in care, health systems must sit up and recognize that there is a problem.”
A total of 15,685 hip fracture patients, all enrollees from the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), met inclusion criteria. (PACE is a state-run program that provides unrestricted drug coverage for patients aged 65 or older whose income is too high for Medicaid, but below $20,000. Dr. Cadarette conceded that the relatively low income status of this cohort, and the fact that the majority was white, means that “extrapolating the exact level of care to the rest of the U.S. population may be difficult, but I expect that the general trend of undertreatment holds nationwide.”) Although Dr. Cadarette did not confirm the presence of osteoporosis in this cohort, she pointed to a recent Canadian trial that found that 21% of hip fracture patients aged 50 years or older had normal bone mass, but 45% had osteoporosis and were thus clear candidates for pharmacotherapy (Arch. Intern. Med. 2007;167:2110-5). “Our population was much older than the [randomized clinical trial] referenced here, and thus I expect that fewer hip fracture patients in our study would have normal bones and rather the majority had osteoporosis.”
In 1995, 7% of patients received pharmacotherapy to treat osteoporosis within 6 months of fracture; this figure increased to 31% in 2002, and then remained stable through 2004, the study's cutoff date.
The study also found that the type of therapy patients receive varies according to what sort of physician treats them. The specialty of the prescribing physician was identified in 94% (3,038) of the total 3,231 treated cases. Rheumatologists and endocrinologists prescribed bisphosphonates in 59.5% of cases, calcitonin in 32.5%, hormone therapy in 3.5%, raloxifene in 3%, and teriparatide or a combination of drugs very rarely, in 1% or fewer of cases. Obstetricians and gynecologists most often prescribed hormone therapy, in 63.3% of patients, followed by bisphosphonates in 22.4%, calcitonin in 8.2%, raloxifene in 4%, and teriparatide or combination therapy hardly ever. Geriatricians prescribed calcitonin about half the time and for about the other half prescribed bisphosphonates.
Dr. Cadarette, of the Brigham and Women's Hospital, Boston, urged caution in interpreting this seemingly alarming finding. “Patients seeing specialists may have other chronic health conditions contraindicating bisphosphonate therapy, or may be more frail, making the complex bisphosphonate dosing difficult.” She also said her findings did not reflect the time periods in which the different therapies were prescribed. For example, fracture patients seen by obstetricians and gynecologists were largely treated in 1995, before the 2002 Women's Health Initiative results showed the potential harm associated with hormone therapy.
Also significant was the finding that, over time, family physicians and general practitioners have become the prescribing physicians in a greater proportion of these cases. In 1995, general practitioners were the prescribers in about 71% of treated fracture patients, and in 2004, they were responsible for 80% of these cases. Rheumatologists and endocrinologists, on the other hand, dropped from being the treating physician in 15% of cases in 1995 to only 3.5% in 2004. A similar decline was seen among obstetrics/gynecology physicians and orthopedic surgeons.
Responding to this finding, Dr. Steven Petak, chancellor of the American College of Endocrinology, said in an interview, “There are a limited number of endocrinologists and rheumatologists in proportion to the number of patients with or at risk for osteoporosis.”
Poorly responsive patients who have bone mineral density loss on DXA, continued fractures, intolerance of oral therapies, or secondary osteoporosis should have consultations with specialist, he said.
Dr. Cadarette reported no disclosures for herself or any of her fellow researchers in relation to this study.