Aggressive bone care could prevent hip fractures

NEW YORK (Reuters Health) - If the US health care system "started to take osteoporosis seriously," it could slash the number of Americans who suffer hip fractures by at least 25 percent, according to one of the authors of a new report on managing the brittle bone disease.

Dr. Richard Dell, an orthopaedic surgeon with Kaiser Southern California, and his colleagues describe a program initiated by the 3.1 million-member HMO to identify patients at risk of fragility fractures and make sure they received treatment. The Healthy Bones Program, which was up and running in all of the health plan's 11 sites by 2002, saw reductions in hip fracture rates ranging from 23.1 percent to 60.7 percent.

Osteoporosis can have disabling and even deadly consequences, the researchers note; a quarter of the 325,000 patients who suffer a hip fracture every year will wind up in a nursing home, and a quarter will die within the year. Thirty percent of men die within the first year of a hip fracture, compared to 17 percent of women.

Orthopaedic surgeons leading multidisciplinary teams identified 620,000 Kaiser Southern California members who were eligible to have their bone mineral density checked with a type of X-ray exam called dual X-ray absorptiometry, or DEXA. These included women over 65, men over 70, anyone on drugs that could worsen bone thinning, such as corticosteroids, and anyone over 50 who had previously had a fragility fracture, defined as a bone break that occurs after a fall from standing height or lower.

Patients whose DEXA scans revealed dangerously thin bones were offered an osteoporosis education program, and those who had suffered fragility fractures were enrolled in a treatment plan that included home health care and safety checks of the home.

Between 2002 and 2006, the researchers report, the number of health plan members getting DEXA scans more than doubled, while the rate for men increased six-fold. The number of patients on osteoporosis medications such as bisphosphonates rose by 35 percent. The average reduction in hip fractures seen across all of the HMO's medical centres was 37.2 percent.

While Kaiser has the great advantage of a comprehensive electronic medical record system that makes it possible to keep track of at-risk patients and monitor whether they are getting recommended DEXA scans and filling their prescriptions, Dell said in an interview, it should be possible even for private practitioners to reduce the risk of hip fractures in their patients by at least 25 percent.

"There remains a widely held misconception among many orthopaedic surgeons that nothing can be done to prevent or treat osteoporosis," Dell and his team note in their report in the Journal of Bone & Joint Surgery. "The present study should help to dispel that misconception.

The researcher argues that orthopaedic surgeons should take a leading role in treating patients who are at risk of fragility fractures, or who have already sustained them. "The problem with the current system is that we as orthopaedic surgeons basically aren't the ones who typically initiate treatment," he said. "We defer that to other providers."

And often, Dell added, at-risk patients fall through the cracks due to continuity of care issues. "We should be identifying these people earlier, before they fracture," he said.

SOURCE: The Journal of Bone & Joint Surgery, online November 3, 2008.