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Osteoporosis: it’s time to ‘mind the gap’

2007; Wiley; Volume: 37; Issue: 10 Linguagem: Inglês

10.1111/j.1445-5994.2007.01495.x

1445-5994

Peter R. Ebeling,

Bone fractures and treatments

Osteoporosis is often called a ‘silent’ disease, with minimal trauma fractures being its first manifestation. Osteoporosis is the disease and minimal trauma fractures are the outcome we are trying to prevent. It is common, affecting 2.2 million or 10% of Australians and this will increase to 3 million by 2021 as the population ages.1,2 Of those affected, 1.65 million are women and 0.51 million are men. Among those aged more than 60 years, one in two women and one in three men will have minimal trauma fractures because of osteoporosis. The direct costs associated with these fractures amount to an estimated $1.9 billion each year in Australia.3 Of all reported osteoporotic fractures, 46% are vertebral, 16% are hip and 16% are wrist fractures. Armed with this information and evidence of treatments that reduce fractures by approximately 50%, why are Australian doctors not implementing therapy to prevent these fractures and their attendant increased morbidity and mortality? Osteoporosis is a good example of an evidence–practice gap.4 This gap is present in both public hospitals and in general practice. Teede et al. confirm the presence of this gap in this issue of the Journal.5 They conducted a retrospective audit of 1829 minimal trauma fracture cases presenting to 16 Australian public hospital emergency departments. Less than 13% had fracture risk factors identified, only 10% were appropriately investigated and only 12% were started on treatment with calcium and/or vitamin D. Specific anti-osteoporotic therapy was initiated in only 9% of patients. This group has the highest risk for subsequent fracture and the underrecognition and undertreatment obviously shows a missed opportunity to reduce the fracture burden in Australians. These investigators are not alone. Previous Australian and international studies have shown only 7–20% of patients with a minimal trauma fracture receive anti-osteoporotic therapy to prevent further fractures and these rates are low in both tertiary and primary care settings.6,7 Rates of screening for osteoporosis after minimal trauma fracture are also low in tertiary care.6 The study by Vaile et al. from a tertiary referral hospital in Sydney also reported in this issue, showed that dual X-ray absorptiometry (DXA) was rarely performed, fewer than 20% of patients were on any form of anti-osteoporotic therapy with 8800 postmenopausal Australian women attending primary care physicians, 29% reported at least one low-trauma fracture after menopause.9 However, only less than one-third of these women were on specific treatment for osteoporosis and only 40% were ever told they had osteoporosis. The reasons for these low rates of treatment and diagnostic testing with DXA are unclear. Perhaps a key issue is that no single professional group takes responsibility for osteoporosis – responsibility is spread among endocrinologists, rheumatologists, geriatricians and general practitioners (GPs). This allows patients to fall through a therapeutic gap. Other barriers may include lack of recognition of osteoporosis, lack of follow up after the acute fracture episode, presence of other more pressing medical problems, perceived lack of treatment efficacy or inappropriate concern about side-effects of treatment and unrealistic beliefs that lifestyle modification alone will prevent further fractures.8 In the tertiary setting, systematic approaches using fracture protocols7 and taking a multidisciplinary approach in the hospital setting, which included liaising with the family doctor,10 have both improved rates of treatment. However, the approach used by Vaile et al. seems to hold the most promise.8 A ‘First Fracture Project’ was initiated, the key feature being the use of a dedicated osteoporosis nurse to identify patients in the hospital or attending fracture clinics with minimal trauma fractures, who might benefit from anti-osteoporotic therapy. Screening tests were also carried out to exclude secondary causes of osteoporosis and bone densitometry organized. The authors estimate that each prevented hip fracture paid for a nurse for 6 months or screening tests for 54 patients, indicating this approach is also cost-effective. Similar nurse-led approaches have also been successful in Scotland.11 In summary, the most successful interventions have been those providing specific advice after individualized review or through inpatient or outpatient protocols.12,13 One issue specific to DXA testing may be accessibility of bone densitometry in rural and remote areas of Australia and this is supported by data from UK GPs suggesting DXA is used more where GPs perceive a simpler path to accessing the service for their patients.14 In Australia, poor access may also be related to lack of Pharmaceutical Benefits Scheme reimbursement for bone densitometry for some patients, particularly those aged <70 years. However, the decision by GPs of whether to screen a patient for osteoporosis involves considerably more complex factors than simply being aware of clinical guidelines, or of the importance of osteoporosis.14 Given this complexity, multidisciplinary and systems-based approaches will probably be needed to improve levels of both diagnosis and treatment of osteoporosis in Australia.15 A large-scale research project is now required to identify and implement sustainable practice change within a multidisciplinary health-provider framework. In osteoporosis it is now time to ‘mind the gap’.