After Hip Fracture, Osteoporosis Dx Overlooked


WASHINGTON — Three-fourths of patients hospitalized for a hip fracture do not receive an osteoporosis diagnosis before discharge, and the majority are not taking a bisphosphonate at discharge or 6 months after the injury, a small study has shown.

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 who were admitted to a hospital with a hip fracture. Most (80%) were white females older than 70 years. At the time of discharge, 25% had been assigned a diagnosis of osteoporosis. Only 30% were taking calcium; patients who had been diagnosed with osteoporosis were significantly more likely to be taking both calcium and vitamin D than were patients without a diagnosis. Furthermore, only 15% were taking a bisphosphonate at discharge, Dr Bansal said in a poster session at an international symposium sponsored by the National Osteoporosis Foundation. Clinical contraindications did not appear to play a significant role in the lack of treatment: Only 2% of patients had a glomerular filtration rate of less than 30 mL/min per 1.73 m

Dr. Bansal then performed a telephone survey of the 105 patients who could be contacted; 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,” Dr. Bansal said.

To help improve the rate of osteoporosis diagnosis at his hospital, Dr. Bansal and his colleagues have instituted a standardized protocol. “It's very simple,” he said. “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.”

He had no conflicts of interest.

'If you have a hip fracture, you're likely to be discharged without even the underlying diagnosis.' DR. BANSAL

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