Fragility fracture warrants a clinical diagnosis of osteoporosis [1
], yet osteoporosis remains under-diagnosed and under-treated in the secondary fracture prevention setting worldwide [3
]. With global incidence, morbidity, mortality, and costs of fragility fractures expected to increase with the aging population [5
], osteoporosis is currently recognized as a major public health concern [5
]. The annual incidence of fragility fractures in Canada and the USA is estimated to be higher than that for myocardial infarction, stroke, and breast cancer combined [10
], while the excess 1-year mortality associated with a fragility fracture is estimated to be comparable to that for myocardial infarction [13
]. Direct healthcare costs attributed to fragility fracture within the first year post-fracture are estimated at $1.9 billion in Canada [14
In many countries, including Canada, osteoporosis is predominantly managed by primary care physicians (PCP) [15
], with more complex cases being referred to specialists. PCP management after an incident fragility fracture has not been widely investigated, with most existing data collected prior to shifts in recent guidelines for the clinical management of osteoporosis [17
]. After the availability of 10-year fracture risk assessment tools in 2008 (i.e., the Fracture Risk Assessment Tool [FRAX] and the Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool), management of osteoporosis relied on both bone mineral density (BMD) and 10-year fracture risk, incorporating fracture history along with BMD, age, and other risk factors [21
]. Furthermore, recent fragility fracture (≤ 2 years) is associated with a very high or imminent risk of subsequent fracture [1
]. For instance, median time to subsequent fragility fracture was recently estimated to be 555 (IQR 236–955) days following index fracture in Canadian adults aged > 65 years [23
]. This imminent fracture risk is not captured in FRAX or CAROC, but should motivate more aggressive osteoporosis treatment in patients soon after their fragility fracture. Indeed, this treatment paradigm is reflected in recent international guidelines [1
]. Specifically, recent North American guidelines recommend initiation of pharmacotherapy in post-menopausal women soon after an incident fragility fracture, and more potent pharmacotherapies (i.e., bone formation therapies, denosumab or zoledronic acid) are recommended first-line [1
]. Recent guidelines germane to our study also validate that a clinical diagnosis of osteoporosis based on a history of fragility fracture and independent of BMD should prompt treatment initiation [1
The primary objective of this real-world retrospective cohort study was to characterize osteoporosis treatment patterns in the primary care setting after incident fragility fracture. The secondary objectives were to describe fracture risk assessment, BMD assessment, and the establishment of osteoporosis diagnosis in patients with fragility fracture. For both objectives, the post-fracture care gap was characterized in the context of the 2010 Canadian osteoporosis guidelines, applicable to the surveillance period and geographic origin of this post-fragility fracture cohort [21
This study observed that a fragility fracture did not prompt osteoporosis diagnosis or treatment in 6 out of 10 (61.3% previously undiagnosed and 60.2% previously untreated) patients managed post-fracture in primary care. These data are noteworthy in the context of recent Endocrine Society, American Association of Clinical Endocrinologists, and International Osteoporosis Foundation guidelines for post-menopausal osteoporosis [1
], which recommend a clinical diagnosis of osteoporosis and urgent initiation of pharmacotherapy following a fragility fracture at any osteoporotic fracture site, regardless of other risk factors. Although the 2010 Canadian guidelines (current during the surveillance period of this study) recommended treatment initiation only after hip, vertebral, or > 1 fragility fractures [21
], substantial gaps in the uptake of the 2010 guidelines were still observed as 62.2% of patients with a subsequent fracture remained untreated thereafter. Further, a fragility fracture did not prompt fracture risk assessment in 83.2% of patients and did not prompt BMD assessment in 59.8% of patients, despite these recommendations in the applicable guidelines [21
]. Taken together, these results signify that in the primary care setting, a fragility fracture is often not well recognized and/or acted upon as a serious clinical event requiring initiation of therapy to prevent subsequent fracture.
Compared to prior data, the current study suggests treatment rates post-fragility fracture are improving. Approximately twice as many patients received osteoporosis treatment (39.8%) compared to the < 20% rate reported by the Canadian Chronic Disease Surveillance System (CCDSS) in adults aged ≥ 65 during 2015–2016 [5
]. It should, however, be noted that the CCDSS surveillance data included all fractures, which may have led to a lower treatment rate [5
]. Given the subjectivity and potential confusion in identifying which fractures are low-trauma, international osteoporosis experts have recently urged the inclusion of high-trauma fractures in the clinical assessment for underlying osteoporosis and in the evaluation of future fracture risk, as both fractures showed a similar relationship with BMD and future fracture risk in a study of Canadian adults (aged ≥ 40 years) receiving a DXA scan between 1996 and 2016 [27
Considering the low rate of fracture risk assessment specifically after a fracture (16.8%) in the current study, the importance of such assessment post-fracture was perhaps not adequately clarified in the guidelines applicable to this cohort [21
]. Nonetheless, of the fracture risk assessments completed after index fracture, 61.7% were completed within 6 months, suggesting the majority of PCPs who do recognize the prognostic significance of fragility fracture act relatively promptly. In addition, some patients with risk assessments completed prior to their fracture may have already been identified as high risk and on treatment. However, among clinicians using the CAROC tool, there is evidence that it was not applied correctly. More than one third (36.6%) of patients assessed were deemed to be at low risk of fracture, which is not possible in those with a prior fracture where the risk should be increased by 1 strata. It is important to qualify that incorrect use of the CAROC tool may have occurred at the radiologist setting and not by the referring PCP. Some radiologists in Canada provide CAROC risk calculations along with the BMD report shared with the PCP, but often rely on only age and BMD, excluding fracture history or other modifiers [2
]. Furthermore, only 38.7% of patients were diagnosed with osteoporosis on or after the date of their index fracture, which suggests limited clinical recognition by the primary care or orthopedic team of the diagnostic significance of fragility fracture. However, our data cannot discriminate what proportion of diagnoses may have rather relied on a subsequent densitometric diagnosis. Thus, the need to recognize fragility fracture as a serious diagnostic clinical event influencing future fracture risk likely extends beyond primary care.
In addition, the low rates of fracture risk assessment observed post-fracture may reflect diversion of PCP attention and resources from osteoporosis to competing issues. Qualitative studies have shown that PCPs perceive osteoporosis management to be of lesser priority than other chronic conditions, such as cardiovascular disease [29
], despite research showing comparable 1-year mortality associated with a fragility fracture and myocardial infarction [13
]. Strikingly, in a recent Canadian cohort of > 100,000 patients aged > 65, 21.5% of women and 32.3% of men died within 1 year following a hip fracture and 9.4% of women and 14.4% of men following a non-hip fracture [13
Recognizing fracture as an important prognostic event has been urged by recent calls to action by the Public Health Agency of Canada and various international advocacy organizations as a key strategy toward helping address the secondary fracture prevention gap [5
]. In a recent Canadian cohort of older patients (aged > 65), median time between index fracture at any site and subsequent fracture was < 2 years [23
]. Imminent fracture risk was also evident in the current study wherein 11.1% of patients had ≥ 1 subsequent fracture within a relatively short study follow-up period (median 363 days, IQR 91–808 days).
This observational study provides an update on post-fragility fracture care patterns in the Canadian primary care setting. Patient data were collected from across Canada with differing osteoporosis care priorities and barriers [15
]. Our data support the findings from a recently published Canadian study demonstrating that diagnosis and treatment rates of osteoporosis after a fragility fracture of the hip are alarmingly low in the absence of a formal multidisciplinary treatment program [32
]. However, our study has some important limitations. Three quarters (74.9%) of patients (and 75.9% of study PCPs) were from primary care centers in Ontario, the province accounting for approximately one third of all fractures and 36.1% of PCPs in Canada (total 46,797 PCPs) [5
]. Furthermore, Ontario is only one of two provinces with government action plans focusing on osteoporosis, and has among the best access to osteoporosis treatment and Fracture Liaison Services relative to other provinces [15
]. Together, these factors may limit the generalizability of our findings to the entire Canadian population. Nonetheless, Ontario is the most populous province in Canada, inhabited by over 14 million of Canada’s 37 million population [34
], hence the inherent value in understanding the osteoporosis practice patterns in this province. There is also potential for study site selection bias as specific PCPs were invited to participate in this study and may have been particularly interested in osteoporosis care. Collectively, all of these factors may underestimate the osteoporosis post-fracture care gap in Canadian primary care described herein and should be considered for future research. Furthermore, the scope of this study was to observe fracture risk and BMD assessment in a real-world setting, and the participating centers were not asked to ascertain pre-/post-index fracture risk based on the available chart data, thus leaving only a small number of patients with available BMD and fracture risk results pre-/post-index fracture. Finally, whether osteoporosis diagnosis and treatment initiation were based on BMD or fracture remains unknown in the current study and should be documented in future studies.
Conflict of interest
AB has received research grants, speaker honoraria, and/or consultancies from Amgen, AstraZeneca, Bausch Health, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, HLS Therapeutics, Janssen, Novartis, Pfizer, Sanofi, and Spectrum Therapeutics. DLK has received research grants, speaker honoraria, and/or consultancies from Alexion, Amgen, BioSyent, and Radius Health. AAK has received research grants from Alexion, Amgen, Ascendis, Chugai, Radius Health, Takeda, and Ultragenyx. MS has received research grants, speaker honoraria, and/or consultancies from Amgen, Aspen, Astellas, Bayer, BioSyent, Duchesnay, GlaxoSmithKline, Merck, Mithra, Pfizer, Searchlight, Sprout, Sunovion, and Therapeutics MD. AM has received speaker honoraria and/or consultancies from Amgen, Eli Lilly, and Sanofi. MR, SMC, LS, and MP are/were employees at the time of study completion and own stock in Amgen. JPL declares no conflict of interest.
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