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Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Osteoporosis in the Australian setting

Osteoporosis is most common in Caucasian people, followed by Asians and African Americans.49 Therefore, there is an advantage in using normal ranges derived from ethnicity appropriate BMD T-scores.

Some ethnic groups in Australia are at greater risk of vitamin D insufficiency (Asians, people with darker skin, and people who cover their skin for cultural or religious reasons) and relatively low calcium intakes; both should be corrected before initiating anti-osteoporotic therapy.

Osteoporosis is most common in Caucasian people, followed by Asians and African Americans.49 Therefore, there is an advantage in using normal ranges derived from ethnicity appropriate BMD T-scores.

Some ethnic groups in Australia are at greater risk of vitamin D insufficiency (Asians, people with darker skin, and people who cover their skin for cultural or religious reasons) and relatively low calcium intakes; both should be corrected before initiating anti-osteoporotic therapy.

Any osteoporotic fracture predisposes an individual to at least a two-fold risk in further fractures,1–9 significant morbidity and premature death.10,11 In a 2012 report of New South Wales hospital admission data from the Agency for Clinical Innovation, 46% of patients with an osteoporotic fracture were re-admitted to hospital due to a further fracture.12

The timely diagnosis and optimal treatment of osteoporosis prevents further fractures by up to 30%, 50% and 70% in patients with non-vertebral, hip and vertebral fractures, respectively. Several safe and effective medications are available for those who have sustained a minimal trauma fracture.13–19 Internationally, however, 70–85% of patients presenting with a minimal trauma fracture to their general practitioner (GP) or hospital are neither assessed for osteoporosis, nor appropriately managed to prevent further fractures.20–26 Two large retrospective studies of primary care practice in Australia demonstrated less than one-third of patients presenting with a minimal trauma fracture receive specific osteoporosis pharmacotherapy.27,28 This treatment gap is also evident in hospitals and tertiary referral centres.29

Fracture liaison services or secondary fracture prevention (SFP) programs are the most proven methods to address the care gap in osteoporosis. SFP programs identify patients with a minimal trauma fracture, assess them for osteoporosis, initiate treatment (as appropriate) within the program and communicate with primary care providers. SFP programs in Australia have demonstrated improved osteoporosis treatment initiation and reduced re-fracture rates, compared to standard care.

The objectives of an SFP program are encapsulated by the ‘3i’s’ – identify patients with osteoporosis, investigate and determine fracture risk (also incorporating falls risk) and initiate interventions to reduce fracture risk. A 2013 systematic review30 divided interventions into four models of care, according to intervention intensity (Table 2). A key aspect of any Type A or Type B SFP program is the presence of a coordinator who oversees all aspects of the program – from the initial patient contact following minimal trauma fracture, osteoporosis and falls risk assessment, and follow-up once interventions have been initiated. Once patients are captured, most programs perform a full risk factor assessment, including clinical osteoporosis risk factors, falls risk assessment and bone mineral density (BMD) testing.

Type A (3i) and Type B (2i) SFP programs have been shown in randomised controlled trials (RCTs) to improve process outcome measures (BMD testing and treatment initiation rates) compared to less-intensive Type C (1i) and Type D (0i) programs,31,32 while also reducing re-fracture rate33–35 in a clinically and economically effective manner.33,36–39 The SFP program at Concord Hospital, Sydney, was deemed highly cost-effective with a cost of around $17,000 per quality-adjusted life year (QALY) gained.37 It must be noted that the data demonstrating re-fracture risk reduction used historical controls or concurrent controls of patients who did not attend the SFP program.

Table 2. Description of models of care for secondary fracture prevention according to intervention intensity

Table 2.

Description of models of care for secondary fracture prevention according to intervention intensity30

A number of patients with a minimal trauma fracture may not present to a hospital, whereas almost all patients with a minimal trauma fracture will eventually see their primary care physician (although, it should be noted, not necessarily for a minimal trauma fracture). Therefore, the primary care physician is key to ensuring patients are appropriately managed after a minimal trauma fracture. Furthermore, SFP programs primarily capture patients with non-hip, non-vertebral fractures and thus will not capture all patients at high risk of fracture or re-fracture, such as those with vertebral body fracture, frail elderly, those in institutionalised care and those with hip fractures managed via orthopaedic pathways.40 Ortho-geriatric services, which are now present in most Australian hospitals, are critical to addressing this deficit. Potentially more importantly, primary care physicians need to be adequately equipped to detect and manage osteoporosis. The latter is being achieved through initiatives such as SFP in primary care and HealthPathways.

A recent systematic review of ortho-geriatric models of care, covering 18 (mainly retrospective cohort) studies from 1992 to 201241 demonstrated a reduction in in-patient and long-term (6–12 months post-fracture) mortality (relative risk [RR]: 0.60, 95% confidence interval [CI]: 0.43–0.84 and RR: 0.83, 95% CI: 0.74–0.94, respectively). Length of stay was reduced in the ortho-geriatric care model. A number of important outcome measures were not reported in many of these studies, such as delirium, functional status, post-discharge destination of patients, time to surgery, complications post-surgery, institution of falls risk assessment, measures to reduce falls risk, institution of measures aimed at secondary fracture prevention.

The treatment gap in osteoporosis care in Australia can be addressed through implementation of SFP programs and ortho-geriatric services in both the hospital and primary care setting. Supporting primary care physicians to manage osteoporosis in patients who do not have access to these programs is critical to ensuring that all patients with a minimal trauma fracture are evaluated and managed appropriately.

In general, there tends to be less utilisation of health services in rural and remote areas and poorer global health outcomes.42 People living in rural and remote areas are more likely to suffer from chronic diseases than those in major cities. However, diagnosis of osteoporosis is more prevalent in major cities than in most other areas of Australia.42

Bone densitometry (DXA) claims to Medicare increased by overall 78% in the 10 years from 2006 to 2015. The largest increase was seen in the service specific to osteoporosis screening in people older than 70 years of age. Claims for densitometry in this group more than tripled, while the population of men and women older than 70 years of age grew by an estimated 28% over the same 10-year period. Despite this overall growth in awareness and activity surrounding bone health, bone densitometry utilisation rates are significantly lower in rural and remote areas when compared to regional and urban areas. One study of Medicare claims between 2001 and 2005 showed that men and women in capital cities are around three times more likely to undergo densitometry than those in remote areas.43

There is a particular need to facilitate health service activity for the detection and management of osteoporosis in rural and remote areas. Important factors are likely to be the limited provision of both primary healthcare and bone densitometry services in rural areas.

Data from the most recent Australian epidemiological study indicates a female:male fracture incidence ratio of 2.5:1.44 The ratio for bone densitometry (DXA) utilisation, based on Medicare claims for 2015, is approximately 4.3:1.

This suggests significant underuse of bone densitometry in men. The sex difference is more pronounced in rural and remote areas.43

Research on differences in the burden of osteoporosis in the Aboriginal and Torres Strait Islander population is very limited. A 2001 study from the Cairns Hospital in northern Queensland reported similar overall agestandardised rates for fractured neck of femur in Aboriginal and Torres Strait Islanders compared to the nonIndigenous population of that area, but with a pattern of older age at the time of fracture for Aboriginal and Torres Strait Islander women.45 The 2004–05 National Aboriginal and Torres Strait Islander Health Survey showed that an estimated 0.9% of the Aboriginal and Torres Strait Islander population reported that they had been told by a doctor that they had osteoporosis.46 Aboriginal and Torres Strait Islander females were 1.5 times more likely to report having osteoporosis than Aboriginal and Torres Strait Islander males.46 Comparing age-standardised rates, Aboriginal and Torres Strait Islander males are almost twice as likely to report osteoporosis than nonIndigenous males.47 This contrasts with Aboriginal and Torres Strait Islander females, who are half as likely to report osteoporosis than non-Indigenous females.47 BMD data are lacking for Aboriginal and Torres Strait Islander peoples. Findings from a recent small study indicate higher femoral neck BMD in Aboriginal and Torres Strait Islander peoples than in Caucasian Australians.48 It is unknown at this stage whether this apparent difference in BMD translates into differences in fracture rates.

Differing patterns of risk factors such as smoking, nutrition, exercise, underweight, and high alcohol consumption are likely to be important in Aboriginal and Torres Strait Islander populations. The interaction of these factors, lower life expectancy, higher comorbidity rates, widely variable access to health services and socio-economic factors, is difficult to estimate. Promotion of good nutrition and reduction of risk factors is very important for a wide range of health issues, not only osteoporosis. It is expected that Aboriginal and Torres Strait Islander women and men suffer at least the same, if not a greater, limitation to densitometry access as noted for other rural and remote living people.

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