Adherence to osteoporosis pharmacotherapy one year after osteoporotic fracture - a Swiss trauma center secondary prevention project.

AIMS OF THE STUDY: According to current evidence, one out of ten fracture patients with osteoporosis does not sustain another fracture if he or she is on adequate medication. However, epidemiological surveys show that only about 15 to 30% of affected patients avail themselves of the treatments. This cohort study investigated how many fracture patients with a recommendation for antiosteoporotic therapy effectively received treatment and the possible reasons why the treatment was not implemented. METHODS: As part of a quality improvement programme in a Swiss trauma centre, fracture patients were actively checked for osteoporosis in accordance with a standardised outpatient programme. The results, together with detailed therapy recommendations, were transmitted to each patient's general practitioner (GP). A prospective questionnaire survey evaluated all patients with a diagnosis of osteoporosis for subsequent realisation of therapy 1 year after the fracture (mean ± standard deviation; chi-square; analysis of variance; significance level p <0.05). RESULTS: A total of 305 patients received a recommendation for antiosteoporotic therapy, of whom 18 (5.9%) died before 1 year. The questionnaire was completed for 255 out of 287 patients (follow-up 88.9%; 73.8±11.5 years old at the time of survey; 77.7% female). Of these, 117 patients (45.9%) sustained a fracture of the lower extremities and 105 patients (41.1%) a fracture of the upper extremities; 33 patients (13%) had other or multiple fractures. Fifty-two cases (20.4%) had pre-existing osteoporosis at the time of fracture. At the 1-year follow-up, 132 (52%) patients were receiving prescribed drugs. The most frequent patient explanation for not taking treatment (n = 123) was, in 47.2% of cases (n = 58), that none had been prescribed; 30.1% of patients were not interested. Multivariate analysis of verifiable factors of influence confirmed that fracture patients were treated significantly more reliably with antiosteoporotic therapy if osteoporosis was diagnosed with dual energy x-ray absorptiometry alone in patients with fewer comorbidities, and that fracture patients persisted significantly more reliably with antiosteoporotic therapies when pre-existing osteoporosis was present (R2 0.17; p <0.001). CONCLUSIONS: Following a standardised diagnostic work up for osteoporosis as part of fracture treatment, and including the communication of recommendations for antiosteoporotic therapy to the GP, only every second patient actually received the proposed treatment. This appears to be better than described in the literature but still calls for improvement. Two different solutions appear to be possible based on these findings: to endeavour to better inform and convince GPs about the need for treatment and/or for the diagnosing team to initiate antiosteoporotic therapy where indicated rather than just recommending it.

Screening for osteoporosis following non-vertebral fractures in patients aged 50 and older independently of gender or level of trauma energy-a Swiss trauma center approach.

Screening in a standardized manner for osteoporosis in non-vertebral fracture patients aged 50 and older independently of both gender and level of trauma energy yielded the indication for osteoporotic therapy for every fourth male high-energy fracture patient. PURPOSE: This study aimed to identify the rate of osteoporosis in patients of both genders after fracture independently of the underlying level of trauma energy. METHODS: A random cohort of patients aged 50 or older with non-vertebral fractures participated in a standardized diagnostic protocol to evaluate the indication for treatment of osteoporosis (number needed to screen (NNS)). Univariate and multivariate analysis as well as correlation testing were performed to determine statistical relationships. Significance was set at p < 0.05. RESULTS: Of 478 fracture patients with a mean age of 69.3 ± 11.8 years, 317 (66.3%) were female and 161 (33.7%) male. One hundred nineteen patients (24.9%) sustained high-energy fractures (HEFs) and 359 (75.1%) low-energy fractures (LEFs). Twenty-eight percent of males and 47% of females qualified as osteoporotic in densitometry (dual-energy X-ray absorptiometry (DXA)), resulting in a NNS of 2.1 for women and 3.6 for men. The indication for treatment of osteoporosis increased to an NNS of 1.5 for females and 2.4 for males if the fracture risk assessment tool (FRAX) was included in the diagnostics (DXA and FRAX). With regard to the energy of trauma, the NNS for treatment following DXA and FRAX was 1.5 for LEF and 2.9 for HEF. Subgroup analysis revealed that HEF males within the decennia 50+ and 80+ had an NNS of around 3, i.e., comparable to females and about twice as high as LEF patients. CONCLUSIONS: These preliminary findings appear to confirm the pragmatic approach to screening in a standardized manner for osteoporosis in all non-vertebral fracture patients aged 50 and older-independently of both gender and level of trauma energy.

Influence of preoperative nucleus pulposus status and radiculopathy on outcomes in mono-segmental lumbar total disc replacement: results from a nationwide registry.

BACKGROUND: Currently, herniated nucleus pulposus (HNP) with radiculopathy and other preconditions are regarded as relative or absolute contraindications for lumbar total disc replacement (TDR). In Switzerland it is left to the surgeon's discretion when to operate. The present study is based on the dataset of SWISSspine, a governmentally mandated health technology assessment registry. We hypothesized that preoperative nucleus pulposus status and presence or absence of radiculopathy has an influence on clinical outcomes in patients treated with mono-segmental lumbar TDR. METHODS: Between March 2005 and April 2009, 416 patients underwent mono-segmental lumbar TDR, which was documented in a prospective observational multicenter mode. The data collection consisted of perioperative and follow-up data (physician based) and clinical outcomes (NASS, EQ-5D).Patients were divided into four groups according to their preoperative status: 1) group degenerative disc disease ("DDD"): 160 patients without HNP and no radiculopathy, classic precondition for TDR; 2) group "HNP-No radiculopathy": 68 patients with HNP but without radiculopathy; 3) group "Stenosis": 73 patients without HNP but with radiculopathy, and 4) group "HNP-Radiculopathy": 132 patients with HNP and radiculopathy. The groups were compared regarding preoperative patient characteristics and pre- and postoperative VAS and EQ-5D scores using general linear modeling. RESULTS: Demographics in all four groups were comparable. Regarding the improvement of quality of life (EQ-5D) there were no differences across the four groups. For the two main groups DDD and HNP-Radiculopathy no differences were found in the adjusted postoperative back- and leg pain alleviation levels, in the stenosis group back- and leg pain relief were lower. CONCLUSIONS: Despite higher preoperative leg pain levels, outcomes in lumbar TDR patients with HNP and radiculopathy were similar to outcomes in patients with the classic indication; this because patients with higher preoperative leg pain levels benefit from a relatively greater leg pain alleviation. The group with absence of HNP but presence of radiculopathy showed considerably less benefits from the operation, which is probably related to ongoing degenerative processes of the posterior segmental structures. This observational multicenter study suggests that the diagnoses HNP and radiculopathy, combined or alone, may not have to be considered as absolute or relative contraindications for mono-segmental lumbar TDR anymore, whereas patients without HNP but with radiculopathy seem to be suboptimal candidates for the procedure.