The results of our large population-based study demonstrated that only 31.4% of patients were managed at all after fracture during the study period between 2000 and 2004. The variation in management patterns after osteoporosis-related fracture was explained primarily by patient characteristics; physician characteristics had almost no explanatory power. Patients over 90 years old, who were at the highest risk for future fracture, were the least likely to be managed consistently with other literature demonstrating the “treatment-risk” paradox.19
Black patients were also less likely to be managed after fracture, consistent with the large amount of literature on racial and ethnic disparities.20
In contrast, the only physician factor that predicted appropriate management was gender, yet this factor did not appreciably influence the predictive power of our models.
As such, our results highlight the need for quality improvements in the treatment of osteoporosis after fracture for all physicians and suggest that certain subgroups of patients should be the focus of particular attention. Unfortunately, interventions to improve osteoporosis management have had limited success. One intervention, supplying a system of reminders to physicians and phone calls to patients, led to a 45% relative improvement in osteoporosis management, but only a 4% absolute improvement in treatment, which did not translate into a statistically significant reduction in fractures.21
In another recently published study, an educational intervention delivered to patients with osteoporosis and/or their physicians had no impact on the appropriate osteoporosis treatment rates.22
Other interventions including treatment algorithms for physicians and follow-up letters for patients have also achieved modest results at best.23
Accordingly, there is an urgent need to develop and evaluate interventions to help physicians effectively manage this increasingly important clinical condition.
The positive correlation between pneumonia vaccine use and osteoporosis treatment may indicate that patients with better preventative care are more likely to be treated after fracture. It is possible that the presence of a formalized relationship with a primary care physician, where it is understood by both parties that this physician is the coordinating point of contact for medical care, may predict osteoporosis management. One county-level analysis found a correlation between primary care physician presence and lower mortality rates, a correlation that did not hold for the supply of specialist physicians.24,25
In contrast to existing literature, we found that physician specialty or physician experience did not predict the likelihood of osteoporosis management, which was found across specialties including cardiology,26
Our study has several limitations. First, the physician responsible for osteoporosis treatment for each fracture was attributed exclusively to the dominant prescriber. It is possible that we mis-assigned patients to providers, which may have led to incorrect inferences about physician predictors of osteoporosis management. Second, our study focused on drugs of proven efficacy, so we did not look at other preventive treatments, such as over-the-counter calcium or vitamin D supplements and hip protectors. Similarly, while we tried to control for contraindications such as gastrointestinal disease, coronary disease, and other comorbidities that may have reasonably impacted osteoporosis treatment, it is conceivable that other comorbidities not included in the model may have confounded the results.
Third, although this study is focused on physician prescribing, the data followed only filled prescriptions. It is possible that some groups were prescribed drugs, but did not fill their prescriptions. In particular, age may be correlated with the ability to actually fill prescriptions written by physicians, and thus our observation that older patients are particularly under-treated may be confounded by this fact. Finally, this study was limited to females over age 65 living in Pennsylvania, and the predictors of osteoporosis prescriptions may not be generalizable to other states, the treatment of men, or younger women. Some patients prescribed medications by physicians may not have filled prescriptions, a rate that could vary across physicians. However, it is unlikely that variation in preferences in the cohort of strictly low-income Pennsylvania women over age 65 could explain the observed variation between patient groups. Other unobserved variables include education, communication, and health beliefs.
In conclusion, although fracture is the greatest single predictor of future fracture, only 31% of hip or wrist fracture patients had their osteoporosis managed. The treatment of osteoporosis is well predicted by patient characteristics, but physician characteristics do not predict treatment. In spite of hip or wrist fracture, a sentinel event indicating risk of future fracture, prior use of osteoporosis therapy, and patient characteristics best predict osteoporosis treatment.