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Undertreatment of Osteoporosis in Men With Hip Fracture
Gary M. Kiebzak, PhD;
Garth A. Beinart, MD;
Karen Perser, BA;
Catherine G. Ambrose, PhD;
Sherwin J. Siff, MD;
Michael H. Heggeness, MD, PhD
Arch Intern Med. 2002;162:2217-2222.
ABSTRACT
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Background Women are not aggressively treated for osteoporosis after hip fracture;
the treatment status of men with hip fracture has not been extensively studied.
Objective To evaluate the outcome and treatment status of men with hip fracture.
Methods Data from medical records were obtained for 363 patients (110 men and
253 women) aged 50 years and older with atraumatic (low-energy) hip fracture
who were admitted to St Luke's Episcopal Hospital between January 1, 1996,
and December 31, 2000. Surveys were mailed to surviving patients. Main outcome
variables were osteoporosis treatments (antiresorptive or calcium and vitamin
D) at hospital discharge, current osteoporosis treatments at 1- to 5-year
follow-up, bone mineral density testing, mortality, current disability, and
living arrangements (home or institution).
Results The mean age for men was 80 years vs 81 years for women. Most fractures
(89% for men and 93% for women) resulted from falls from a standing height.
At hospital discharge, 4.5% of men (n = 5) had treatment of any kind for osteoporosis,
compared with 27% of women (n = 69) (P<.001).
The 12-month mortality was 32% in men, compared with 17% in women (P = .003). Surveys were usable from 168 (87%) of 194 survivors. At
1- to 5-year follow-up, 27% (12/44) of men were taking treatment of any kind
for osteoporosis, compared with 71% (88/124) of women (P<.001). Of those treated, 67% (8/12) of men and 32% (28/88) of
women were taking calcium and vitamin D only. At 1- to 5-year follow-up, 11%
of men had a bone mineral density measurement, compared with 27% of women.
After hospital discharge, the number of men and women who required wheelchairs,
walkers, and canes and who lived in institutions increased significantly.
Conclusions The burden of hip fracture is illustrated by the high incidence of postfracture
disability and the high mortality rate in both men and women. Nevertheless,
few men receive antiresorptive treatment.
INTRODUCTION
FROM A PUBLIC health perspective, hip fractures are by far the most
important type of osteoporosis-related fracture.1-6 They
are the predominant cause of death as a consequence of osteoporosis and are
associated with a high rate of morbidity.7-9 Furthermore,
hip fractures account for most medical costs related to osteoporosis. In the
United States in 1995, direct expenditures for osteoporotic fractures were
estimated to be $13.8 billion, and hip fractures were responsible for 63%
of the total.10-11 Globally, there
were an estimated 1.7 million hip fractures in 1990. As the population ages
in the United States and as the incidence in other parts of the world increases,
there could be as many as 6.3 million hip fractures annually by 2050.12
In the United States, the lifetime risk of hip fracture is about 17.5%
for women and 6% for men.1 Men account for
roughly 20% to 30% of all hip fractures.4, 13 Although
there is a high level of awareness about the problem of osteoporosis in women,
the same is not true for men. Like women, men older than about 55 years become
susceptible to age-related bone mineral loss, which continues for the remainder
of life. In men, this inexorable loss of bone mineral weakens bones, and vertebral
and hip fracture rates increase with advancing age.
Recent studies14-15 have
revealed the underuse of antiresorptive medications in women who have had
hip fractures. The explanation is unclear. In the acute setting, the orthopedist
is concerned with early repair of the fracture and rapid return to mobilization,
as delays are associated with higher 1-year mortality rates and a higher incidence
of delirium, fatal pulmonary embolism, and other postoperative complications.
The medical management of patients hospitalized with hip fracture focuses
on prevention of complications; concern about initiating long-term treatments
to prevent further fractures is not a pressing issue. Furthermore, it is possible
that practitioners are generally not aware that antiresorptive treatments
can increase bone mineral density and perhaps reduce fracture incidence even
in the oldest patients.
We hypothesized that after hip fracture men receive less treatment for
osteoporosis than do women. The objective of our study was to determine the
percentage of men taking antiresorptive treatment at hospital discharge and
at follow-up after a hip fracture.
SUBJECTS AND METHODS
SUBJECTS
After study approval by the hospital's institutional review board, a
medical records query identified all patients admitted to St Luke's Episcopal
Hospital for hip fracture between January 1, 1996, and December 31, 2000.
Among 456 fracture events that were identified, 363 (80%) met the eligibility
criteria. Exclusions consisted of patients whose admitting physician refused
to grant consent for medical chart review, patients younger than 50 years,
patients with hemiparesis, patients with fractures that were related to a
pathologic condition (metastatic disease, tumor, etc) or caused by high-energy
traumatic injury (such as a motor vehicle crash), and patients with fractures
2 cm or more below the lesser trochanter. Eleven medical charts were missing
or destroyed in the June 2001 flood caused by Tropical Storm Allison.
DATA COLLECTION AND OUTCOME MEASURES
Medical record review confirmed that fractures were intracapsular (29%),
trochanteric (3%), or intertrochanteric (68%). Patient demographic information,
number of comorbid conditions, cause of the fracture, medication at hospital
admission and discharge, and radiology reports were also obtained from the
medical record review.
Patients were then contacted via a mailed survey that requested information
on prefracture and postfracture living arrangements (ie, home vs institution),
disability, degree of independence in activities of daily living, history
of new fractures since the incident hip fracture, whether they had a bone
mineral density measurement, and current medications. If surveys were not
returned within 2 weeks, patients or their next of kin (who were listed in
the medical records) were contacted by telephone, and the surveys were completed
by telephone interview or were remailed. Deaths were confirmed using the Social
Security Death Index available on the Internet (available at: http://ssdi.genealogy.rootsweb.com).
The main outcome measures of interest were the percentage of men with
osteoporosis treatment at hospital discharge, the percentage of men with osteoporosis
treatment 1 to 5 years after fracture (as determined by the survey data),
bone mineral density testing, 12-month mortality, living arrangements, and
level of disability after fracture. Data were collected from women to provide
a reference benchmark for comparison with men. Treatments were categorized
as antiresorptive agents or calcium and vitamin D only. Antiresorptive agents
included estrogen (any form of hormone replacement therapy), selective estrogen
receptor modulators (eg, raloxifene hydrochloride), bisphosphonates (eg, alendronate
sodium), and calcitonin. Testosterone was not considered a conventional treatment
for osteoporosis. Although it may conceivably be beneficial in older men,
there is little information in the literature to support its use as an osteoporosis
treatment. In our cohort, it was administered to treat hypogonadism.
DATA ANALYSIS
Data were summarized using descriptive statistics (mean ± SD,
number of patients per category, etc). The unpaired, 2-tailed t test was used to compare mean values between men and women (eg, age).
Fisher exact test (a type of contingency testing) was used to determine the
significance of ratios, such as the number of men with or without treatment
vs the number of women with or without treatment. Pearson r statistic was used for correlation analysis, assuming that data were
normally distributed. P<.05 represented statistical
significance.
RESULTS
MEDICAL CHART REVIEW
Demographics
There were 110 men (mean age, 80 years; range, 53-99 years) and 253
women (mean age, 81 years; range, 51-101 years). The mean body mass index
(calculated as [weight in kilograms divided by the square of height in meters])
was 24.7 for men and 22.6 for women. Eighty-five percent of men and 92% of
women were white. Falls were the main cause of fractures in 89% of men and
in 93% of women. The percentages of men with intracapsular fractures (27%)
and extracapsular fractures (73%) were not significantly different (P = .45) from those in women (31% and 69%, respectively).
The percentages of men having open reduction internal fixation (66%), hemiarthroplasty
(15%), and total hip replacement (9%) as treatment for their hip fracture
were not significantly different (P = .37) from the
percentages for women with these treatments (65%, 17%, and 4%, respectively).
Osteoporosis Treatments
Only 5 men (4.5%) were taking treatment of any kind for osteoporosis
at hospital discharge. Of these, 3 men (2.7% of the total) were taking antiresorptive
treatment: 1 man was taking a bisphosphonate and 2 were taking calcitonin.
Two men (1.8% of the total) were taking calcium and vitamin D treatment only. Table 1 and Figure 1 show the distribution of patients receiving each type of
treatment. One man was taking bisphosphonate treatment and another was taking
calcium and vitamin D before admission. Two of 5 men with hypogonadism were
taking testosterone, but this was not considered as osteoporosis treatment.
In contrast, 69 women (27%) were taking treatment of any kind for osteoporosis
at hospital discharge. Nine women (3.6% of the total) were taking calcium
and vitamin D only at discharge (Table 1 and Figure 1). Fifty-six
(93%) of the 60 women taking an antiresorptive agent were taking treatment
before the incident hip fracture. The differences between the numbers of men
and women receiving treatment at discharge were statistically significant
(P<.001) (Figure
1).
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Table 1. Osteoporosis Treatments at Discharge*
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Figure 1. Percentage of 110 men and 253
women taking antiresorptive treatment (estrogen, selective estrogen receptor
modulators, calcitonin, or a bisphosphonate alone or in combination, with
or without calcium and vitamin D) or calcium and vitamin D only at hospital
discharge, based on medical chart review. Asterisk indicates a significant
difference (P<.001) in the ratio of the number
of men receiving treatment divided by the total number of men vs the number
of women receiving treatment divided by the total number of women.
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Fourteen men (13%) and 34 women (13%) had a previous hip fracture. One
man (7%) and 5 women (15%) were taking antiresorptive therapy before their
second hip fracture.
Eight men (7%) and 66 women (26%) had a history or diagnosis of osteoporosis
recorded in their medical records (P<.001, men
vs women). Twenty men (18%) and 78 women (31%) had an in-hospital radiograph
report noting osteopenia or osteoporosis (P = .01,
men vs women).
Bone Mineral Density Testing
One man and 3 women had notations in their medical records regarding
bone mineral density measurements.
Comorbid Conditions and Osteoporosis Risk Factors
Information pertaining to comorbid conditions and osteoporosis risk
factors was not uniformly documented in the medical records. Forty-seven men
(43%) and 86 women (34%) (this difference was not statistically significant; P = .12) had a history of 5 or more concurrent medical
conditions, including osteoarthritis, diabetes mellitus, hypertension, cancer,
coronary artery disease, end-stage renal disease, chronic obstructive pulmonary
disease, congestive heart failure, systemic lupus erythematosus, Alzheimer
disease, other dementias, chronic liver disease, stroke, arrhythmia, thyroid
disease, diverticulitis, and peptic ulcer disease. The percentages of men
and women with notations regarding corticosteroid medication, smoking, excessive
use of alcohol, and dementia were approximately the same. However, these risk
factors were not consistently documented; thus, these data were deemed incomplete
and statistical analyses were not performed.
Mortality
At 12 months after discharge, 32% of men had died, compared with 17%
of women (P = .003). Overall mortality in this cohort
was 58% for men and 42% for women (P = .004) (Table 2). There was a significant and linear
relationship between 12-month mortality and age (r =
0.89, P<.001). There were no differences in mortality
rates between patients with intracapsular fractures vs those with extracapsular
fractures (P = .45). The cumulative mortality was
not significantly higher in men and women with a prior fracture (P = .75). However, men with 5 or more comorbid conditions had a cumulative
mortality of 75%, which was significantly higher than that of men with fewer
than 5 comorbid conditions (46%) (P = .003). Similarly,
women with 5 or more comorbid conditions had a cumulative mortality of 65%,
which was higher than that of women with fewer than 5 comorbid conditions
(29%) (P<.001). The cumulative mortality rates
for men and women with 5 or more comorbid conditions were not significantly
different (P = .33).
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Table 2. Mortality With Time After Fracture*
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SURVEY RESULTS
Response Rate
Complete survey information was obtained from 168 (87%) of 194 surviving
patients; 15 surveys were incomplete or internally inconsistent and thus not
usable, and 11 patients were unavailable for follow-up. The mean age for men
and women in this subgroup was 79 years (range, 53-99 years for men and 51-100
years for women). Mean follow-up was 3 years (range, 1-5 years).
Osteoporosis Treatments
The number of patients with treatment for osteoporosis increased with
time after fracture. Table 3, Figure 2, and Figure 3 show the distribution of patients receiving each type of
treatment. Among the survey respondents, 6.8% (3/44) of men compared with
31% (38/124) of women were receiving osteoporosis treatment of any kind at
hospital discharge (P = .001). At 1- to 5-year follow-up,
27% (12/44) of men were receiving treatment, compared with 71% (88/124) of
women (P<.001). The increase in the number of
patients with osteoporosis treatment of any type between discharge and follow-up
was significant for men (P = .02) and women (P<.001). At follow-up, 18% (8/44) of men and 23% (28/124)
of women were taking calcium and vitamin D only (the percentage was not significantly
different, P = .67).
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Table 3. Osteoporosis Treatment at Follow-up*
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Figure 2. Percentage of 44 men and 124 women
taking antiresorptive treatment (estrogen, selective estrogen receptor modulators,
calcitonin, or a bisphosphonate alone or in combination, with or without calcium
and vitamin D) at hospital admission, discharge, and 1- to 5-year follow-up.
These data are for men and women who completed surveys. Asterisk indicates
a significant difference (P .001) in the ratio
of the number of men receiving treatment divided by the total number of men
vs the number of women receiving treatment divided by the total number of
women. The percentage of men taking antiresorptive treatment did not significantly
increase from hospital admission to follow-up (P =
.36) in contrast to women (P<.001).
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Figure 3. Percentage of 44 men and 124 women
taking calcium and vitamin D only at hospital admission, discharge, and 1-
to 5-year follow-up. These data are for men and women who completed surveys.
Percentages were not significantly different between men and women. The percentage
of men and women taking calcium and vitamin D only increased from hospital
admission to follow-up: P = .03 for men; P<.001 for women.
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New Fractures
Of the men, 9% (4/44) reported new fractures (any type) in the surveys,
compared with 16% (20/124) of the women (the percentage was not signficantly
different, P = .32).
Bone Mineral Density Testing
At 1- to 5-year follow-up, 11% (5/44) of men and 27% (34/124) of women
reported having had a bone mineral density measurement (the difference was
significant at P = .04). Thirty percent (13/44) of
men and 31% (39/124) of women reported that they were uncertain if they had
had such a test.
Living Arrangements and Level of Disability Before and After Fracture
Table 4 summarizes the living
arrangements and level of disability before and after fracture. The number
of men and women living independently at home and who required walking aids
or wheelchairs increased after hip fracture (P<.02
or less). The number of men and women pursuing recreational activities decreased
after hip fracture (P<.02 or less). The percentages
of men who entered institutions, who required walking aids or wheelchairs,
and who could not pursue recreational activities were not significantly different
from those of women.
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Table 4. Living Arrangements and Level of Disability Before and After
Fracture*
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COMMENT
Most previous studies7, 9, 13, 16-21 of
hip fracture outcomes have focused on women. However, there are known risk
factors associated with hip fracture in men. Others2, 9, 13, 18, 22-24 have
previously reported that mortality after hip fracture is higher in men than
in women. Nevertheless, attention to treatment of men for underlying osteoporosis
has been minimal. We report herein that osteoporosis treatment after hip fracture
for men is uncommon in a large hospital setting and that, during 1- to 5-year
follow-up after discharge, few men get treated. Colon-Emeric et al25 reported similar undertreatment of men with hip fracture
at discharge.
Undertreatment of women with hip fracture has been recognized.14-15 In our study, the difference in the
percentage of men and women leaving the hospital with a treatment regimen
is misleading, because most of the women who left the hospital with treatment
had been receiving treatment at admission. With time after discharge, the
number of women eventually commencing treatment increased to 71%. However,
with time after discharge, only 27% of men were taking treatment for osteoporosis.
Furthermore, a large percentage of men and women were receiving nonaggressive
therapy (calcium and vitamin D supplements only), despite the wide acceptance
and proven efficacy of potent antiresorptive agents.
Fewer conventional treatments were available to clinicians for treating
osteoporosis in men between 1996 and 2000,26 when
these patients presented. This contrasts with the number of treatments that
were available for women, most notably estrogen replacement therapy, which
has been the mainstay of prevention and management of osteoporosis for many
years. In fact, it is the widespread use of estrogen that largely explains
the difference in the percentage of women vs men who are treated. However,
calcium and vitamin D were available, and although not an aggressive treatment,
older women (and presumably men as well) are often vitamin D deficient and
have a calcium-deficient diet.27-28 In
institutionalized patients, calcium and vitamin D treatment may reduce the
incidence of fracture.28 Off-label use of bisphosphonates
and calcitonin was also available. However, the approval of alendronate in
October 2000 for the treatment of osteoporosis in men29 made
little difference in the immediate aftercare of men with hip fractures: from
October 2000 to June 2001, we identified 11 men with hip fracture who met
inclusion criteria for this study (patients from 2001 were not included in
this study), and none were receiving bisphosphonate treatment at hospital
discharge.
We suggest that the problem is not a lack of available treatment but
rather a lack of physician awareness of the lifetime risk of osteoporosis
and fracture in men. Insufficient patient education may also be a problem.
If patients are provided with information that helps them understand that
their fractured hip was due to osteoporosis, they and their families may be
more active in seeking treatment. Nevertheless, it remains enigmatic as to
why so few men (and women) receive treatment, as in our study 13% of men had
a previous hip fracture, 7% had a diagnosis of osteoporosis recorded in their
medical chart, and 18% had a radiology report indicating the presence of osteopenia
or osteoporosis. Furthermore, most men and women reported never having had
a bone mineral density measurement, a simple yet established method for assessing
bone status (as normal, osteopenic, or osteoporotic) and risk for fracture.
A substantial number of men (30%) and women (32%) were uncertain if they ever
had a test, suggesting that the results and significance were not effectively
explained if they had a bone mineral density measurement.
The urgency in addressing osteoporosis treatment and aftercare plans
for patients with hip fracture is reflected in the morbidity and mortality
associated with hip fractures. Our findings, similar to those of previous
reports, show high postfracture mortality rates. Within 12 months of hospital
discharge, 32% of men and 17% of women had died. These rates are higher than
those for age-matched patients without hip fracture.8, 22 Data
from the Centers for Disease Control and Prevention suggest that the mean
life expectancy is 7.5 years for an 80-year-old white man and 9.1 years for
an 80-year-old white woman.30 The reasons have
been addressed by others and include factors such as medical complications
(many of these older patients have serious comorbid conditions) and the negative
effects of loss of independence with respect to activities of daily living
and increased disability.1, 7, 9, 16-21
Survey results from survivors 1 to 5 years after fracture show a statistically
significant loss of mobility, with the number of men requiring a wheelchair
tripling and the number needing a walker or cane doubling. The number of men
pursuing recreational activities decreased by 50%. The numbers were similar
in women. These changes correlated with a significant increase in the number
of men and women living in institutions.
Who is responsible for ensuring osteoporosis treatment for the hip fracture
patient? Strictly speaking, any physician who evaluates a patient with a history
of hip fracture should consider treatment options. Anecdotally, it is often
said that recognizing and managing osteoporosis in the patient with hip fracture
is the responsibility of the orthopedist who repairs the fracture. However,
osteoporosis is a multidisciplinary problem. Older men and women should be
evaluated for osteoporosis long before the first fracture event. For many
years, osteoporosis was defined as the presence of a fragility fracture. To
promote early detection and reduce the incidence of fractures, the World Health
Organization31 redefined osteoporosis, based
on bone mineral density; thus, it became possible to identify individuals
at high risk for fractures and to initiate treatment in an effort to prevent
fractures.
In the hospital setting, during the care of acute hip fracture, the
primary concern of the orthopedist is to attain rapid reduction and fixation
of the fracture and to restore prefracture mobility. Hip fracture is a serious
event, and several issues, including deep venous thrombosis prophylaxis, antibiotic
prophylaxis, altered mental status, nutrition, and urinary tract management,
demand immediate attention.23, 32 Low
bone mineral density is not a life-threatening problem, and initiating antiresorptive
treatment immediately after a hip fracture has secondary importance. Other
factors can affect treatment decisions, such as comorbid conditions and extreme
age. The effects of bisphosphonates on bone healing have not been thoroughly
studied. Furthermore, orthopedists are appropriately reluctant to initiate
treatment for patients whom they are unlikely to follow up long-term. Nevertheless,
while the patient is in the hospital, there is a window of opportunity to
provide educational materials to patients and their families regarding osteoporosis
and to advise the patient's primary care physician of appropriate antiresorptive
treatments.
More attention should be given to older men at high risk for hip fracture
before the first fracture event. Hypogonadism, alcoholism, and corticosteroid
use are associated with a high risk of osteoporosis and fracture in men. Furthermore,
metabolic disorders leading to secondary osteoporosis (hyperthyroidism, inflammatory
bowel disease, etc) and disorders of movement or balance leading to falls
(parkinsonism, seizures, blindness, etc) are predictors of hip fracture in
men. Poor vision, smoking, reduced mental status, overall poor health, and
low circulating insulin-like growth factor I are among other risk factors
associated with hip fracture in men and women.7, 9, 13, 16-21 Therefore,
many candidates for hip fracture could potentially be identified during routine
medical office visits. Countermeasures could include commencement of antiresorptive
therapy to increase bone mineral density and physical rehabilitation to increase
muscle strength and improve balance. Treatment for older individuals is cost-effective
and and increases bone mineral density with a possible reduction in fracture
incidence.29, 33-35 Increased
awareness of risk factors and appropriate countermeasures could decrease the
incidence of hip fractures in men, with a consequent reduction in morbidity
and mortality and great savings in health care costs to society.
AUTHOR INFORMATION
Accepted for publication February 27, 2002.
This work was supported by grants from the John S. Dunn Research Foundation,
Houston; the MacDonald General Research Fund, Houston; and Merck & Co,
Inc, Westpoint, Penn. These funding organizations had no role in the design,
conduct, interpretation, or analysis of the study, nor did they review the
manuscript before submission for publication.
We acknowledge the technical support of Connie Gooden, RN.
Corresponding author and reprints: Gary M. Kiebzak, PhD, Center for
Orthopaedic Research and Education, St Luke's Episcopal Hospital, 6720 Bertner
Ave, Mail Stop MC4-183, Houston, TX 77030 (e-mail: gkiebzak{at}sleh.com).
From the Center for Orthopaedic Research and Education (Drs Kiebzak,
Siff, and Heggeness) and Department of Orthopaedic Surgery (Dr Siff), St Luke's
Episcopal Hospital; Department of Orthopaedic Surgery, Baylor College of Medicine
(Drs Kiebzak, Siff, and Heggeness), Houston, Tex; The University of Texas
Houston Medical School (Ms Perser); and Department of Orthopaedics, The University
of Texas Houston Health Science Center (Dr Ambrose). During the preparation
of this article, Dr Beinart was in medical school at Baylor College of Medicine.
He is now affiliated with the Department of Internal Medicine, University
of California, San Francisco.
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