Nancy A. Melville

September 27, 2011

September 27, 2011 (San Diego, California) — An intervention program to inform primary care physicians of vertebral fractures identified incidentally on chest x-rays taken for other purposes can improve bone mineral density (BMD) testing and osteoporosis treatment in patients at risk for fracture, according to research presented here at the American Society for Bone and Mineral Research 2011 Annual Meeting.

As much as two thirds of vertebral compression fractures go undetected because symptoms are not severe enough for patients to report them to their doctors, and current guidelines do not recommend radiographic screening for vertebral fractures in the general population, explained lead author Sumit Majumdar, MD, associate professor in the division of general internal medicine at the University of Alberta in Calgary, Canada.

However, the chest x-rays that many older patients receive for a host of other reasons provide a unique opportunity to identify otherwise undetected fractures and improve care, Dr. Majumdar asserted.

"About a quarter of people over the age of 60 have clinically important moderate to severe vertebral fractures that can be identified on regular plain film chest x-rays. Yet, as in many other aspects of osteoporosis, 75% of those patients are neither diagnosed nor treated for osteoporosis," he said.

To find out how information from chest x-rays can be used to improve care for patients with vertebral fractures, Dr. Majumdar and his team identified patients 60 years and older who were discharged from emergency departments with vertebral fractures but not treated for osteoporosis.

Of the 1315 patients identified, 1075 were excluded for reasons such as being unwilling or unable to consent, already being treated for osteoporosis, or being admitted to the hospital. The remaining patients were assigned to a physician intervention group (n = 117) or to a control group in which patients received usual care (n = 123).

The physician intervention involved sending the patient's primary care physician a report describing the vertebral fracture, along with an evidence summary signed by 3 local osteoporosis experts. The summary included key messages, such as the fact that patients with a fracture and osteoporosis have a 20-fold increased risk of having another fracture without treatment and that evidence-based treatments can reduce the risk for fracture by about 50%.

After 3 months, patients in the control group who remained untreated crossed over into a counseling group. These patients were provided with the same information that was sent to their primary care physician; in addition, they received a 10-minute counseling session with a registered nurse who had osteoporosis expertise.

The results showed that osteoporosis treatment increased significantly in the physician intervention group, compared with the control group (17% vs 2%; P < .001), as did BMD testing (44% vs 4%; < .001) and the composite of BMD testing and treatment (49% vs 6%; P < .001).

BMD testing or osteoporosis treatment improved in another 16% of patients in the counseling group, compared with physician intervention group (65% vs 49%; P = .01).

The results underscore the potential benefits of intervening when vertebral fractures are identified, Dr. Majumdar said.

"Compared with usual care, [the physician intervention] substantially improved bone density testing and osteoporosis treatment," he said.

He noted, however, that an important part of the equation is improving awareness about the benefits of reporting fractures in the first place.

"A pilot study that we conducted showed that only about 60% of moderate to severe fractures on chest x-rays are even reported by board-certified radiologists. It's not that they're missing them, it's just that they're not reporting them," he said.

"I believe that is because many radiologists consider these fractures to be just a normal part of aging; hence, 40% are not reported."

The results bring to light an issue that is often lost in the shuffle of other clinical issues, said Laura A.G. Armas, MD, assistant professor at Creighton University's Osteoporosis Research Center, in Omaha, Nebraska.

"In a busy primary practice, there needs to be an obvious cue for the primary care physician to realize that there is a vertebral compression fracture," said Dr. Armas, who moderated the session.

"Many radiologists don't report them. Even if they do, the x-ray was likely done for another reason, so the physician isn't necessarily thinking about bone."

"To work well in the community, an effort would be needed to [educate] radiologists as well as primary care physicians," she noted. "It would require a concerted effort, but one that looks worthwhile based on Dr. Majumdar's work."

Dr. Majumdar and Dr. Armas have disclosed no relevant financial relationships.

American Society for Bone and Mineral Research (ASBMR) 2011 Annual Meeting: Abstract 1136. Presented September 18, 2011.

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