Women’s Perceptions of Future Risk After Low-Energy Fractures at Midlife

Despite growing awareness that osteoporosis is an important health problem,[1] few patients with a low-trauma fracture are ever evaluated or treated for osteoporosis, even though most fractures are related to skeletal fragility. Moreover, patients with one osteoporotic fracture are at substantially greater risk of another, and this is a treatment indication in most clinical practice guidelines. This situation is usually blamed on some combination of deficiencies on the part of the patient, the physician, and/or the healthcare system. To address such problems, we recently completed a clinical practice intervention, whereby local adults with a moderate trauma distal forearm fracture were automatically scheduled for bone densitometry and referred to their own physician for osteoporosis counseling.[2] Almost 40% of the patients refused to participate in this scheme. This indicates that the problem is not fundamentally a systems one, although important barriers exist, nor active physician resistance to osteoporosis management. Instead, as Meadows et al. point out in their report, the core issue is one of patient attitudes and beliefs.

However, patient judgments are not always erroneous with respect to treatment decisions. The forearm and vertebral fractures that predominate in midlife are not as disabling as hip fractures in the elderly.[3] Moreover, side effects and costs are associated with any pharmacologic therapy, and potential benefits are not assured. Indeed, most middle-aged osteoporotic patients will not experience a fracture, at least over the near term, even if they refuse treatment. Conversely, since fractures involve multiple factors beyond osteoporosis, other patients will fracture even though therapy successfully slowed their bone loss.

A critical problem here is lack of data about the patient’s actual fracture risk. Clearly, it matters when treatment reduces osteoporotic fracture risk by half if that reduction is from 2% to 1% over the next 10 years, as it might be for osteopenic women at the menopause, or from 34% to 17%, as it is for 70-year-old women with osteoporosis.[4] Under the auspices of the World Health Organization, the National Osteoporosis Foundation in the U.S. and the International Osteoporosis Foundation are jointly developing a fracture prediction algorithm that combines bone density results with clinical risk factors to predict a patient’s absolute risk of fracture,[5] the results of which may be available by late 2005. With an estimate of their own 10-year fracture risk in hand, patients should be better able to decide if the potential reduction achievable by intervention accords with their personal values.

References

1. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General, 2004. (http://www.surgeongeneral.gov/ library/bonehealth/content.html)

2. Cuddihy MT, Amadio PC, Gabriel SE, Pankratz VS, Kurland RL, Melton LJ. A prospective clinical practice intervention to improve osteoporosis management following distal forearm fracture. Osteoporos Int. 2004;15:695 -700.

3. Melton LJ III. Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res. 2003;18:1139-1141.

4. Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A. The burden of osteoporotic fractures: A method for setting intervention thresholds. Osteoporos Int. 2001;12:417-427.

5. Kanis JA, Black D, Cooper C, Dargent P, Dawson-Hughes B, de Laet C, Delmas P, Eisman J, Johnell O, Jonsson B, Melton L, Oden A, Papapoulos S, Pols H, Rizzoli R, Silman A, Tenenhouse A. A new approach to the development of assessment guidelines for osteoporosis. Osteoporos Int. 2002;13:527-536.

L. Joseph Melton, III, M.D., M.P.H., Senior Consultant, Department of Health Sciences Research, Mayo Clinic; Michael M. Eisenberg Professor, Mayo Clinic College of Medicine

Competing interests:   None declared