Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study
© Kung et al; licensee BioMed Central Ltd. 2013
Received: 28 June 2012
Accepted: 28 January 2013
Published: 14 February 2013
A vast amount of literature describes the incidence of fracture as a risk for recurrent osteoporotic fractures in western and Asian countries. Osteoporosis evaluation and treatment after a low-trauma fracture, however, has not been well characterized in postmenopausal women in Asia. The purpose of this study was to characterize patient and health system characteristics associated with the diagnosis and management of osteoporosis among postmenopausal women hospitalized with a fragility fracture in Asia.
Patient surveys and medical charts of postmenopausal women (N=1,122) discharged after a fragility hip fracture from treatment centers in mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand between July 1, 2006 and June 30, 2007 were reviewed for bone mineral density (BMD) measurement, osteoporosis diagnosis, and osteoporosis treatment.
The mean (SD) age was 72.9 (11.5) years. A BMD measurement was reported by 28.2% of patients, 51.5% were informed that they had osteoporosis, and 33.0% received prescription medications for osteoporosis in the 6 months after discharge. Using multivariate logistic regression analyses, prior history of fracture decreased the odds of a BMD measurement (OR 0.63, 95% CI 0.45-0.88). Having a BMD measurement increased the odds of osteoporosis diagnosis (OR 10.1, 95% CI 6.36-16.0), as did having health insurance (OR 4.95, 95% CI 1.51-16.21 for private insurance with partial self-payment relative to 100% self-payment). A history of fracture was not independently associated with an osteoporosis diagnosis (OR 0.80, 95% CI 0.56-1.15). Younger age reduced the odds of receiving medication for osteoporosis (OR 0.59, 95% CI 0.36-0.96 relative to age ≥65), while having a BMD measurement increased the odds (OR 1.79, 95% CI 1.23-2.61).
Osteoporosis diagnosis and treatment in Asian countries were driven by BMD measurement but not by fracture history. Future efforts should emphasize education of general practitioners and patients about the importance of fracture.
KeywordsOsteoporosis Bone density Female Fractures Asia
The prevalence of osteoporosis increases markedly after age 50 in postmenopausal women in Asia [1–3]. In Korea the prevalence of osteoporosis measured by bone mineral density (BMD) scanning of the lumbar spine has been reported to be 31% in postmenopausal women 45–64 years, 53% in those 65–74 years, and 69% in those ≥75 years . Similar observations have been made in Taiwan .
A definitive diagnosis of osteoporosis in asymptomatic women is achieved via BMD measurement but, because of the relatively high cost of these measurements, a case-finding strategy is recommended . A simple risk index based only on age and body weight can be used to screen for osteoporosis in Asian postmenopausal women prior to BMD measurement [5–8]. Since prior fracture is a well-documented risk factor for a future non-vertebral osteoporotic fracture in postmenopausal women in western and Asian countries [9–11], therefore, it is recommended that after a fragility fracture all postmenopausal women should be evaluated for osteoporosis . Recent studies in western countries indicate that rates of treatment with medications for osteoporosis after a fracture vary widely. In a study in Italy 78% of patients received a medication for osteoporosis after a hip fracture . Conversely, in the Netherlands only 19% of women age ≥50 years were treated with medications for osteoporosis in the year after a low-trauma fracture  and in Belgium only 6% of postmenopausal women received a bisphosphonate or hormone therapy after a hip fracture .
Little is known, however, about osteoporosis evaluation and treatment after a low-trauma fracture in countries in Asia. The objective of this study was to evaluate the diagnosis and treatment of osteoporosis among postmenopausal women after hospitalization for a fragility fracture in a selection of Asian countries.
Study design and patient sample
This was a patient survey and medical chart review carried out at multiple centers in six Asian countries including mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand. Women who were hospitalized due to fragility fracture of the hip between July 1st, 2006 and June 30th, 2007 (the case identification period) were identified using discharge records of participating hospitals. A random sample of these patients was selected for inclusion in the study. Patients were included if they had been hospitalized because of non-traumatic hip fracture (defined as resulting from a fall from standing height), were postmenopausal, and were able to participate independently in an interview. The index fracture, i.e., the fracture qualifying the subject for enrollment, was identified by reviewing hospitalization, emergency room or outpatient visit records for ICD-9/10 diagnosis codes 820.0, 820.2, or 820.8. Approval was obtained from participating hospital IRB committees; informed consent was provided by all patients.
Medical chart review
Medical charts were reviewed during hospitalization to obtain data on BMD (T-score for spine, femoral neck, or total hip), height and weight, comorbidities, and medications prescribed for osteoporosis.
Face-to-face and telephone interviews were conducted with patients to collect data about an osteoporosis diagnosis, BMD measurement, and osteoporosis treatment in the 6-month period following hospitalization for fragility fracture. Patients were asked “Have you ever been told that you have osteoporosis?” If they answered “yes”, they were asked when they were told they had osteoporosis (in relation to the index fracture). They were also asked whether and when they had a BMD measurement for osteoporosis and what reimbursement, if any, they received for their hospital stay. Response options were either items in a checklist or “yes”, “no”, or “don’t know”. Questions about their post-fracture follow-up included whether they were advised to take prescription drugs or dietary supplements in the 6 month period after hospitalization for the index fracture, whether they were still being treated by a physician for osteoporosis, and the specialty of the physician. Other items recorded their demographic and, clinical characteristics and their fracture history prior to the index fracture.
The main outcome variables were binary variables (yes/no) for a BMD measurement, an osteoporosis diagnosis, and receipt of an osteoporosis medication. The associations between patient characteristics (age category, fracture history, and payment type) and the outcome variables were examined in univariate analyses; P values were computed using Fisher’s exact test. Logistic regression analyses were applied to identify significant factors independently associated with the outcome variables BMD measurement, osteoporosis diagnosis and receipt of medications. For the model with BMD screening as outcome variable, independent variables were age category, history of fracture, and payment type. Only patients who answered “yes” or “no” were included in the model with a BMD measurement as dependent variable; patients who responded “don’t know” were excluded. For the model with osteoporosis diagnosis as outcome variable, independent variables included were age category, fracture history, BMD measurement and type of payment. For the model with receipt of osteoporosis medications as outcome variable, independent variables included were age category, fracture history, fracture diagnosis timing, BMD measurement and type of payment.
A subgroup analysis assessed the impact of lower BMD on osteoporosis diagnosis and receipt of osteoporosis medications among patients whose BMD values were recorded. BMD values were expressed as a categorical variable, and Fisher’s exact test was applied. BMD of the total spine, femoral neck, or total hip was used in the stated order as available. A logistic regression model was applied to this patient subset, with osteoporosis treatment as dependent variable and the following independent variables: age category, a history of fracture, and T score category. Percent of patients using osteoporosis medications were calculated.
Results and discussion
Selection of sample
A total of 1,148 post-menopausal women hospitalized due to fragility fractures met the inclusion criteria and were enrolled in the study. Of these, 26 (2.3%) patients did not answer the question about an osteoporosis diagnosis and were excluded from the analysis. The data analysis was applied to the remaining 1,122 subjects.
Age category (years)
Been told had osteoporosis
Prescription drug for osteoporosis
History of fragility fracture
Falls in past 12 months
Family history of osteoporosis
Family history of fracture
Type of payment
100% self pay
Partial self pay with social insurance
Partial self pay with private insurance
100% paid by social insurance
100% paid by private insurance
Hospital treatment free of charge
Rates of BMD measurement, osteoporosis diagnosis, and osteoporosis medication
BMD measurement (N=1,122)
Osteoporosis diagnosis (N=1,122)
Osteoporosis medication (N=1,122)
100% self pay
Partial self pay with social insurance
Partial self pay with private insurance
100% paid by social insurance
100% paid by private insurance
Hospital treatment free of charge
Logistic regression analyses
BMD measurement (N=837)
Fracture diagnosis timing
Before index fracture
During index fracture
After index fracture
A BMD measurement
Type of payment
100% private insurance
100% social insurance
Other type of insurance
Free hospital, government pay
Partial self with private insurance
Partial self with social insurance
100% self pay
Osteoporosis diagnosis and treatment among the subgroup of patients with a BMD measurement
Osteoporosis diagnosis (%)a
Osteoporosis medication (%)a
Greater than −1
−1 to −2.5
−2.5 to −3
Lower than −3
Prescription medications for osteoporosisa
Any prescription drugs
Patient age category and payment type were significantly associated with treatment for osteoporosis in univariate analyses (Table 2). Age category, having had a BMD measurement, fracture history and type of payment were associated with osteoporosis treatment in multivariate logistic analysis (Table 3). Younger age category (50–64 years) reduced the odds of receiving medication for osteoporosis, while having had a BMD measurement increased the odds of treatment. The odds of treatment were reduced by having 100% social insurance and increased by “other type of insurance” when compared to 100% self pay. A history of fracture was not associated with receiving medications for osteoporosis. A more negative T score was associated with osteoporosis treatment in the univariate analysis (Table 4).
Rates of BMD measurement, osteoporosis diagnosis and treatment, by country
In this population of elderly (average age 72.9 years) women discharged from hospital after a fragility fracture, having a BMD measurement (28.2% of patients) increased the odds of a diagnosis of osteoporosis and treatment. Compared to 100% self-payment, having any known type of health insurance increased the odds of a BMD measurement-suggesting an unwillingness to pay out of pocket for preventive care-while having 100% social insurance reduced both the odds of receiving prescription medicines for osteoporosis and the odds of an osteoporosis diagnosis-almost half (48.5%) of the patients had not been told that they had osteoporosis.
Among the 41% of patients who reported their physician’s specialty, the same percentage (29%) of orthopedic specialists and general practitioners (GPs) prescribed medications for osteoporosis. However, information about osteoporosis was communicated to patients largely by orthopedic specialists (76%) rather than by GPs (11%), suggesting that GPs need more education about osteoporosis.
Results of this study suggest that greater attention should be paid to patients with a history of fracture. A history of fracture, recorded for 13.2% of patients, was not significantly associated with an osteoporosis diagnosis independently of other factors-BMD, age, payment type-or with receiving medications for osteoporosis medications after the index fracture. The only statistically significant sequelae of a history of prior fracture was that it reduced the odds of a BMD measurement-perhaps because physicians deduced that a prior fracture was indicative of osteoporosis, obviating the need for a BMD test. A recurrent fracture after the index fracture was experienced by 9% of the patients in this study. A history of prior fracture was a significant independent predictor of a recurrent facture (OR 1.67, 95% CI 1.02-2.72), while other factors (age, an osteoporosis diagnosis, a BMD measurement) were not significantly predictive.
In this study, an average of 33.0% of patients received a prescription medication for osteoporosis in the 6 months after the index fracture, though this varied from 6.5% in mainland China to 63.5% in Thailand. These rates are comparable or better than recent practice recorded in Western countries. In a 2003–04 UK study of patients (97% women) after a fracture of the distal radius, 8.5% were referred for BMD scanning, calcium and vitamin D was prescribed to 22%, and bisphosphonates to 9% . In a 2006 study set in Sweden, management of patients post fracture depended on the results of a BMD scan . In the three years after the fracture, antiresorptive medicines (excluding calcium-vitamin D) had been received by two thirds of osteoporotic, one sixth of osteopenic, and none of the patients with normal BMD . There is little recent data for the United States, and most studies of medical practice after low-trauma or hip fracture relate to small single-center studies in the 1990s. Among these US studies the median rate of prescribed medicines for osteoporosis after a fracture was 24% (range 5-60%) [18–24].
Even after experiencing a fragility fracture, 48.5% of Asian postmenopausal women reported that they had not been told that they had osteoporosis and only 33.0% were receiving prescription medications for osteoporosis. A history of fracture did not increase the odds of an osteoporosis diagnosis or treatment, indicating that both patients and GPs should be educated about the importance of fractures in the evaluation of osteoporosis.
Bone mineral density
International Statistical Classification of Diseases and Related Health Problems
Institutional review board
Funding for this study was provided by Merck & Co., Inc. The authors thank Julia Vishnevetsky, MPH, Dimitra Panagiotoglou, Lauren Weisenfluh, and Melissa Stauffer, PhD, in collaboration with SCRIBCO, for medical writing assistance.
- Lin JD, Chen JF, Chang HY, Ho C: Evaluation of bone mineral density by quantitative ultrasound of bone in 16,862 subjects during routine health examination. Br J Radiol. 2001, 74: 602-606.View ArticlePubMedGoogle Scholar
- Kim CH, Kim YI, Choi CS, Park JY, Lee MS, Lee SI, Kim GS: Prevalence and risk factors of low quantitative ultrasound values of calcaneus in Korean elderly women. Ultrasound Med Biol. 2000, 26: 35-40. 10.1016/S0301-5629(99)00126-X.View ArticlePubMedGoogle Scholar
- Jang SN, Choi YH, Choi MG, Kang SH, Jeong JY, Choi YJ, Kim DH: [Prevalence and associated factors of osteoporosis among postmenopausal women in chuncheon: hallym aging study (HAS)]. J Prev Med Public Health. 2006, 39: 389-396.PubMedGoogle Scholar
- Koh LK, Ng DC: Osteoporosis risk factor assessment and bone densitometry-current status and future trends. Ann Acad Med Singapore. 2002, 31: 37-42.PubMedGoogle Scholar
- Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, Huang QR, Rajatanavin R, Tsai KS, Park HM, Reginster JY: A simple tool to identify asian women at increased risk of osteoporosis. Osteoporos Int. 2001, 12: 699-705. 10.1007/s001980170070.View ArticlePubMedGoogle Scholar
- Lerttrakul S, Soontrapa S: Modified OSTA index for referring women for DEXA measurement. J Med Assoc Thai. 2005, 88 (Suppl 5): S80-S83.PubMedGoogle Scholar
- Pongchaiyakul C, Nguyen ND, Nguyen TV: Development and validation of a new clinical risk index for prediction of osteoporosis in Thai women. J Med Assoc Thai. 2004, 87: 910-916.PubMedGoogle Scholar
- Tao B, Liu JM, Li XY, Wang JG, Wang WQ, Zhou HF, Guo HF, Wen Y, Zhou WW, Du PF, Ning G: [The relationship between quantitative ultrasound and osteoporosis self-assessment tool for Asians (OSTA) score and non-vertebral fracture in postmenopausal Chinese women]. Zhonghua Nei Ke Za Zhi. 2006, 45: 988-991.PubMedGoogle Scholar
- Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M: Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000, 15: 721-739.View ArticlePubMedGoogle Scholar
- Roux C, Briot K, Horlait S, Varbanov A, Watts NB, Boonen S: Assessment of non-vertebral fracture risk in postmenopausal women. Ann Rheum Dis. 2007, 66: 931-935. 10.1136/ard.2006.064071.View ArticlePubMedPubMed CentralGoogle Scholar
- Kung AW, Lee KK, Ho AY, Tang G, Luk KD: Ten-year risk of osteoporotic fractures in postmenopausal chinese women according to clinical risk factors and BMD T-scores: a prospective study. J Bone Miner Res. 2007, 22: 1080-1087. 10.1359/jbmr.070320.View ArticlePubMedGoogle Scholar
- Bouxsein ML, Kaufman J, Tosi L, Cummings S, Lane J, Johnell O: Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture. J Am Acad Orthop Surg. 2004, 12: 385-395.View ArticlePubMedGoogle Scholar
- Carnevale V, Nieddu L, Romagnoli E, Bona E, Piemonte S, Scillitani A, Minisola S: Osteoporosis intervention in ambulatory patients with previous hip fracture: a multicentric, nationwide Italian survey. Osteoporos Int. 2006, 17: 478-483. 10.1007/s00198-005-0010-0.View ArticlePubMedGoogle Scholar
- Panneman MJ, Lips P, Sen SS, Herings RM: Undertreatment with anti-osteoporotic drugs after hospitalization for fracture. Osteoporos Int. 2004, 15: 120-124. 10.1007/s00198-003-1544-7.View ArticlePubMedGoogle Scholar
- Rabenda V, Vanoverloop J, Fabri V, Mertens R, Sumkay F, Vannecke C, Deswaef A, Verpooten GA, Reginster JY: Low incidence of anti-osteoporosis treatment after hip fracture. J Bone Joint Surg Am. 2008, 90: 2142-2148. 10.2106/JBJS.G.00864.View ArticlePubMedGoogle Scholar
- Talbot JC, Elener C, Praveen P, Shaw DL: Secondary prevention of osteoporosis: Calcium, Vitamin D and bisphosphonate prescribing following distal radial fracture. Injury. 2007, 38: 1236-1240. 10.1016/j.injury.2007.03.004.View ArticlePubMedGoogle Scholar
- Astrand J, Thorngren KG, Tagil M, Akesson K: 3-year follow-up of 215 fracture patients from a prospective and consecutive osteoporosis screening program. Fracture patients care!. Acta Orthop. 2008, 79: 404-409. 10.1080/17453670710015328.View ArticlePubMedGoogle Scholar
- Cuddihy MT, Gabriel SE, Crowson CS, Atkinson EJ, Tabini C, O'Fallon WM, Melton LJ: Osteoporosis intervention following distal forearm fractures: a missed opportunity?. Arch Intern Med. 2002, 162: 421-426. 10.1001/archinte.162.4.421.View ArticlePubMedGoogle Scholar
- Follin SL, Black JN, McDermott MT: Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy. 2003, 23: 190-198. 10.1592/phco.126.96.36.199090.View ArticlePubMedGoogle Scholar
- Andrade SE, Majumdar SR, Chan KA, Buist DS, Go AS, Goodman M, Smith DH, Platt R, Gurwitz JH: Low frequency of treatment of osteoporosis among postmenopausal women following a fracture. Arch Intern Med. 2003, 163: 2052-2057. 10.1001/archinte.163.17.2052.View ArticlePubMedGoogle Scholar
- Simonelli C, Chen YT, Morancey J, Lewis AF, Abbott TA: Evaluation and management of osteoporosis following hospitalization for low-impact fracture. J Gen Intern Med. 2003, 18: 17-22. 10.1046/j.1525-1497.2003.20387.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Kamel HK: Secondary prevention of hip fractures among the hospitalized elderly: are we doing enough?. J Clin Rheumatol. 2005, 11: 68-71. 10.1097/01.rhu.0000158545.26370.5c.View ArticlePubMedGoogle Scholar
- Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE: Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000, 109: 326-328. 10.1016/S0002-9343(00)00457-5.View ArticlePubMedGoogle Scholar
- Hooven F, Gehlbach SH, Pekow P, Bertone E, Benjamin E: Follow-up treatment for osteoporosis after fracture. Osteoporos Int. 2005, 16: 296-301. 10.1007/s00198-004-1676-4.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/13/7/prepub
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