The association between multimorbidity and osteoporosis investigation and treatment in high-risk fracture patients in Australia: A prospective cohort study

Abstract

Background Multimorbidity is common among fracture patients. However, its association with osteoporosis investigation and treatment to prevent future fractures is unclear. This limited knowledge impedes optimal patient care. This study investigated the association between multimorbidity and osteoporosis investigation and treatment in persons at high risk following an osteoporotic fracture. Methods and findings The Sax Institute’s 45 and Up Study is a prospective population-based cohort of 267,153 people in New South Wales, Australia, recruited between 2005 and 2009. This analysis followed up participants until 2017 for a median of 6 years (IQR: 4 to 8). Questionnaire data were linked to hospital admissions (Admitted Patients Data Collection (APDC)), emergency presentations (Emergency Department Data Collection (EDDC)), Pharmaceutical Benefits Scheme (PBS), and Medicare Benefits Schedule (MBS). Data were linked by the Centre for Health Record Linkage and stored in a secured computing environment. Fractures were identified from APDC and EDDC, Charlson Comorbidity Index (CCI) from APDC, Dual-energy X-ray absorptiometry (DXA) investigation from MBS, and osteoporosis treatment from PBS. Out of 25,280 persons with index fracture, 10,540 were classified as high-risk based on 10-year Garvan Fracture Risk (age, sex, weight, prior fracture and falls) threshold ≥20%. The association of CCI with likelihood of investigation and treatment initiation was determined by logistic regression adjusted for education, socioeconomic and lifestyle factors). The high-risk females and males averaged 77 ± 10 and 86 ± 5 years, respectively; >40% had a CCI ≥2. Only 17% of females and 7% of males received a DXA referral, and 22% of females and 14% males received osteoporosis medication following fracture. A higher CCI was associated with a lower probability of being investigated [adjusted OR, females: 0.73 (95% CI, 0.61 to 0.87) and 0.43 (95% CI, 0.30 to 0.62); males: 0.47 (95% CI, 0.33 to 0.68) and 0.52 (0.31 to 0.85) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] and of receiving osteoporosis medication [adjusted OR, females: 0.85 (95% CI, 0.74 to 0.98) and 0.78 (95% CI, 0.61 to 0.99); males: 0.75 (95% CI, 0.59 to 0.94) and 0.37 (95% CI, 0.23 to 0.53) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively]. The cohort is relatively healthy; therefore, the impact of multimorbidity on osteoporosis management may have been underestimated. Conclusions Multimorbidity contributed significantly to osteoporosis treatment gap. This suggests that fracture risk is either underestimated or underprioritized in the context of multimorbidity and highlights the need for extra vigilance and improved fracture care in this setting.

Health Perceptions, Multimorbidity, and New Fractures and Mortality Among Patients With a Fracture

“…The present findings highlight the need to develop a practical framework for treating patients with multiple health conditions who sustain a fracture. This need has been underscored by the significant underdiagnosis and undermanagement of osteoporosis after fracture in these patients shown by our group’s recent work …”

“…This need has been underscored by the significant underdiagnosis and undermanagement of osteoporosis after fracture in these patients shown by our group’s recent work. 16 …”

“…Several studies have reported a high proportion of patients with fractures and multimorbidity . A recent study by our group found that multimorbidity at the time of fracture significantly affects the gap in fracture management, reducing the likelihood of individuals receiving appropriate investigation and treatment for osteoporosis . However, the effect of multimorbidity on postfracture adverse outcomes has not been widely explored.…”

“… 13 , 14 , 15 A recent study by our group found that multimorbidity at the time of fracture significantly affects the gap in fracture management, reducing the likelihood of individuals receiving appropriate investigation and treatment for osteoporosis. 16 However, the effect of multimorbidity on postfracture adverse outcomes has not been widely explored. The Charlson Comorbidity Index (CCI), an objective measure of comorbidity, has been shown to be associated with mortality, morbidity, and other health outcomes 17 , 18 but has not been widely evaluated in people with fractures.…”

Chronic Kidney Disease in Patients with Hip Fracture: Prevalence and Outcomes

“…In our HF cohort, the vast majority of patients were not investigated or treated for OP, antiresorptive medications were rarely used in the months preceding the fracture, with no diference between patients with and without CKD. In many countries a wide therapeutic gap in OP/OF management (underdiagnosis and undertreatment) in the general population as well as in patients with CKD has been reported [36,[117][118][119][120][121][122][123][124].…”