Bone Health Assessment in men and women with risk factors for fragility fractures

Problem

Osteoporosis is commonly known to affect post-menopausal women with fragility fractures seen in one in two women. However, this condition also affects men with one in five men over the age of fifty years expected to sustain a fragility fracture during their lifetime (NICE 2018). Identifying all patients at risk of fragility fractures is thus important to improve health outcomes. Assessment of men at risk of osteoporotic fractures seems to be poorly appreciated and possibly undertreated. This study has assessed whether bone health assessments (BHA) were carried out on patients aged 50 years and over with one or more risk factor(s) for fragility fractures, including those who have suffered from previous fractures at sites commonly affected by osteoporotic fractures, falls and taking steroids for three months or more utilising a primary care database. We hypothesised that access to bone health assessment for patients with the above risk factors should not vary with sex and that there will be no difference in the assessment rate of bone health between women and men.

Approach

Patients aged 50 years and over who presented with a fracture, fall or who were taking steroids (measured as taking prednisolone) for three months or more within the study period of January 1st, 2002 and December 31st, 2014 were identified from the Consultations in Primary Care Archive (CiPCA) database. These patients were evaluated to see whether a BHA was carried out within twelve months of presentation. Evidence of a BHA was defined with documentation of codes for a fragility fracture assessment tool (FRAX/QFracture), referral for bone density measurement, referral to the osteoporosis clinic/rheumatologist, osteoporosis-related codes or if bone protection medication was started.

Findings

Of the 15,581 patients identified in the study period, 1172 patients (7.5%) had evidence of BHA within one year of presentation. 8.9% of females and 5.5% of males had BHA. This difference was found to be statistically significant on Chi squared test (X2 = 59.88, p < 0.0001), meaning that women were more likely to undergo a BHA than men. This relationship prevailed after adjusting for age, type of risk factor, co-morbidity and number of consultations with an odds ratio for sex of 1.25 (95% Confidence Interval 1.08-1.43).

Consequences

This study has highlighted that BHA in at-risk patients is under-recorded in men and women, and that women are more likely to have a BHA compared to men with an increase in odds around 25%. Health care professionals and patients should be made more aware of the need to carry out a BHA in men and women, and particularly in men, to reduce the risk of fragility fractures. Increased use of fracture assessment tools (FRAX/QFracture) can help identify patients at risk of fractures.