Undetected High Fracture Risk in an Acute Medical Inpatient Cohort
Deniz Demirdal (1), Gillian Fitzgerald (1), Eimear Keane (1), Caleb Powell (1), Declan Byrne (2), Finbar O’ Shea (1)
1. Department of Rheumatology, St James's Hospital, Dublin 8; 2. Department of Medicine, St James's Hospital, Dublin 8
Osteoporosis is a growing public health problem, with significant morbidity and mortality. It is poorly managed, with most individuals at high risk neither identified nor treated, including those who have already fractured. The majority of fractures occur in patients at moderate risk. The World Health Organisation (WHO) Fracture Risk Assessment tool (FRAX) is a validated computer based algorithm that provides models for the assessment of fracture probability in men and women. It uses easily obtained clinical risk factors to estimate the 10-year probability of a major osteoporotic fracture and hip fracture.
The aim of this study is to determine the fracture risk of a patient cohort admitted under an acute medical team of an inner city tertiary teaching hospital.
Consecutive patients between the age of 40 and 90 years admitted under an acute medical speciality in St James’s Hospital over a 3-month period were screened. Patients were excluded if they lacked capacity to answer questions or had exposure to osteoporosis treatments. We evaluated previous fractures, family history of fractures, smoking, alcohol consumption, use of glucocorticoids and secondary causes of osteoporosis. Weight and height of the participants was measured. The FRAX tool was used to calculate the 10-year probability of a major osteoporotic and hip fracture. The National Osteoporosis Guideline Group (NOGG) intervention thresholds were used to categorise patients into low, medium or high fracture risk.
In total, 54 patients (51.9% (n=28) females, mean age 68.8 ± 14.5 years) were screened. The mean BMI is 26.6 kg/m2 (SD 8.1) and 48.2% of the cohort is overweight or obese. With regards to clinical risk factors, 25.9% are smokers, 16.7% have had clinically significant exposure to steroids, 16.7% have risk factors for secondary osteoporosis, 18.5% of patients consume more than 3 units of alcohol per day and 20.4% have had a fragility fracture.
The mean 10-year risk of a major osteoporotic fracture is 12.3% (SD 8.8) and of a hip fracture is 5.7% (SD 6.2). Applying the NOGG thresholds, 48.1% of the cohort is in the low risk category for fracture, 37% are in the intermediate category and 14.8% are in the high-risk category. No-one in the low-risk category has ever had a fracture. However, 30% of patients in the intermediate and 62.5% of patients in the high-risk categories have had fragility fractures.
A dual-energy x-ray absorptiometry (DXA) scan has been previously performed in 36.8% of patients with intermediate fracture risk and 75% of patients with high fracture risk.
Over 50% of acute medical inpatients have an intermediate or high 10-year risk of fracture. One-third of the intermediate and almost 2/3 of the high-risk groups have already sustained a fragility fracture, yet are not on treatment. This suggests that the FRAX tool is not being used effectively to capture patients at risk of fracture.