Morell Sabrina, Hemmeler Christoph, Amsler Felix, Gross Thomas
Department of Traumatology, Cantonal Hospital, Aarau, Switzerland.
Department of Rheumatology, Cantonal Hospital, Aarau, Switzerland.
Swiss Med Wkly. 2017 Jul 10;147:w14451. doi: 10.4414/smw.2017.14451. eCollection 2017.
According to current evidence, one out of ten fracture patients with osteoporosis does not sustain another fracture if he or she is on adequate medication. However, epidemiological surveys show that only about 15 to 30% of affected patients avail themselves of the treatments. This cohort study investigated how many fracture patients with a recommendation for antiosteoporotic therapy effectively received treatment and the possible reasons why the treatment was not implemented.
As part of a quality improvement programme in a Swiss trauma centre, fracture patients were actively checked for osteoporosis in accordance with a standardised outpatient programme. The results, together with detailed therapy recommendations, were transmitted to each patient's general practitioner (GP). A prospective questionnaire survey evaluated all patients with a diagnosis of osteoporosis for subsequent realisation of therapy 1 year after the fracture (mean ± standard deviation; chi-square; analysis of variance; significance level p <0.05).
A total of 305 patients received a recommendation for antiosteoporotic therapy, of whom 18 (5.9%) died before 1 year. The questionnaire was completed for 255 out of 287 patients (follow-up 88.9%; 73.8±11.5 years old at the time of survey; 77.7% female). Of these, 117 patients (45.9%) sustained a fracture of the lower extremities and 105 patients (41.1%) a fracture of the upper extremities; 33 patients (13%) had other or multiple fractures. Fifty-two cases (20.4%) had pre-existing osteoporosis at the time of fracture. At the 1-year follow-up, 132 (52%) patients were receiving prescribed drugs. The most frequent patient explanation for not taking treatment (n = 123) was, in 47.2% of cases (n = 58), that none had been prescribed; 30.1% of patients were not interested. Multivariate analysis of verifiable factors of influence confirmed that fracture patients were treated significantly more reliably with antiosteoporotic therapy if osteoporosis was diagnosed with dual energy x-ray absorptiometry alone in patients with fewer comorbidities, and that fracture patients persisted significantly more reliably with antiosteoporotic therapies when pre-existing osteoporosis was present (R2 0.17; p <0.001).
Following a standardised diagnostic work up for osteoporosis as part of fracture treatment, and including the communication of recommendations for antiosteoporotic therapy to the GP, only every second patient actually received the proposed treatment. This appears to be better than described in the literature but still calls for improvement. Two different solutions appear to be possible based on these findings: to endeavour to better inform and convince GPs about the need for treatment and/or for the diagnosing team to initiate antiosteoporotic therapy where indicated rather than just recommending it.
根据现有证据，每十名骨质疏松性骨折患者中，如果接受了适当的药物治疗，就有一人不会再发生骨折。然而，流行病学调查显示，只有约15%至30%的受影响患者接受了治疗。这项队列研究调查了有抗骨质疏松治疗建议的骨折患者中有多少实际接受了治疗，以及未实施治疗的可能原因。
作为瑞士一家创伤中心质量改进计划的一部分，按照标准化门诊程序对骨折患者进行骨质疏松症的主动检查。检查结果以及详细的治疗建议被传送给每位患者的全科医生（GP）。一项前瞻性问卷调查评估了所有诊断为骨质疏松症的患者在骨折后1年的后续治疗落实情况（平均值±标准差；卡方检验；方差分析；显著性水平p<0.05）。
共有305名患者收到了抗骨质疏松治疗的建议，其中18名（5.9%）在1年前死亡。287名患者中有255名完成了问卷调查（随访率88.9%；调查时年龄73.8±11.5岁；女性占77.7%）。其中，117名患者（45.9%）发生了下肢骨折，105名患者（41.1%）发生了上肢骨折；33名患者（13%）有其他骨折或多处骨折。52例（20.4%）在骨折时已患有骨质疏松症。在1年随访时，132名（52%）患者正在服用处方药。患者未接受治疗的最常见原因（n = 123）中，47.2%（n = 58）的情况是未开任何药物；30.1%的患者不感兴趣。对可验证影响因素的多变量分析证实，如果仅通过双能X线吸收法在合并症较少的患者中诊断出骨质疏松症，骨折患者接受抗骨质疏松治疗的可靠性会显著提高；并且当患者之前就患有骨质疏松症时，骨折患者坚持抗骨质疏松治疗的可靠性也会显著提高（R2 0.17；p<0.001）。
作为骨折治疗一部分的骨质疏松症标准化诊断检查，包括将抗骨质疏松治疗建议传达给全科医生后，实际上只有每两名患者中的一名接受了建议的治疗。这似乎比文献中描述的情况要好，但仍需要改进。基于这些发现，似乎有两种不同的解决方案：努力更好地向全科医生宣传并使其相信治疗的必要性，和/或让诊断团队在有指征时启动抗骨质疏松治疗，而不仅仅是建议。
