Mary E Walsh1, Mari Nerdrum1,2, Tom Fahey1, Frank Moriarty1,3. 1. HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland. 2. Graduate Entry Medicine Royal College of Surgeons in Ireland, Dublin, Ireland. 3. School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
Abstract
BACKGROUND: Adults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common. OBJECTIVE: This study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care. DESIGN: This was a retrospective cohort study. SETTING: The study used data from forty-four general practices in Ireland from 2011-2017. SUBJECTS: The study included adults aged ≥ 65 years who were naïve to bone-health medication for 12 months. METHODS: Overall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with the Poisson distribution. RESULTS: Of 36,799 patients (51% female, mean age 75.4 (SD = 8.4)) included, 8% (n = 2,992) were observed to initiate bone-health medication during the study. One-fifth of all patients (n = 8,193) had osteoporosis or had high fracture-risk but only 21% of them (n = 1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR = 1.33 (95% CI = 1.17-1.50), P < 0.01) and all fractures (IRR = 1.30 (95% CI = 1.17-1.44), P < 0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association. CONCLUSIONS: Bone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.
BACKGROUND: Adults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common. OBJECTIVE: This study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care. DESIGN: This was a retrospective cohort study. SETTING: The study used data from forty-four general practices in Ireland from 2011-2017. SUBJECTS: The study included adults aged ≥ 65 years who were naïve to bone-health medication for 12 months. METHODS: Overall fracture-risk (based on QFracture) and individual fracture-risk factors were described for patients initiated and not initiated onto medication and compared using generalised linear model regression with the Poisson distribution. RESULTS: Of 36,799 patients (51% female, mean age 75.4 (SD = 8.4)) included, 8% (n = 2,992) were observed to initiate bone-health medication during the study. One-fifth of all patients (n = 8,193) had osteoporosis or had high fracture-risk but only 21% of them (n = 1,687) initiated on medication. Female sex, older age, state-funded health cover and osteoporosis were associated with initiation. Independently of osteoporosis and co-variates, high 5-year QFracture risk for hip (IRR = 1.33 (95% CI = 1.17-1.50), P < 0.01) and all fractures (IRR = 1.30 (95% CI = 1.17-1.44), P < 0.01) were associated with medication initiation. Previous fracture, rheumatoid arthritis and corticosteroid use were associated with initiation, while liver, kidney, cardiovascular disease, diabetes and oestrogen-only hormone replacement therapy showed an inverse association. CONCLUSIONS: Bone-health medication initiation is targeted at patients at higher fracture-risk but much potential under-treatment remains, particularly in those >80 years and with co-morbidities. This may reflect clinical uncertainty in older multimorbid patients, and further research should explore decision-making in preventive bone medication prescribing.