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Population-Based Fracture Risk Assessment and Osteoporosis Treatment Disparities by Race and Gender

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ABSTRACT

BACKGROUND

Undertreatment of osteoporosis has been recognized as a common problem in selected patient subgroups. However, primary prevention has been hampered by limited risk assessment tools that can be applied to large populations.

OBJECTIVES

Using clinical risk factors with a new tool from the World Health Organization (FRAX) and recommendations from the National Osteoporosis Foundation (NOF), we evaluated fracture risk and osteoporosis treatment in a US cohort.

PARTICIPANTS

African Americans and Caucasians recruited from 2003–7 across the US as part of a longitudinal study.

DESIGN

Cross-sectional.

MEASURES

The number of persons receiving prescription osteoporosis medications was assessed by race, sex, and fracture risk. Multivariable logistic regression evaluated the association between receipt of osteoporosis medications and fracture risk after controlling for potential confounders.

RESULTS

Among 24,783 participants, estimated fracture risk was highest for Caucasian women. After multivariable adjustment for fracture-related risk factors, the likelihood of receipt of osteoporosis medications among African Americans was lower than among Caucasians [odds ratio (OR) = 0.44, 95% confidence interval (CI) 0.37, 0.53] and for men compared to women (OR = 0.08, 95% CI 0.06–0.10). Even for the highest risk group, Caucasian women with 10-year hip fracture risk ≥3% (n = 3,025, 39.7%), only 26% were receiving treatment.

CONCLUSIONS

A substantial gap exists between 2008 NOF treatment guidelines based on fracture risk and the receipt of prescription osteoporosis medications. This gap was particularly notable for African Americans and men. FRAX is likely to be useful to assess risk at a population level and identify high-risk persons in need of additional evaluation.

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Acknowledgements

Work for this analysis was supported in part by the National Institutes of Arthritis and Musculoskeletal and Skin Diseases (AR053351) and the Arthritis Foundation. REGARDS is supported by a cooperative agreement U01 NS041588 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Neurological Disorders and Stroke or the National Institutes of Health. Representatives of the funding agency have been involved in the review of the manuscript, but not directly involved in the collection, management, analysis, or interpretation of the data. The authors acknowledge the participating investigators and institutions for their valuable contributions: The University of Alabama at Birmingham, Birmingham, Alabama (Study PI, Statistical and Data Coordinating Center, Survey Research Unit): George Howard DrPH, Leslie McClure PhD, Virginia Howard PhD, Libby Wagner MA, Virginia Wadley PhD, Rodney Go PhD, Monika Safford MD, Ella Temple PhD, Margaret Stewart MSPH, J. David Rhodes BSN; University of Vermont (Central Laboratory): Mary Cushman MD; Wake Forest University (ECG Reading Center): Ron Prineas MD, PhD; Alabama Neurological Institute (Stroke Validation Center, Medical Monitoring): Camilo Gomez MD, Susana Bowling MD; University of Arkansas for Medical Sciences (Survey Methodology): LeaVonne Pulley PhD; University of Cincinnati (Clinical Neuroepidemiology): Brett Kissela MD, Dawn Kleindorfer MD; Examination Management Services, Incorporated (In-Person Visits): Andra Graham; Medical University of South Carolina (Migration Analysis Center): Daniel Lackland DrPH; Indiana University School of Medicine (Neuropsychology Center): Frederick Unverzagt PhD; National Institute of Neurological Disorders and Stroke, National Institutes of Health (funding agency): Claudia Moy Ph.D.

Conflicts of Interest

JRC: Consulting: Roche, UCB, Procter & Gamble, CORRONA; speakers bureau: Procter & Gamble, Eli Lilly, Roche, Novartis; research grants: Merck, Procter & Gamble, Eli Lilly, Amgen, Novartis

KGS: Consulting: Merck, Novartis, Procter & Gamble, Amgen, Aventis, Eli Lilly; speakers bureau: Novartis; research grants: Amgen

ED: Research grants: Amgen

Others: None

EO: E.O. has received honoraria from and served as a consultant for Merck. He has received research support from Amgen, Pfizer, Novartis, Zelos Therapeutics, Imaging Therapeutics, and Solvay Pharmaceuticals. He has received research support from and served as a consultant for Ely Lilly & Co. and served as a consultant for Servier.

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Authors and Affiliations

  1. Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, USA

    Jeffrey R. Curtis MD MPH & Kenneth G. Saag MD MSc

  2. Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA

    Leslie A. McClure PhD & George Howard DrPh

  3. Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA

    Elizabeth Delzell ScD & Virginia J. Howard PhD

  4. Department of Medicine, Oregon Health Sciences University, Portland, OR, USA

    Eric Orwoll MD

  5. Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, USA

    Monika Safford MD

  6. Center for Education and Research on Therapeutics of Musculoskeletal Disorders, University of Alabama at Birmingham, FOT 840, 510 20th Street South, Birmingham, AL, 35294, USA

    Jeffrey R. Curtis MD MPH

  7. Department of Medicine and Epidemiology, University of Alabama at Birmingham, Birmingham, USA

    Kenneth G. Saag MD MSc

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  1. Jeffrey R. Curtis MD MPH
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  2. Leslie A. McClure PhD
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  4. Virginia J. Howard PhD
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  6. Kenneth G. Saag MD MSc
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  7. Monika Safford MD
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  8. George Howard DrPh
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Corresponding author

Correspondence to Jeffrey R. Curtis MD MPH.

Appendix

Appendix

Definitions for Comorbidities of Interest

Diabetes: fasting glucose ≥126 mg/dl, non-fasting glucose ≥200 mg/dl, or self-reported diabetes medication

History of heart disease: self-reported myocardial infarction, coronary artery bypass grafting (CABG), bypass, angioplasty or stenting, OR evidence of myocardial infarction via electrocardiography

Prior stroke: self-report

Dyslipidemia: total cholesterol ≥240, low density lipoprotein ≥160 or high density lipoprotein ≤40, or self-reported lipid medication use

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Curtis, J.R., McClure, L.A., Delzell, E. et al. Population-Based Fracture Risk Assessment and Osteoporosis Treatment Disparities by Race and Gender. J GEN INTERN MED 24, 956–962 (2009). https://doi.org/10.1007/s11606-009-1031-8

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  • DOI: https://doi.org/10.1007/s11606-009-1031-8

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