An analysis of osteoporosis-related hip fractures using hospital discharge data [review; review, tutorial] [see comments]

              Rubin et al • Original Contribution JAOA • Vol 103 • No 4 • April 2003 • 169
The purpose of this study was to assess whether physicians
in practice inadequately diagnose osteoporosis in a high-risk
population of postmenopausal women who have sus-tained
hip fractures.
Using the Texas Hospital Discharge Data–Public Use
Data File (PUDF) provided through the Texas Health Care
Information Council, the authors conducted a review of all
postmenopausal women older than 55 years with frac-tured
hips discharged from Texas hospitals during 1999. A
total of 13,628 patients meeting these criteria were found
using the PUDF. In their diagnoses, physicians for 2233
(16.3%) of these 13,628 women also specified the code for
osteoporosis (P .001) from the ninth revision of the Inter-national
Classification of Diseases. It is estimated that
between 40% and 50% of postmenopausal women have
osteoporosis. Therefore, women with fragility fractures
form an even more at-risk subset of the population—so
much so that one would expect a majority of these women
to carry diagnoses of osteoporosis. The age distribution in
each group was comparable, implying that receiving a
coded diagnosis for osteoporosis was not related to the
age of the patient when she was admitted to the hospital.
Further, when data was analyzed by race or ethnicity, per-centages
for each group (ie, diagnosed with hip fracture
only versus diagnosed with hip fracture and osteoporosis)
were comparable.
In conclusion, physicians practicing in Texas during
calendar year 1999 inadequately diagnosed osteoporosis in
a high-risk population of postmenopausal women who
were admitted to hospitals with fractured hips. Future
analysis of subsequent annual databases will identify
whether continuing medical education efforts cause physi-cians
to diagnosis osteoporosis in this high-risk population
more frequently.
Osteoporosis is defined as a skeletal disorder characterized
by diminished bone strength that predisposes patients
to an above average risk of fractures.1 Bone strength consists
of two main features: bone density and bone quality. Bone
density in any given individual is determined by peak bone
mass and by the amount of bone loss. Bone quality refers to
the architecture and mineralization of bone. A fracture occurs
when a force such as trauma is applied to osteoporotic bone.
Osteoporosis has been called “the silent epidemic” because
bone damage occurs over years or decades without symp-toms.
Eventually, bones become so weak that minor trauma
and even normal movements like bending or turning can
cause bone fractures (ie, fragility fractures).2
Osteoporosis affects more than 28 million people in the
United States.3 Women represent 80% of the affected popu-lation,
and many of these women do not know that they
have osteoporosis. The risk for osteoporosis-related mor-bidity
is high. The lifetime risk for hip fractures among white
women is 17%, which is an incidence rate higher than a
woman’s combined risk for breast cancer, endometrial cancer,
and ovarian cancer.2 In the United States, osteoporosis risks
are highest in Asian and non-Hispanic white women, but
African American women and Hispanic women are also at
risk.
There are approximately 300,000 hip fractures per year
in the United States. It is believed that 75% of fractures that
occur in the elderly are related to osteoporosis.4 Virtually
everyone who fractures a hip requires a hospital stay and
surgery. Twenty-five percent of patients die within one year
of suffering a hip fracture. A recent study5 showed that the
total cost of caring for osteoporotic fractures in the United
States approached $14 billion per year. Of this total, hip frac-tures
alone accounted for annual medical costs of nearly $9
billion.5
The purpose of this research study was to evaluate the
adequacy of diagnoses of osteoporosis in postmenopausal
women who presented to Texas hospitals in 1999 with hip
fractures.
An Analysis of Osteoporosis-Related Hip Fractures
Using Hospital Discharge Data
Bernard R. Rubin, DO, MPH; Antonio A. René, PhD, MPH; Douglas A. Mains, DrPH, MBA;
Muriel A. Marshall, DO, MPH, DrPH
Dr Rubin is an adjunct professor in the department of epidemiology and
assessment in the School of Public Health at the University of North Texas
Health Science Center at Fort Worth. Dr Rubin was the chairman of the
American Osteopathic Association’s Bureau of Research from 1998 to 2001.
Also at the School of Public Health, Mr René is an assistant professor in the
department of epidemiology and assessment; Dr Mains is an assistant professor
in the department of health management and policy; and Dr Marshall is an
associate professor in the department of social and behavioral sciences.
Address correspondence to Bernard R. Rubin, DO, MPH, University of
North Texas Health Science Center at Fort Worth, Department of Medicine,
855 Montgomery St, Fl 4, Fort Worth, TX 76107-2553.
E-mail: brubin@hsc.unt.edu
ORIGINAL CONTRIBUTION
170 • JAOA • Vol 103 • No 4 • April 2003
Methods
This is a retrospective analysis, utilizing the Texas Hospital Dis-charge
Data–Public Use Data File (PUDF) from January 1,
1999 to December 31, 1999 (see http://www.thcic.state.tx.us/
PUDF.htm). The Texas Health Care Information Council
(THCIC), which was created in 1995 by the 74th Texas Legis-lature
to administer and compile the Texas Hospital Discharge
Data–PUDF, operates within the Texas Health and Human Ser-vices
Commission (see http://www.thcic.state.tx.us/ and
http://www.hhsc.state.tx.us/). The THCIC’s primary pur-pose
is to provide data that enables consumers and health
plan purchasers in the state of Texas to make informed deci-sions
on their health care choices. In the state of Texas, the
THCIC is responsible for collecting data and reporting on (1)
the performance and quality of health maintenance organi-zations
operating within the state, and (2) inpatient and out-patient
discharge data from all Texas hospitals.
The THCIC gathers data from hospitals using the UB92
Patient Discharge Billing Form, an administrative form for
submitting patient charges to third-party payers. The infor-mation
gathered from these forms ranges from patient diag-noses
to costs incurred for available medical procedures. Four
quarterly PUDFs containing patient-level information for inpa-tient
hospital stays are provided annually by the THCIC for
approximately 2 million discharged patients. Texas PUDF
data, which contains 104 “data elements,” can be used to study
and compare health care services, although any analysis of
these records requires the use of computer software. Indi-vidual
patient identities are protected in the PUDF and the
THCIC will seek civil and criminal penalties against anyone
trying to determine an individual’s identity based on the data
they have compiled.
Study Population
The investigators selected female patients only as the study
population for this retrospective analysis because women are
much more likely than men to have osteoporosis. Additional
exclusion criteria included a minimum age of 55 years because
the average age of menopause is 50 years (range from 45 years
to 55 years), with 98.5% of women having experienced
menopause by age 55.6 Census data indicates that in the state
of Texas in 1999, 70% of the female population over the age of
55 years were non-Hispanic white, 9.3% were non-Hispanic
African American, 18.7% were Hispanic, and 2% were classi-fied
as Other. Women aged 55 years and older form the largest
risk group for having osteoporosis, rather than other causes,
as the etiology of hip fractures.
All female patients in the PUDF who sustained hip frac-tures
during 1999 (ie, the study period) were included in this
retrospective study. The diagnosis was identified by the use of
the general code 820 (ie, Fracture of neck of femur) from the
fourth edition of the ninth revision of ICD-9-CM 2002: Inter-national
Classification of Diseases, Clinical Modification (ICD 9)
and eight additional 820 codes that provide more specific
diagnostic information about this type of fracture.7,8 Only
women aged 55 or older whose physicians provided a 820
ICD 9 code indicating their diagnoses were included in the
study population.
This population was then cross-referenced with the ICD 9
codes for osteoporosis (ie, 733.0 and five alternate code descrip-tions
used to indicate this diagnosis).
These outcome variables were chosen to maximize the
study population. Should a diagnosis of osteoporosis have
been made during a patient’s hospitalization, this concurrent
diagnosis would have been a clear indication that metabolic
bone disease was the underlying etiology for the hip fracture,
demonstrating the physician’s awareness of this fact rather
than his or her assumption that the hip fracture was simply an
isolated event.
Statistical Analysis
Chi-squares ( 2) were calculated to determine whether there
were differences in characteristics between patients who had
a hip fracture and osteoporosis on their discharge records and
those who had only a hip fracture noted. Statistical analysis was
performed using the SPSS statistical analysis program (Version
10.0, SPSS Science, Chicago, Ill).
Results
Investigators found that 13,628 women met the aforemen-tioned
study criteria for the period under review. All patients
in the study population are women, have an ICD 9 code con-firming
Fracture of neck of femur during 1999 (Table 1), and are
older than 55 years (Table 2).
The most frequent Fracture of neck of femur principal diag-nostic
codes used by physicians for their patients in the study
population were:
  820.21 indicating Pertrochanteric fracture, closed – Intertro-chanteric
section;
  820.08, Unspecified part of neck of femur, closed (Hip, Not oth-erwise
specified [NOS]; Neck of femur, NOS); and
  820.09, Unspecified part of neck of femur, open.
This principal diagnostic code was further evaluated for
each of the two groups (ie, osteoporosis diagnosed and osteo-porosis
not diagnosed). In both groups, ICD 9 code 820.21,
Fracture of neck of femur – Pertrochanteric fracture, closed –
Intertrochanteric section, was the most frequently used code,
accounting for 5044 (44.3%) of the 11,395 patients who had a
diagnosis of a hip fracture only and for 1109 (49.7%) of the 2233
patients who had a diagnosis of hip fracture and a concomi-tant
diagnosis of osteoporosis.
The second most frequently used ICD 9 code is 820.8,
Fracture of neck of femur – Unspecified part of neck of femur, closed
(Hip, NOS; Neck of femur, NOS). This diagnostic code was used
for 3333 (29.2%) of the 11,395 women diagnosed with a hip frac-ture
only. This diagnostic code was also noted in 551 (24.7%)
of the 2233 women diagnosed with a hip fracture and osteo-porosis.
Rubin et al • Original Contribution
ORIGINAL CONTRIBUTION
JAOA • Vol 103 • No 4 • April 2003 • 171
with osteoporosis (26.6%) was greater than the percentage of
women who suffered a hip fracture but were not diagnosed as
having osteoporosis (24.4%). This trend continued in the
women older than 90 years. Of the women 90 years and older,
451 (20.2%) had been diagnosed with hip fractures and a diag-nosis
of osteoporosis, whereas only 1889 (16.6%) had diag-noses
of hip fracture alone.
When the demographics of the study population are
reviewed for race or ethnicity (Table 3), white, non-Hispanic
women accounted for 8485 (74.5%) of the 11,395 documented
cases in which hip fractures were not initially coded for osteo-porosis.
Of women who did not receive concurrent diagnoses
Diagnostic code 820.09, Fracture of neck of femur – Unspec-ified
part of neck of femur, open, was the third-largest subset.
This diagnostic code was used in 2714 (23.8%) of the 11,395
women who had a diagnosis of a hip fracture only and in 507
(22.7%) of the 2233 women who had a hip fracture and a con-comitant
diagnosis of osteoporosis.
The age of patients in the study population was evaluated
in 5-year segments from age 55 to 90 years and older (Table 2).
The subset of women ages 85 to 89 years comprised the largest
percentage of women suffering hip fractures in either of the two
subgroups. From ages 85 to 89, the percentage of women who
suffered a hip fracture and were concomitantly diagnosed
Rubin et al • Original Contribution
ORIGINAL CONTRIBUTION
Table 1
Characteristics of Women Diagnosed with Hip Fractures
and Discharged from Texas Hospitals in 1999
by Type of Principal Diagnostic Code* Assigned by Their Physicians†
Fracture, No. (%)
Osteoporosis Osteoporosis
Diagnosed Not Diagnosed Total, No. (%)
820.09 Other (Head of femur, 507 (22.7) 2714 (23.8) 3221 (23.6)
Subcapital)
820.20 Pertrochanteric fracture, 62 (2.8) 277 (2.4) 339 (2.5)
closed—Trochanteric section,
unspecified (Trochanter:
not otherwise specified
[NOS], greater, lesser)
820.21 Pertrochanteric fracture, 1109 (49.7) 5044 (44.3) 6153 (45.1)
closed—Intertrochanteric
section
820.31 Pertrochanteric fracture, 1 (  .1) 5 (  .1) 6 (  .1)
open—Intertrochanteric
section
820.8 Unspecified part of neck 551 (24.7) 3333 (29.2) 3884 (28.5)
of femur, closed (Hip, NOS;
Neck of femur, NOS)
820.9 Unspecified part of neck of 3 (.1) 22 (.2) 25 (.2)
femur, open
Total‡ 2233 (100) 11395 (99.9) 13628 (99.9)
* Diagnostic codes were assigned by the patients’ physicians and are based on the following source: American Medical Association.
ICD-9-CM 2002: International Classification of Diseases, Clinical Modification. Vols 1 and 2. 9th rev. 4th ed. Chicago, Ill:
American Medical Association; 2001.
† Pearson’s  2 test, 27.989 (5, n = 13,628); P = .001.
‡ Percentages reported were rounded for each principal diagnostic code used for these patients. Therefore the sum of these percentages
may not equal 100%.
Principal
Diagnostic
Code
Fracture of Neck of Femur,
Type
172 • JAOA • Vol 103 • No 4 • April 2003
of hip fracture and osteoporosis, 1050 (9.2%) were Hispanic,
and 500 (4.4%) were African American.
Of the 2233 patients whose physicians simultaneously
assigned ICD 9 codes indicating a diagnosis of a hip fracture
and a diagnosis of osteoporosis, 1740 (77.9%) were white, non-
Hispanic women. There were 184 (8.2%) Hispanic women
and 62 (2.8%) African American women who received similar
diagnoses.
The majority of women in each of the two groups (osteo-porosis
diagnosed and osteoporosis not diagnosed) by length
of hospital stay (Table 4) had an average length of hospital
stay between 1 day and 7 days. The length of stay (LOS) quar-tiles
were arbitrarily chosen in weekly intervals of one, two,
three, and four or more weeks to determine whether diag-noses
of osteoporosis increased complications and prolonged
hospitalization. We found that 7701 (67.5%) women who were
diagnosed with a hip fracture only had a LOS of 1 day to 7
days. The same average LOS of one week (ie, between 1 and
7 days) was seen in 1596 (71.5%) of the 2233 women who had
concomitant diagnoses.
Of the 13,628 patients meeting the study’s basic criteria,
only 2233 (16.4%) also had a diagnosis of osteoporosis. Other
studies9 have shown a significant decreasing rate in the diag-nosis
of osteoporosis with increasing age. In our analysis, the
data indicate a different trend, with a progressive increase in
the percentage of women with fractured hips receiving con-current
diagnoses of osteoporosis.
Discussion
In the United States alone, 1.5 million frac-tures,
including 300,000 hip fractures, occur
each year as a result of osteoporosis.10 These
osteoporotic fractures, particularly hip frac-tures,
result in substantial morbidity and mor-tality
for postmenopausal women. Approxi-mately
3% of women die during the acute
period of treatment for hip fractures.11 Within
one year, the death rate increases to 20% for
women younger than 80 years.12 After the
first year, 40% of patients with prior hip frac-tures
remain unable to walk independently.
Two-thirds require assistance with activities of
daily living such as dressing, bathing, and
cooking.11 Psychologically, patients become
depressed and may fear further fractures.8,13
Freedman et al9 demonstrated that less than
25% of individuals who sustained osteoporotic
fragility fractures had been placed on calcium
and vitamin D.
Improved medical management of
patients sustaining hip fractures should
include (1) an increased recognition that frac-tures
are due to osteoporosis, (2) documenta-tion
of the extent of osteoporosis, and, most
importantly, (3) initiation of appropriate therapy—not only
calcium and vitamin D supplementation but medical therapy
as well.
Because fractures are clearly related to decreasing bone
mass, recognition of low bone mass and treatment of it might
decrease the risk of subsequent fractures. The following rec-ommendations
from the National Osteoporosis Foundation5
for treating patients with osteoporosis have been widely pub-lished
in the medical literature:
  Physicians should perform evaluations for osteoporosis
using bone-density testing to confirm the diagnosis and to
determine the severity of the disease for all postmenopausal
women who suffer fractures.
  Physicians should advise all patients at risk for calcium
deficiency to ensure that they have an adequate intake of
dietary calcium (at least 1200 mg daily, including supple-ments
if necessary) and vitamin D (400 to 800 IU daily).
  Physicians should initiate therapy to reduce fracture risk in
women with (1) low bone mass as indicated by bone min-eral
density test scores (ie, T-scores) of less than  2 standard
deviation (SD) in the absence of risk factors, and (2) low bone
mass as indicated by T-scores of less than  1.5 SD if other
risk factors are present, including a history of adult fractures.
  Women older than 70 years with multiple risk factors (espe-cially
those with previous fractures involving either the
hips or the spine are at high enough risk for fracture to jus-tify
the initiation of treatment for osteoporosis without
bone-density testing.
Rubin et al • Original Contribution
ORIGINAL CONTRIBUTION
Table 2
Characteristics of Women Diagnosed with Hip Fractures
and Discharged from Texas Hospitals in 1999 by Age*
Fracture, No. (%)
Osteoporosis Osteoporosis
Age, y Diagnosed Not Diagnosed Total, No. (%)
55 to 59 25 (1.1) 188 (1.6) 213 (1.6)
60 to 64 40 (1.8) 303 (2.7) 343 (2.5)
65 to 69 92 (4.1) 619 (5.4) 711 (5.2)
70 to 74 174 (7.8) 1047 (9.2) 1221 (9.0)
75 to 79 348 (15.6) 1979 (17.4) 2327 (17.1)
80 to 84 508 (22.7) 2586 (22.7) 3094 (22.7)
85 to 89 595 (26.6) 2784 (24.4) 3379 (24.8)
90 and older 451 (20.2) 1889 (16.6) 2340 (17.2)
Total† 2233 (99.9) 11395 (100) 13628 (100.1)
* Pearson’s  2 test, 40.584 (7, n = 13,628); P = .001.
† Percentages reported were rounded for each demographic age group. Therefore the sum
of these percentages may not equal 100%.
  Medical therapy should include
the use of pharmacologic
options approved by the US
Department of Health and
Human Services Food and Drug
Administration for osteoporosis
prevention and/or treatment:
hormone replacement therapy
(ie, HRT), alendronate sodium,
calcitonin-salmon, raloxifene
hydrochloride, and risedronate
sodium.
Age is an independent risk
factor for osteoporosis. The older
an individual is, the greater the risk
for osteoporosis. Only 15% of
women between the ages of 50
and 59 have osteoporosis, while up
to 70% of those older than 80 years
show some evidence of this disease.14 Therefore, one would
expect that the diagnoses of osteoporosis should increase as
the population ages—particularly for the subset of the popu-lation
that suffers hip fractures, which are a well-known con-sequence
of long-standing osteoporosis.
While the diagnosis of osteoporosis can be made for
patients of virtually any age, there are particular decision
points at which the risks are higher and diagnoses of osteo-porosis
are more likely. Certainly the presence of a fragility
fracture would be one of those major decision points. A
fragility fracture occurs as a result of a patient falling with a
force less than what would be present if one were to fall from
a standing height. A fractured rib or perhaps a fractured ver-tebral
body without major trauma would be examples of
fragility fractures. Such fractures are often the first indication
that bone mass has dropped to a low level, as is characteristic
in patients who have osteoporosis. Fractures are usually iden-tified
by radiograph.
The National Osteoporosis Foundation’s current guide-lines
suggest that physicians should respond to fragility frac-tures
by offering patients preventive and restorative treat-ment.
Such treatment is important because the risk of future
fractures is high in this patient group. For example, women
who sustain any fracture prior to menopause (younger than
40 years) are at a 30% greater risk for repeat fracture after
menopause (older than 60 years).15 Another study16 found
that postmenopausal women who had prior vertebral fractures
are at a fivefold risk for new vertebral fractures as they age.
Patients with a history of hip fracture are at a greater risk of
suffering another hip fracture than patients who have not
displayed evidence of fragility fractures.17 Therefore, any his-tory
of fracture should raise the physician’s suspicions of
osteoporosis.
Hip fracture was chosen as the topic for this study because
hip fractures are an even more dramatic indicator for con-
ORIGINAL CONTRIBUTION
Rubin et al • Original Contribution JAOA • Vol 103 • No 4 • April 2003 • 173
comitant osteoporosis. Our analysis indicates that although
there is a slight increase in the percentage of cases of women
with hip fractures also being diagnosed with osteoporosis, it
is always less than 30%, even in the most elderly population.
Fracture risk is closely related to bone mass. One standard
deviation of decreased bone mass increases the risk for a
spinal fracture by a factor of two and a hip fracture by a factor
of 2.5, compared with normal peers.1 Other major risk fac-tors
that lead to fragility fractures include low body weight,
a personal or family history of such fractures, family history
of osteoporosis, and smoking. These risk factors are inde-pendent
of bone density.
Because a hip fracture in a patient similar to those in this
study population may be the presenting event that prompts
physicians to diagnose osteoporosis, it is critical that the
attending physician recognize the possibility of underlying
bone fragility (ie, osteoporosis) in such patients. Careful med-ical
histories taken by physicians should identify whether
patients have osteoporosis. Appropriate diagnostic measures
and treatment should begin immediately thereafter. The med-ical
management of osteoporosis can start at the time a fragility
fracture is diagnosed.
A dual energy x-ray absorptiometry (DEXA) scan is rec-ommended
for all patients with fragility fractures. All of these
patients should be assessed for their nutritional status and
probably placed calcium and vitamin D, with doses of
vitamin D depending on each patient’s age. Simply adding cal-cium
and vitamin D may decrease the risk of future fracture,
even if bone density measurements do not increase.18 In addi-tion,
pharmacologic treatment can be used to reestablish bone
mass and could potentially decrease the risk of subsequent
fracture.19,20 Kamel et al21 reviewed the medical records of
170 patients older than 65 years who were hospitalized for hip
fractures, finding that less than 10% were treated with cal-cium,
vitamin D, or alendronate sodium at discharge.
Table 3
Characteristics of Women Diagnosed with Hip Fractures
and Discharged from Texas Hospitals in 1999
by Race or Ethnicity
Fracture, No. (%)
Osteoporosis Osteoporosis
Race or Ethnicity Diagnosed Not Diagnosed Total, No. (%)
African American 62 (2.8) 500 (4.4) 562 (4.1)
Hispanic 184 (8.2) 1050 (9.2) 1234 (9.1)
White (non-Hispanic) 1740 (77.9) 8485 (74.5) 10225 (75)
Other 247 (11.1) 1360 (11.9) 1607 (11.8)
Total 2233 (100) 11395 (100) 13628 (100)
174 • JAOA • Vol 103 • No 4 • April 2003
Physician awareness from continuing medical education
efforts—which could emphasize and highlight the correlation
between hip fracture and osteoporosis—should ensure an
increase in the percentage of women older than 55 years who
present with hip fracture and who are additionally diagnosed
with osteoporosis. This trend can be followed as the Texas
PUDF is extended over the next several years.
Study Limitations
There are several potential limitations to this study. Physi-cians
may have inappropriately or incorrectly recorded diag-noses
in the medical records we accessed through the PUDF.
These errors would, of course, translate into inappropriate
ICD 9 codes for patient diagnoses. Additionally, physicians
could have written the correct diagnosis within patients’ med-ical
records, but medical records personnel could have either
missed the diagnosis code or misinterpreted it, therefore coding
the data in the PUDF incorrectly. This potential error would
apply not only to the type of hip fractures patients suffered but
may also apply to the diagnosis of osteoporosis.
Another potential source of bias could occur if patients
were not covered by insurance. Using ICD 9 coding might be
moot in that instance. While the correct surgical procedure
might be coded, there would perhaps be little incentive to
code for osteoporosis if there was no reason to think that a
patient was going to be followed long-term because of a lack
of insurance coverage. Additionally, if patients did not have
health care insurance, they would not be covered for bone
density testing, and therefore additional testing would not
have been done during hospitalization to detect osteoporosis.
The likelihood of these patients being followed up on an out-patient
basis to be evaluated for osteoporosis would also be
minimal.
If the only physicians providing care were orthopedic
surgeons, rather than internists or family physicians, the coding
might also be different.
In conclusion, certainly a key to the prevention of osteo-porosis
is the recognition of its existence. There is substantial in-hospital
mortality in patients with hip fractures, ranging up to
8%.22 Many people who have suffered hip fractures are dis-charged
to nursing homes rather than returned to their homes.
Such patients may suffer subsequent fractures. Given this high
degree of mortality and morbidity, it is shocking that such a
small number of individuals hospitalized in Texas in 1999 with
hip fractures had a concomitant diagnosis of osteoporosis. This
discrepancy seems to indicate that physicians had poor knowl-edge
of the underlying metabolic bone disease and hip fracture.
If osteoporosis is not diagnosed for these patients and included
in the discharge summary, patients will not be placed on med-ications
to prevent further fractures. Subsequent fractures there-fore
cannot be prevented in these patients—nor can subse-quent
surgeries for osteoporotic fractures.
Osteoporosis is a disease of fracture risk, which physi-cians
can assess through bone mineral density tests and any his-tory
of fractures. Failure to diagnose metabolic bone disease in
someone who presents with a fracture, particularly a hip frac-ture,
indicates a lack of physician awareness to known risk
factors. Subsequent modification of lifestyle and diet and phar-macologic
intervention are therefore minimized because of a
poor understanding of the problem. It is hoped that the number
Rubin et al • Original Contribution
ORIGINAL CONTRIBUTION
Table 4
Characteristics of Women Diagnosed with Hip Fractures
and Discharged from Texas Hospitals in 1999
by Length of Hospital Stay in Days
Fracture, No. (%)
Osteoporosis Osteoporosis
Hospital Stay, d Diagnosed Not Diagnosed Total, No. (%)
1 to 7 1596 (71.5) 7701 (67.5) 9297 (68.2)
8 to 14 390 (17.5) 2294 (20.1) 2684 (19.7)
15 to 21 116 (5.2) 702 (6.2) 818 (6)
22 or more 131 (5.9) 697 (6.2) 828 (6.1)
Total* 2233 (100.1) 11394† (100) 13627† (100)
*Percentages reported were rounded for the number of days each patient spent in the hospital. Therefore
the sum of these percentages may not equal 100%.
† The length of hospital stay in days was not available for one patient in the Osteoporosis Not Diagnosed group.
Therefore the sum for this group and the grand total differ from the other totals in this study.
JAOA • Vol 103 • No 4 • April 2003 • 175
11. Walker-Bone K, Dennison E, Cooper C. Epidemiology of osteoporosis. In:
Lane NE, ed. Rheumatic Disease Clinics of North America. Philadelphia, Penn:
WB Saunders Company; 2001:1-18.
12. Brunelli MP, Einhorn TA. Medical management of osteoporosis. Frac-ture
prevention [review]. Clin Orthop.1998;348:15-21.
13. Cooper C. The crippling consequences of fractures and their impact on
quality of life [review]. Am J Med. 1997;103(2A):12S-19S; discussion 17S-19S.
14. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality
following clinical fractures. Osteoporos Int. 2000;11:556-561.
15. Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective.
How many women have osteoporosis [review]? J Bone Miner Res.1992;7:1005-
1010.
16. Melton LJ 3rd. Epidemiology of hip fractures: implications of the expo-nential
increase with age [review]. Bone. 1996;18(3 Suppl):121S-125S.
17. Schroder HM, Petersen KK, Erlandsen M. Occurrence and incidence of the
second hip fracture. Clin Orthop. 1993;289:166-169.
18. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and
vitamin D supplementation on bone density in men and women 65 years of
age or older. N Engl J Med. 1997;337:670-676.
19. Lane JM, Russell L, Khan SN. Osteoporosis [review]. Clin Orthop.
2000;372:139-150.
20. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al.
Effect of risedronate on the risk of hip fracture in elderly women. Hip Inter-vention
Program Study Group. N Engl J Med. 2001;344:333-340.
21. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose
and treat osteoporosis in elderly patients hospitalized with hip fracture. Am
J Med. 2000;109:326-328.
22. Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ 3rd. Popu-lation-
based study of survival after osteoporotic fractures. Am J Epidemiol.
1993;137:1001-1005.
of concomitant diagnoses for hip fracture and osteoporosis
among women older than 55 years presenting with hip fractures
will increase with continuing medical education efforts and
topic-specific workshops.
References
1. Melton LJ 3rd. Epidemiology of spinal osteoporosis [review]. Spine. 1997;
22(24 Suppl):2S-11S.
2. Assessment of fracture risk and its application to screening for post-menopausal
osteoporosis [review]. Report of a WHO Study Group. World
Health Organ Tech Rep Ser. 1994;843:1-129.
3. Watts NB. Postmenopausal osteoporosis [review]. Obstet Gynecol Surv.
1999;54:532-538.
4. Cornell CN, Schwartz S, Bansal M, Lane JM, Bullough P. Quantification of
osteopenia in hip fracture patients. J Orthop T. 1988;2:212-217.
5. National Osteoporosis Foundation. Physician’s guide to prevention and
treatment of osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc; 1999. Avail-able
at: http://www.nof.org/_vti_bin/shtml.dll/physguide/index.htm. Accessed
April 2, 2003.
6. Krailo MD, Pike MC. Estimation of the distribution of age at natural
menopause from prevalence data. Am J Epidemiol. 1983;117:356-361.
7. American Medical Association. ICD-9-CM 2002: International Classifica-tion
of Diseases, Clinical Modification. Vols 1 and 2. 9th rev. 4th ed. Chicago,
Ill: American Medical Association; 2001.
8. Gold DT. The clinical impact of vertebral fractures: quality of life in women
with osteoporosis [review]. Bone. 1996;18(3 Suppl):185S-189S.
9. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of
osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am.
2000;82:1063-1070.
10. Ray NF, Chan JK, Thamer M, Melton LJ 3rd. Medical expenditures for the
treatment of osteoporotic fractures in the United States in 1995: report from
the National Osteoporosis Foundation. J Bone Miner Res. 1997;12:24-35.
Rubin et al • Original Contribution
ORIGINAL CONTRIBUTION
As a charter member of the US Bone and Joint Decade (USBJD), the
American Osteopathic Association (AOA) is enhancing its efforts to
reduce suffering from bone and joint disorders during the USBJD, from
2002 to 2011. Publishing articles such as this one is among the many
ways that the AOA is supporting the efforts of USBJD.