Rate of bone mineral density (BMD) testing and vitamin d nutritional (VDN) status among patients admitted for proximal femur fractures: A retrospective cohort study of a fracture consultative service at a tertiary care medical center
Das LMV, Huq SN, Guthrie ST, Hakeos W, Hoegler J, Divine G, Kaur M, Rao SD, and Bhan A. Rate of bone mineral density (BMD) testing and vitamin d nutritional (VDN) status among patients admitted for proximal femur fractures: A retrospective cohort study of a fracture consultative service at a tertiary care medical center. Endocr Rev 2018; 39(2)
INTRODUCTION: Osteoporotic fractures are a major cause of disability, morbidity, and mortality. A hip fracture is associated with 20% excess mortality in the year following fracture. Approximately 20% of hip fracture patients require long-term nursing home care and only 40% fully regain their prefracture functional level. Despite significant advances in our understanding of the pathogenesis of hip fractures and robust clinical trials demonstrating therapeutic efficacy with an array of drugs, it is unclear how best this knowledge and trial data is translated into patient care. Although much has been reported about the importance of Vitamin D Nutrition (VDN) in preventing hip fractures, the prevalence of vitamin D deficiency or insufficiency among hip fracture patients is largely unknown. A few reports studying this relationship have been published from other countries, but to the best of our knowledge only one such report has been published from the United States. METHODS: The aim of our study is to determine the rate of Bone Mineral Density (BMD) testing and the prevalence of vitamin D deficiency or insufficiency among patients admitted for acute proximal femur fractures over a 5 year period (January 1st, 2011 to December 31st, 2016). The electronic health records of 135 patients with proximal femur fractures were reviewed to determine the rate of BMD testing prior to the fracture and VDN status, as assessed by serum 25-hydroxyvitamin D levels (25-OHD). RESULTS: Of the 135 patients, 91 were women (67%), and 61 were white (45%) with a mean age of 79.2 ± 12.9 y (range 49-98 y). Mean serum 25-OHD was 22.8 ± 12.9 ng/ml (range 4-66 ng/ml), mean serum PTH level was 73.6 ± 58.6 (range 17-430 pg/ml), and mean serum creatinine (Cr) was 1.26 ± 0.94 mg/dl (range 0.16-7.1 mg/dl). The proportions of race and gender, or the mean age, or 25-OHD, or PTH did not change significantly after excluding patients with serum Cr >1.5 mg/dl (n=15) or Cr >2.0 (n=10). Surprisingly, only 35% (n=47) have ever had BMD testing, even though it was approved for screening at-risk population almost a quarter century ago! Unlike the only previous report published in the US, the mean 25-OHD was much higher, but the prevalence of vitamin D deficiency (<20 ng/ml) and insufficiency (<30 ng/ml) was 31% and 54% respectively. Only 15% had optimal VDN. The PTH levels were significantly higher in the entire cohort, and may have contributed to the femur fractures in addition to poor VDN. CONCLUSION: Despite revolutionary advances in our understanding of the pathogenesis of femur fractures, tools to detect it, and effective array of drugs to prevent it, very little impact appears to have occurred in clinical care of the contemporary hip fracture patients. Concerted system based approaches must be incorporated to avoid such preventable and devastating consequences of hip fractures.