Background: Vertebral fractures are the most common type of osteoporotic fracture in older adults in the United States, and can result in acute and chronic pain, reduced quality of life, decreased survival, and increased costs. The identification and management of vertebral fractures is important because they serve as robust predictors of future fractures. Yet, hospital and transitional care practices have not been adequately explored. The objective of this study was to evaluate current management practices of low impact vertebral fractures in older adults admitted to the hospital.
Methods: This retrospective study included older adults (65+) admitted to the hospital and found to have a new (not previously documented in the electronic health record, EHR) vertebral compression fracture on radiographic imaging (CT scan). Patients were excluded if they: sustained a non-low impact vertebral fracture (i.e., pathologic, high impact trauma) or were receiving hospice care. EHR data was collected via an in-depth chart review, which included: presenting complaints, laboratory studies (e.g., vitamin D, parathyroid hormone), inpatient management (e.g., pain management, spine consult, discharge diagnosis of osteoporosis), and discharge follow-up instructions (e.g., referral for bone mineral density).
Results: Of the charts reviewed (N = 50), the average age was 85.0 years old, 70% (n=35) were female, 66% (n=33) were white, 82% (n=41) came from home, and only 18% (n=9) were independent at baseline (52%, n=26, required both a device and human assistance). Nearly 20% (n=9) had a history of osteoporosis and 32% (n=16) of all patients had a prior osteoporotic related fracture on radiographic findings. Nearly three-quarters (n=36) of patients with new vertebral fractures were admitted to the medicine service. Radiographic findings revealed that 48% (n=24) of patients had both thoracic and lumbar compression fractures and 22% (n=11) had evidence of retropulsion. The most common presenting symptoms were pain (74%, n=37), inability to ambulate (52%, n=26), altered mental status (18%, n=9), and constipation (16%, n=8). Regarding laboratory tests, TSH was checked in 54% (n=27), PTH in 4% (n=2) and vitamin D in 24% (n=12) of patients. Over 90% (n=46) of patients were managed with physical therapy and pain control, and 54% (n=27) were given a thoracic-lumbo-sacral orthosis (TLSO) brace. Spine surgery was consulted in 54% (n=27) of cases. Overall, only 18% (n=9) of patients with a new vertebral fracture had documentation of osteoporosis on their problem list or discharge paperwork. On discharge, 4% (n=2) of patients were initiated on vitamin D and 6% (n=3) on calcium; 48% (n=24) were referred for outpatient spine follow up; and only 2% (n=1) for endocrine. No patients were referred for bone density testing or outpatient follow-up to consider initiation of bisphosphonates or teriparatide.
Conclusions: This study highlights the gaps in inpatient and transitional care identification and management of vertebral compression fracture, which is a potential missed opportunity to prevent future fractures and disability.