Targeted education improves the very low recognition of vertebral fractures and osteoporosis management by general internists

Abstract

Vertebral fractures in older persons are strong predictors of subsequent fracture risk but remain largely under-recognized. To evaluate the impact of an educational intervention on the recognition of vertebral fractures and the prescription of anti-osteoporosis treatment among general internists, we conducted a prospective study in a service of general internal medicine of a large university teaching hospital in Geneva, Switzerland. During a 3.5-month observation period (phase 1), all lateral spinal or chest radiographs performed on consecutive inpatients over 60 years were reviewed by two independent investigators, and vertebral fractures were graded according to their severity. Results were compared with radiology reports and general internists' discharge summaries. During the following 2-month intervention period (phase 2), internists were actively educated about vertebral fracture identification by means of lectures, posters and flyers. Radiologists did not receive this educational strategy and served as controls. Among 292 consecutive patients (54% men; range: 60-97 years) included in phase 1, 85 (29%) were identified by investigators as having at least one vertebral fracture; radiologists detected 29 (34%), and internists detected 19 (22%). During the intervention phase, 58 (34%) of 172 patients were identified with vertebral fractures by investigators; radiologists detected 13 patients (22%) whereas among internists the detection rate almost doubled (25/58 patients, 43%; p=0.008 compared to phase 1). The percentage of patients with vertebral fracture who benefitted from an osteoporosis medical management increased from 11% (phase 1) to 40% (phase 2, p<0.03). Our findings confirm the large under-recognition of vertebral fractures, irrespective of their severity, and demonstrate that a simple educational strategy can significantly improve their detection on routine radiographs and, consequently, improve osteoporosis management.