Health Topics

Lowering Your Risk of Fracture

Andrew Schorr:

There you go. Dr. Shuhart, so there are people who have hip fracture, maybe osteoporosis was certainly at work there, and the last thing you want is more fractures. So what about that situation for somebody who is already started down this road and we want to just lower their risk of more? What about that situation?

Dr. Shuhart:

Andrew, that's a critical time to understand that, you know, this is what we call clinical osteoporosis as Dr. Mease had talked about earlier. We don't need a densitometer to determine whether or not these patients have osteoporosis. They've shown us that they have osteoporosis unfortunately, and it's really up to healthcare providers to respond to that. What we know from information about the minimal needs of patients after hip fracture is that the healthcare system in the United States does a very poor job of identifying those patients for treatment and/or identifying them to have a bone density test. For every 100 patients that fall and break their hip only about 18 of them get either a bone density test or get medication within six months of their fracture diagnosis.

So this is what we would consider to be clinically low fruit, low hanging fruit, but it's been very, very difficult to get this number to budge. Literally, over the last eight or nine years it's barely gone up two or three percent, and that's really because we don't have a concerted effort at developing systems to take care of these patients. A patient comes into the hospital with a hip fracture. They've got a 50/50 chance of ending up in a nursing home, and they've got about a 20 percent chance of ending up in a nursing home for longer than six months. Almost always these are patients are elderly, and what we also know about treatment is that the older you are the better treatment works in terms of lowering your risk for subsequent fracture.

So we need to try to develop systems to take care of these patients and understand the way that these patients move through the healthcare system so that we can approach them from multiple points getting them the treatment that they need, that they really deserve. Because the second fracture is almost a death knell for those patients. Once you have had one hip fracture if you end up with a second fracture chances are great you will never get out of bed again. That's stark but that's the reality. And as we know as clinicians, once these patients end up in bed bad things start to happen to them: pneumonia, bed sores, pulmonary embolism and clots, generally debility, muscle wasting. It's a horrible thing. So we really from a system wide health system level need to try and approach these fractures as what they are, osteoporosis, and find ways to get these patient treated.

Andrew Schorr:

All right. So I'm going to let you be on your soap box for a minute about the patients or just healthcare consumers who are listening, people like Carole but maybe who haven't taken the step. What should they be doing now to understand the risk. At a high level, because we've talked about a lot of the details, that next conversation with their doctor or the appointment they make so that this get addressed for them. And we of course talked about the website that they can go to and do the questionnaire tonight. But as far as that next meeting with their doctor, what should they say?

Dr. Shuhart:

Well, if they're truly concerned I feel like they have to speak to their provider at a level where the provider can communicate with them and that they can get what they need. So literally to model the words, Doctor, I have to tell you I have real concerns about my bone health and my risk for fracture and here's why. And that's where your doctor should pause and let you speak. And as you speak your doctor, your provider should be taking in the information that you have in your heart and your worries and concerns and start to use the analysis in the computer that the healthcare provider has in his or her head to translate that into risk that we can understand scientifically.

And it would be a beautiful thing for at the moment, you know, more and more doctors and other healthcare providers have access to computers and internets in the exam room with patients. It would be a beautiful thing at that time for someone like Carole as they talk about this with their primary care provider for instance, for the provider to know about the FRAX model, to be able to pull up the FRAX model right in front of the patient and say, you know what, let's look at this, and let's understand your risk. Let's see where you fall, and then let's talk about a plan.

And whether that plan involves something simple like modifying your calcium intake, vitamin D supplementation which we've already said is sort of standard for everybody, everybody should be getting that, or whether we need to go and further assess risk. Do we need to in a 57 year old woman who is three years post menopausal do a bone density test because her mom fractured her hip at 71, like Carole, or 70. And really connect with the patient at the time of the visit to show the patient that they're concerned.

It's really important for the doctors to get connected to the patient and respond to the patient's concern. When the patient brings it up genuinely and using the words of, Doctor, I'm concerned, can we talk about it this, I would say most good primary care doctors would take that time. And if they can't deal with it at the moment, for instance the patient comes in for a high blood pressure check and their diabetes check and the half an hour is up, we all have time pressure, to say to them, you know, you're right. This is really important. I'm going to get you back in the next week. We're going to run the risk model. We're going to see what we need to do, form a partnership and try and move forward from there.

Andrew Schorr:

Great advice. Now, I just want to mention in the other programs in our series we're going to talk about how you can get help to fight osteoporosis. Lots of resources, we're going to talk about them, give you some specific resources, more advice about diet and exercise. And as we mentioned with Dr. Mease we're going to get, in a third program, much more in depth information about medications to help you further things you can do and also where research is headed.

Dr. Mease, your dream is that this is no longer a silent crisis and hopefully one day won't even be a crisis. Speak about that for a minute as we wrap up our program on what role an empowered patient can have in making this change.

Dr. Mease:

Because this condition is silent until the fractures start occurring, it is so important for patients to take control and help steer the management. Because unfortunately many doctors, as Chris has described, will just not take the time to explore this particular aspect of a patient's health. They have other issues that seem more front and center, hypertension, diabetes, screening for cancer, etc., and so it's critical that the patient themselves become educated and take control of this conversation. So I'm completely with Chris Shuhart in this regard, and I really appreciate hearing the way he spoke about the nature of the doctor or healthcare practitioner relationship with the patient and the quality of a conversation because I think that having a good quality conversation is critical.

Then spreading awareness to other people as well, to sisters, to friends. In the Washington Osteoporosis Coalition in our state many of us are involved as well as concerned patients and other people, to spread the awareness about osteoporosis as a problem. We do bone density screenings at health fairs. We teach about dietary intake of calcium and vitamin D. We do a lot of things to just kind of get the simple message out to the public that this is a real problem.

But I think it all comes back to one of empowering the individual patient to become knowledgeable, to use the internet, to have conversations, to read and understand about this problem because so much of it is preventable.

Andrew Schorr:

Right. You gentlemen have been so eloquent. And then we have Carole Clarke who is really a model. Carole, what would you say to other women, maybe men? You have your walking group. I imagine you talked about it when that friend had the hip fracture back in the trip to New York from Seattle. What would you say to our listeners today so that they put this on their radar along with those other things, you know, cholesterol and blood pressure, where they make this important too?

Carole:

Well, Andrew, I think you made a great point in the beginning or someone did that one out of two women and one out of four men over 50 have a fracture that is due to osteoporosis. And that all of us are living longer and want to live well when we're young be young as we get older, and so I think that the important thing is to find, first of all find a good doctor, what Dr. Mease called a bonehead, somebody that really is interested in this issue. And go ahead and take that FRAX and take it in if you need it to get him talking about it or her talking about it. And then hopefully get a T score by having a bone density.

And then do whatever it takes to get a routine of taking care of your bones. Just like you would know your blood pressure, your BMI, you want to know your T score, your FRAX score so that you know all about your bones. And all the things that are good for your heart are good for your bones, like really exercising well. Really, those of us that keep fighting weight, the Weight Watchers diet where you're required to take three glasses of milk or three sources of calcium is a great way to do it. So you can take care of yourself. And then finding exercises that help with your posture and are weight bearing will help.

Then I think just keeping up because the research keeps changing and having a doctor like both of these doctors who keep up with the research that you can ask questions about, see your alternatives but then make your decision. But just as you're trying to do, Andrew, with your organization is being proactive as a patient but also realizing that it's something that will happen to so many people if we don't take action, even that young woman that's so smart that she's looking at it young and has a better chance. But I was encouraged to hear that even after a break, even at my age if I were to have one, that there are steps they can take so that you won't have the next one. And I think that's important to get the treatment and protect yourself from all the things that people pointed out can happen due to this.

Andrew Schorr:

Great information, Carole. I want to congratulate you on all you do, and I know the doctors thank you for being with us.

I want to mention to our audience that if you have questions or comments for upcoming programs or any time just send them to this e mail address: Strongbones@patientpower.info. Carole Clarke, all the best to you. Enjoy your continued walks with your friends.

And I want to thank Dr. Philip Mease from Seattle Rheumatology Associates and director of the rheumatology clinical research program at Swedish Medical Center in Seattle. And also Dr. Christopher Shuhart, medical director of the Swedish Physicians Bone Health and Osteoporosis Program. You can hear how passionate they are.

Look for our other programs. We appreciate your comments, suggestions and questions. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Thanks for listening to our programs brought to you by the Washington Osteoporosis Coalition made possible through educational funding from Amgen and Novartis. Good night.

Please remember the opinions expressed on Patient Power are not necessarily the views of Washington Osteoporosis Coalition, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.