Background/Purpose: Non-traumatic vertebral and hip fractures are detrimental complications of osteoporosis and those with a previous fracture have double the risk of subsequent fractures. The objective of this quality improvement (QI) project was to determine the baseline characteristics that may have contributed to the vertebral or hip fracture and determine if bone health was optimized subsequent to the fracture. As corticosteroids can increase the risk of osteoporotic fractures, the initial focus of this analysis was on patients who had an outpatient prednisone prescription prior to admission.

Methods: Data was retrospectively collected from the electronic health record for patients aged 45 and older admitted to UF Health Jacksonville for an active vertebral or hip fracture diagnosis between January 1, 2017 and January 31, 2019. Traumatic injuries were excluded. Retrospective chart review could occur dating back to January 2014 for completeness. Data on patient demographics, any medication that may affect bone health (e.g. steroids, calcium and vitamin D products, bisphosphonates, etc.), DEXA scans, and pertinent labs were collected.

Results: A total of 287 patients were admitted 296 times between January 1, 2017 and January 31, 2019. Of these, 24 patients (8.4%) had an outpatient order for prednisone on at least one occasion prior to admission. Over half of the patients, 58.3%, had an outpatient order for prednisone with an associated diagnosis of chronic obstructive pulmonary disease. A majority, 79.2%, were female with a median age of 70.5 years old (range: 57 – 98 years old). More admissions were due to hip fractures (54.2%) than vertebral fractures (45.8%). Chronic prednisone use ≥ 15 mg/day prior to admission was noted in 9.1% of patients. The remaining 22 patients had prednisone bursts with 9.1% of patients having cumulative burst doses between 10-100 mg, 68.2% patients between 101-500 mg, 18.2% patients between 501-1000 mg, and 4.5% patients > 1000 mg. Of the 24 patients, six patients had a DEXA scan prior to admission and of these DEXA scans, 2 showed osteoporosis and 3 showed osteopenia in the affected fracture area at baseline. Only 8.3% of patients were on a bisphosphonate prior to admission. Baseline Vitamin D 25-OH levels were available in 12 patients with an average level of 30.365 ± 11.35 ng/mL.

Conclusion: In this convenience sample of patients who had an outpatient order for prednisone prior to admission, more hip fractures occurred than vertebral fractures. A small percentage of patients (9%) were on prednisone chronically. The rate of baseline DEXA scan was low as only 25% of patients had one available despite approximately 68% of patients having a cumulative prednisone dose exposure between 101 – 500 mg. The rate of bisphosphate use prior to admission was also low at 8.3%. Data collection for the patients not on prednisone is ongoing. The goal of this QI project is to create a care pathway for patients admitted to the hospital for vertebral or hip fractures to optimize bone health by mitigating modifiable risk factors and increasing appropriate osteoporosis medication prescriptions to reduce the future risk of fractures. No correlation can be made at this time between prednisone use, osteoporosis, and fracture incidence.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/prevalence-of-corticosteroid-use-in-incidental-vertebral-or-hip-fractures/