Fracture prediction from repeat BMD measurements in clinical practice

We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment. We report that repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy.

INTRODUCTION

In clinical practice, many patients selectively undergo repeat bone mineral density (BMD) measurements. We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment and whether this is affected by preceding change in BMD or recent osteoporosis therapy.

METHODS

We identified women and men aged ≥ 50 years who had a BMD measurement during 1990-2009 from a large clinical BMD database for Manitoba, Canada (n = 50,215). Patient subgroups aged ≥ 50 years at baseline with repeat BMD measures were identified. Data were linked to an administrative data repository, from which osteoporosis therapy, fracture outcomes, and covariates were extracted. Using Cox proportional hazards models, we assessed covariate-adjusted risk for major osteoporotic fracture (MOF) and hip fracture according to BMD (total hip, lumbar spine, femoral neck) at different time points.

RESULTS

Prevalence of osteoporosis therapy increased from 18 % at baseline to 55 % by the fourth measurement. Total hip BMD was predictive of MOF at each time point. In the patient subgroup with two repeat BMD measurements (n = 13,481), MOF prediction with the first and second measurements was similar: adjusted-hazard ratio (HR) per SD 1.45 (95 % CI 1.34-1.56) vs. 1.64 (95 % CI 1.48-1.81), respectively. No differences were seen when the second measurement results were stratified by preceding change in BMD or osteoporosis therapy (both p-interactions >0.2). Similar results were seen for hip fracture prediction and when spine and femoral neck BMD were analyzed.

CONCLUSION

Repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy.

Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial

Background

Few studies have systematically examined whether knowledge translation (KT) strategies can be successfully implemented within the long-term care (LTC) setting. In this study, we examined the effectiveness of a multifaceted, interdisciplinary KT intervention for improving the prescribing of vitamin D, calcium and osteoporosis medications over 12-months.

Methods

We conducted a pilot, cluster randomized controlled trial in 40 LTC homes (21 control; 19 intervention) in Ontario, Canada. LTC homes were eligible if they had more than one prescribing physician and received services from a large pharmacy provider. Participants were interdisciplinary care teams (physicians, nurses, consultant pharmacists, and other staff) who met quarterly. Intervention homes participated in three educational meetings over 12 months, including a standardized presentation led by expert opinion leaders, action planning for quality improvement, and audit and feedback review. Control homes did not receive any additional intervention. Resident-level prescribing and clinical outcomes were collected from the pharmacy database; data collectors and analysts were blinded. In addition to feasibility measures, study outcomes were the proportion of residents taking vitamin D (≥800 IU/daily; primary), calcium ≥500 mg/day and osteoporosis medications (high-risk residents) over 12 months. Data were analyzed using the generalized estimating equations technique accounting for clustering within the LTC homes.

Results

At baseline, 5,478 residents, mean age 84.4 (standard deviation (SD) 10.9), 71% female, resided in 40 LTC homes, mean size = 137 beds (SD 76.7). In the intention-to-treat analysis (21 control; 19 intervention clusters), the intervention resulted in a significantly greater increase in prescribing from baseline to 12 months between intervention versus control arms for vitamin D (odds ratio (OR) 1.82, 95% confidence interval (CI): 1.12, 2.96) and calcium (OR 1.33, 95% CI: 1.01, 1.74), but not for osteoporosis medications (OR 1.17, 95% CI: 0.91, 1.51). In secondary analyses, excluding seven nonparticipating intervention homes, ORs were 3.06 (95% CI: 2.18, 4.29), 1.57 (95% CI: 1.12, 2.21), 1.20 (95% CI: 0.90, 1.60) for vitamin D, calcium and osteoporosis medications, respectively.

Conclusions

Our KT intervention significantly improved the prescribing of vitamin D and calcium and is a model that could potentially be applied to other areas requiring quality improvement.

Trial Registration

ClinicalTrials.gov: NCT01398527. Registered: 19 July 2011.

Hip axis length is a FRAX- and bone density-independent risk factor for hip fracture in women

CONTEXT

Bone mineral density (BMD) measurement from dual-energy X-ray absorptiometry (DXA) is widely used to assess skeletal strength in clinical practice, but DXA instruments can also measure biomechanical parameters related to skeletal shape.

OBJECTIVE

The objective of the study was to determine whether DXA-derived hip geometry measures provide information on fracture prediction that is independent of hip fracture probability determined from the fracture risk assessment tool (FRAX) algorithm.

DESIGN AND SETTING

This was a retrospective registry study using BMD results for Manitoba, Canada.

PATIENTS

Women aged 40 years and older with baseline hip DXA, derived hip geometry measures, and FRAX scores (n = 50 420) participated in the study.

MAIN OUTCOME MEASURES

Hospitalized hip fracture (n = 1020) diagnosed during 319 137 person-years of follow-up (median 6.4 y) was measured.

RESULTS

Among the hip geometry measures, hip axis length (HAL) showed a consistent association with hip fracture risk when adjusted for age [hazard ratio (HR) 1.30 per SD increase, 95% confidence interval (CI) 1.22-1.38], and this was unaffected by further adjustment for BMD or FRAX score. Adjusted for FRAX score with BMD, there was a significant effect of increasing HAL quintile on hip fracture risk (linear trend P < .001); relative to quintile 1 (referent), the HR increased from 1.43 (95% CI 1.12-1.82) for quintile 2, 1.61 (95% CI 1.27-2.04) for quintile 3, 1.85 (95% CI 1.47-2.32) for quintile 4, and 2.45 (95% CI 1.96-3.05) for quintile 5. There was a modest but significant improvement in net reclassification improvement (1.5%) and integrated discrimination improvement (0.7%) indices. The effect of HAL was particularly strong among younger, nonosteoporotic women (FRAX adjusted HR 1.70 per SD increase, 95% CI 1.48-1.94).

CONCLUSIONS

DXA-derived hip geometry measurements are associated with incident hip fracture risk, but many do not confer significant independent predictive information. HAL was found to predict hip fractures when adjusted for BMD or FRAX score and may be of clinical value in refining hip fracture risk.

Why does rate of bone density loss not predict fracture risk?

CONTEXT

Intuitively, rapid bone mineral density (BMD) loss should predict fracture risk independently of current BMD, but studies have not confirmed this. We hypothesized that measurement error when characterizing rates of BMD loss might explain this paradox.

OBJECTIVE

To examine the importance of measurement error in predicting BMD loss.

DESIGN AND SETTING

Retrospective registry study using BMD results for Manitoba, Canada.

PATIENTS

Untreated women age 50 years and older with three femoral neck BMD tests.

MAIN OUTCOME MEASURES

Correlation in annualized rates of BMD change for interval 1 (first to second scan) versus interval 2 (second to third scan) with confirmatory model-based simulations that varied measurement error and testing intervals.

RESULTS

Five hundred forty two women with a mean age of 62 years had BMD measurements separated by a mean of 3.5 years for interval 1 and 3.4 years for interval 2. Mean femoral neck BMD loss was stable (-0.5% per year for interval 1, -0.6% per year for interval 2) with a weak negative correlation between intervals (r = -0.11, P = .01). There were no significant correlations for BMD change at the total hip (r = 0.01, P = .74) or total spine (r = -0.01, P = .77). Simulations showed low explained variation for BMD change between intervals 1 and 2 (<20%). To explain 50% of the variation of BMD change between intervals 1 and 2 required a BMD measurement error ≤ 0.008 g/cm(2) or a BMD testing interval ≥ 5 years.

CONCLUSIONS

The low correlation between past and future BMD loss helps explain why the rate of BMD loss is unlikely to be helpful for refining fracture risk.

Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus

This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.

Sex- and age-specific associations between income and incident major osteoporotic fractures in Canadian men and women: a population-based analysis

We investigated sex- and age-specific associations between income and fractures at the hip, humerus, spine, and forearm in adults aged ≥50 years. Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women.

INTRODUCTION

Associations between income and hip fractures are contested, even less is known about other fracture sites. We investigated sex- and age-specific associations between income and major osteoporotic fractures (MOF) at the hip, humerus, spine, and forearm.

METHODS

Incident fractures were identified from administrative health data for adults aged ≥50 years in Manitoba, Canada, 2000-2007. Mean neighborhood (postal code area) annual household incomes were extracted from 2006 census files and categorized into quintiles. We calculated age-adjusted and age-specific sex-stratified fracture incidence across income quintiles. We estimated relative risks (RR) and 95% CI for income quintile 1 (Q1, lowest income) vs. income quintile 5 (Q5) and tested the linear trend across quintiles.

RESULTS

We identified 15,094 incident fractures (4736 hip, 3012 humerus, 1979 spine, and 5367 forearm) in 2718 men and 6786 women. For males, the RR of fracture for the lowest vs. highest income quintile was 1.63 (95% CI 1.42-1.87) and the negative trend was statistically significant (p < 0.0001); individual skeletal sites showed similar associations. For females, the RR of fracture for the lowest vs. highest income quintile was 1.14 (95% CI 1.01-1.28), with a statistically significant negative trend (p = 0.0291); however, the only skeletal site associated with income in women was the forearm (Q1 vs. Q5 RR 1.09, 95% CI 1.01-1.28).

CONCLUSIONS

Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women. For men, these effect sizes seem large enough to warrant public health concern.

Does diabetes modify the effect of FRAX risk factors for predicting major osteoporotic and hip fracture?

In an observational study population of 62,413 individuals (6,455 [10 %] with diabetes), diabetes was independently associated with major osteoporotic fractures (MOFs) but did not significantly modify the effect of FRAX(TM) risk factors or prior fracture site. However, the presence of diabetes exerted a much stronger effect on hip fracture risk in younger versus older individuals.

INTRODUCTION

Diabetes mellitus increases fracture risk independent of risk factors that comprise the WHO FRAX(TM) tool. We explored whether diabetes modifies the effect of FRAX clinical risk factors on MOF and hip fracture risk.

METHODS

Using a registry of clinical dual-energy X-ray absorptiometry (DXA) results for Manitoba, Canada, we identified women and men aged 40 years and older undergoing baseline DXA in 1996-2011. Health services data were used to identify diabetes diagnosis, FRAX risk factors and incident fractures using previously validated algorithms. Prior fracture was stratified as clinical vertebral, hip, humerus, forearm, pelvis and 'other'. Cox proportional hazards models were used to test for statistical interactions of diabetes with FRAX clinical risk factors and prior fracture site.

RESULTS

During a mean follow-up of 6 years, there were 4,218 MOF and 1,108 hip fractures. Diabetes was a significant independent risk factor for MOF adjusted for FRAX risk factors including bone mineral density (BMD) (adjusted hazard ratio [aHR] 1.32 [95 % confidence interval (CI) 1.20-1.46]). No significant interactions of FRAX risk factors or prior fracture site with diabetes were identified in analyses of MOF. For predicting hip fractures, age significantly modified the effect of diabetes (aHR age <60, 4.67 [95 % CI 2.76-7.89], age 60-69, 2.68 [1.77-4.04], age 70-79, 1.57 [1.20-2.04], age >80, 1.42 [1. 10-1.99]; pinteraction <0.001).

CONCLUSIONS

Diabetes is an independent risk factor for MOFs and does not significantly modify the effect of FRAX risk factors or prior fracture site. However, diabetes exerts a much stronger effect on hip fracture risk in younger than older individuals which needs to be considered in hip fracture prediction.

Estimated lean mass and fat mass differentially affect femoral bone density and strength index but are not FRAX independent risk factors for fracture

Although increasing body weight has been regarded as protective against osteoporosis and fractures, there is accumulating evidence that fat mass adversely affects skeletal health compared with lean mass. We examined skeletal health as a function of estimated total body lean and fat mass in 40,050 women and 3600 men age ≥50 years at the time of baseline dual-energy X-ray absorptiometry (DXA) testing from a clinical registry from Manitoba, Canada. Femoral neck bone mineral density (BMD), strength index (SI), cross-sectional area (CSA), and cross-sectional moment of inertia (CSMI) were derived from DXA. Multivariable models showed that increasing lean mass was associated with near-linear increases in femoral BMD, CSA, and CSMI in both women and men, whereas increasing fat mass showed a small initial increase in these measurements followed by a plateau. In contrast, femoral SI was relatively unaffected by increasing lean mass but was associated with a continuous linear decline with increasing fat mass, which should predict higher fracture risk. During mean 5-year follow-up, incident major osteoporosis fractures and hip fractures were observed in 2505 women and 180 men (626 and 45 hip fractures, respectively). After adjustment for fracture risk assessment tool (FRAX) scores (with or without BMD), we found no evidence that lean mass, fat mass, or femoral SI affected prediction of major osteoporosis fractures or hip fractures. Findings were similar in men and women, without significant interactions with sex or obesity. In conclusion, skeletal adaptation to increasing lean mass was positively associated with BMD but had no effect on femoral SI, whereas increasing fat mass had no effect on BMD but adversely affected femoral SI. Greater fat mass was not independently associated with a greater risk of fractures over 5-year follow-up. FRAX robustly predicts fractures and was not affected by variations in body composition.

Quality indicators for hip fracture patients: a scoping review protocol

INTRODUCTION

Hip fractures are a significant cause of morbidity and mortality and care of hip fracture patients places a heavy burden on healthcare systems due to prolonged recovery time. Measuring quality of care delivered to hip fracture patients is important to help target efforts to improve care for patients and efficiency of the health system. The purpose of this study is to synthesise the evidence surrounding quality of care indicators for patients who have sustained a hip fracture. Using a scoping review methodology, the research question that will be addressed is: "What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?".

METHODS AND ANALYSIS

We will employ the methodological frameworks used by Arksey and O'Malley and Levac et al. The synthesis will be limited to quality of care indicators for individuals who suffered low trauma hip fracture. All English peer-reviewed studies published from the year 2000-most recent will be included. Literature search strategies will be developed using medical subject headings and text words related to hip fracture quality indicators and the search will be peer-reviewed. Numerous electronic databases will be searched. Two reviewers will independently screen titles and abstracts for inclusion, followed by screening of the full text of potentially relevant articles to determine final inclusion. Abstracted data will include study characteristics and indicator definitions.

DISSEMINATION

To improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of care are required. The implementation of quality of care indicators enables stakeholders to target areas for improvement in service delivery. Knowledge translation activities will occur throughout the review with dissemination of the project goals and findings to local, national, and international stakeholders.

Spine bone texture assessed by trabecular bone score (TBS) predicts osteoporotic fractures in men: the Manitoba Bone Density Program

INTRODUCTION

One quarter of osteoporotic fractures occur in men. TBS, a gray-level measurement derived from lumbar spine DXA image texture, is related to microarchitecture and fracture risk independently of BMD. Previous studies reported the ability of spine TBS to predict osteoporotic fractures in women. Our aim was to evaluate the ability of TBS to predict clinical osteoporotic fractures in men.

METHODS

3620 men aged ≥50 (mean 67.6years) at the time of baseline DXA (femoral neck, spine) were identified from a database (Province of Manitoba, Canada). Health service records were assessed for the presence of non-traumatic osteoporotic fracture after BMD testing. Lumbar spine TBS was derived from spine DXA blinded to clinical parameters and outcomes. We used Cox proportional hazard regression to analyze time to first fracture adjusted for clinical risk factors (FRAX without BMD), osteoporosis treatment and BMD (hip or spine).

RESULTS

Mean followup was 4.5years. 183 (5.1%) men sustain major osteoporotic fractures (MOF), 91 (2.5%) clinical vertebral fractures (CVF), and 46 (1.3%) hip fractures (HF). Correlation between spine BMD and spine TBS was modest (r=0.31), less than correlation between spine and hip BMD (r=0.63). Significantly lower spine TBS were found in fracture versus non-fracture men for MOF (p<0.001), HF (p<0.001) and CVF (p=0.003). Area under the receiver operating characteristic curve (AUC) for incident fracture discrimination with TBS was significantly better than chance (MOF AUC=0.59, p<0.001; HF AUC=0.67, p<0.001; CVF AUC=0.57, p=0.032). TBS predicted MOF and HF (but not CVF) in models adjusted for FRAX without BMD and osteoporosis treatment. TBS remained a predictor of HF (but not MOF) after further adjustment for hip BMD or spine BMD.

CONCLUSION

We observed that spine TBS predicted MOF and HF independently of the clinical FRAX score, HF independently of FRAX and BMD in men. Studies with more incident fractures are needed to confirm these findings.

The importance of previous fracture site on osteoporosis diagnosis and incident fractures in women

Previous fracture increases the risk of subsequent fractures regardless of the site of the initial fracture. Fracture risk assessment tools have been developed to guide clinical management; however, no discrimination is made as to the site of the prior fracture. Our objective was to determine which sites of previous nontraumatic fractures are most strongly associated with a diagnosis of osteoporosis, defined by a bone mineral density (BMD) T-score of ≤ -2.5 at the femoral neck, and an incident major osteoporotic fracture. Using administrative health databases, we conducted a retrospective historical cohort study of 39,991 women age 45 years and older who had BMD testing with dual-energy X-ray absorptiometry (DXA). Logistic regression and Cox proportional multivariate models were used to test the association of previous fracture site with risk of osteoporosis and incident fractures. Clinical fractures at the following sites were strongly and independently associated with higher risk of an osteoporotic femoral neck T-score after adjustment for age: hip (odds ratio [OR], 3.58; 95% confidence interval [CI], 3.04-4.21), pelvis (OR, 2.23; 95% CI, 1.66-3.0), spine (OR, 2.16; 95% CI, 1.77-2.62), and humerus (OR, 1.74; 95% CI, 1.49-2.02). Cox proportional hazards models, with adjustment for age and femoral neck BMD, showed the greatest increase in risk for a major osteoporotic fracture for women who had sustained previous fractures of the spine (hazard ratio [HR], 2.08; 95% CI, 1.72-2.53), humerus (HR, 1.70; 95% CI, 1.44-2.01), patella (HR, 1.54; 95% CI, 1.10-2.18), and pelvis (HR, 1.45; 95% CI, 1.04-2.02). In summary, our results confirm that nontraumatic fractures in women are associated with osteoporosis at the femoral neck and that the site of previous fracture impacts on future osteoporotic fracture risk, independent of BMD.

Temporal trends in obesity, osteoporosis treatment, bone mineral density, and fracture rates: a population-based historical cohort study

Diverging international trends in fracture rates have been observed, with most reports showing that fracture rates have stabilized or decreased in North American and many European populations. We studied two complementary population-based historical cohorts from the Province of Manitoba, Canada (1996-2006) to determine whether declining osteoporotic fracture rates in Canada are attributable to trends in obesity, osteoporosis treatment, or bone mineral density (BMD). The Population Fracture Registry included women aged 50 years and older with major osteoporotic fractures, and was used to assess impact of changes in osteoporosis treatment. The BMD Registry included all women aged 50 years and older undergoing BMD tests, and was used to assess impact of changes in obesity and BMD. Model-based estimates of temporal changes in fracture rates (Fracture Registry) were calculated. Temporal changes in obesity and BMD and their association with fracture rates (BMD Registry) were estimated. In the Fracture Registry (n=27,341), fracture rates declined 1.6% per year (95% confidence interval [CI], 1.3% to 2.0%). Although osteoporosis treatment increased from 5.6% to 17.4%, the decline in fractures was independent of osteoporosis treatment. In the BMD Registry (n=36,587), obesity increased from 12.7% to 27.4%. Femoral neck BMD increased 0.52% per year and lumbar spine BMD increased 0.32% per year after covariate adjustment (p<0.001). Major osteoporotic fracture rates decreased in models that did not include femoral neck BMD (fully adjusted annual change -1.8%; 95% CI, -2.9 to -0.5), but adjusting for femoral neck BMD accounted for the observed reduction (annual change -0.5%; 95% CI, -1.8 to +1.0). In summary, major osteoporotic fracture rates declined substantially and linearly from 1996 to 2006, and this was explained by improvements in BMD rather than greater rates of obesity or osteoporosis treatment.

Major osteoporotic to hip fracture ratios in canadian men and women with Swedish comparisons: a population-based analysis

Fracture Risk Assessment (FRAX) tools are calibrated from country-specific fracture epidemiology. Although hip fracture data are usually available, data on non-hip fractures for most countries are often lacking. In such cases, rates are often estimated by assuming similar non-hip to hip fracture ratios from historical (1987 to 1996) Swedish data. Evidence that countries share similar fracture ratios is limited. Using data from Manitoba, Canada (2000 to 2007, population 1.2 million), we identified 21,850 incident major osteoporotic fractures (MOF) in men and women aged >50 years. Population-based age- and sex-specific ratios of clinical vertebral, forearm, and humerus fractures to hip fractures were calculated, along with odds ratios (ORs) and 95% confidence intervals (CIs). All ratios showed decreasing trends with increasing age for both men and women. Men and women showed similar vertebral/hip fracture ratios (all p > 0.1, with ORs 0.86 to 1.25). Forearm/hip and humerus/hip fracture ratios were significantly lower among men than women (forearm/hip ratio: p < 0.01 for all age groups, with ORs 0.29 to 0.53; humerus/hip ratio: p < 0.05 for all age groups [except 80 to 84 years] with ORs 0.46 to 0.86). Ratios for any MOF/hip fracture were also significantly lower among men than women in all but two subgroups (p < 0.05 for all age groups [except 80 to 84 and 90+ years] with ORs 0.48 to 0.87). Swedish vertebral/hip fracture ratios were similar to the Canadian fracture ratios (within 7%) but significantly lower for other sites (men and women: 46% and 35% lower for forearm/hip ratios, 19% and 15% lower for humerus/hip ratios, and 19% and 23% lower for any MOF/hip ratios). These differences have implications for updating and calibrating FRAX tools, fracture risk estimation, and intervention rates. Moreover, wherever possible, it is important that countries try to collect accurate non-hip fracture data.

Can change in FRAX score be used to "treat to target"? A population‐based cohort study

It is unknown how responsive the Fracture Risk Assessment (FRAX) tool is to osteoporosis treatment (OTX) or whether it can serve as a target for "goal‐directed" treatment. We studied 11,049 untreated women aged ≥50 years undergoing baseline and follow‐up DXA examinations in Manitoba, Canada. We identified clinical risk factors, intervening OTX based on medication possession ratios (MPR),and incident fractures. FRAX scores for major osteoporotic and hip fractures were computed for each scan using the most current(updated) FRAX inputs. Over 4 years, median FRAX scores showed an increase of 1.1% for major fractures and 0.3% for hip fractures,including women highly adherent to OTX (0.6% and 0.1% increases). Few (2.2%) highly adherent women had a decrease in major fracture probability exceeding 4%, whereas 9.0% had a decrease in hip fracture probability exceeding 1%. Compared with untreated women, OTX was associated with a higher dose‐dependent likelihood of attenuating the expected increase in major fracture risk:adjusted odds ratios (aOR) 2.3 (95% confidence interval [CI] 1.8–2.9) for MPR <0.50; 7.3 (95% CI 5.6–9.6) for MPR 0.50–0.79; and 12.0(95% CI 9.5–15.2) for MPR ≥0.80. In the 4 years after the second DXA scan, 620 (6%) women had major fractures (152 hip fractures). FRAX scores were strongly predictive of incident major fractures (adjusted hazard ratios [aHR] per SD increase in FRAX 1.8, 95%CI 1.7–1.9) and hip fractures (aHR per SD 4.5, 95% CI 3.7–5.7); however, change in FRAX score was not independently associated with major fracture (p=0.8) or hip fracture (p=0.3). In conclusion, FRAX scores slowly increased over time, and this increase was attenuated but not prevented by treatment. Few women had meaningful reductions in FRAX scores, and change in FRAX score did not independently predict incident fracture, suggesting that FRAX with BMD is not responsive enough to be used as a target for goal‐directed treatment.

Temporal trends in the incidence of osteoporotic fractures

Osteoporotic fractures are associated with excess mortality and decreased functional capacity and quality of life. Age-standardized incidence rates of fragility fractures, particularly of the hip and forearm, have been noted to be decreasing in the last decade across many countries with the notable exception of Asia. The causes for the observed changes in fracture risk have not been fully identified but are likely the result of multiple factors, including birth cohort and period effects, increasing obesity, and greater use of anti-osteoporosis medications. Changing rates of fragility fractures would be expected to have an important impact on the burden of osteoporosis.

Fracture risk assessment in long-term care: a survey of long-term care physicians

Background

The majority of frail elderly who live in long-term care (LTC) are not treated for osteoporosis despite their high risk for fragility fractures. Clinical Practice Guidelines for the diagnosis and management of osteoporosis provide guidance for the management of individuals 50 years and older at risk for fractures, however, they cannot benefit LTC residents if physicians perceive barriers to their application. Our objectives are to explore current practices to fracture risk assessment by LTC physicians and describe barriers to applying the recently published Osteoporosis Canada practice guidelines for fracture assessment and prevention in LTC.

Methods

A cross-sectional survey was conducted with the Ontario Long-Term Care Physicians Association using an online questionnaire. The survey included questions that addressed members’ attitudes, knowledge, and behaviour with respect to fracture risk assessment in LTC. Closed-ended responses were analyzed using descriptive statistics and thematic framework analysis for open-ended responses.

Results

We contacted 347 LTC physicians; 25% submitted completed surveys (81% men, mean age 60 (Standard Deviation [SD] 11) years, average 32 [SD 11] years in practice). Of the surveyed physicians, 87% considered prevention of fragility fractures to be important, but a minority (34%) reported using validated fracture risk assessment tools, while 33% did not use any. Clinical risk factors recommended by the OC guidelines for assessing fracture risk considered applicable included; glucocorticoid use (99%), fall history (93%), age (92%), and fracture history (91%). Recommended clinical measurements considered applicable included: weight (84%), thyroid-stimulating hormone (78%) and creatinine (73%) measurements, height (61%), and Get-Up-and-Go test (60%). Perceived barriers to assessing fracture risk included difficulty acquiring necessary information, lack of access to tests (bone mineral density, x-rays) or obtaining medical history; resource constraints, and a sentiment that assessing fracture risk is futile in this population because of short life expectancy and polypharmacy.

Conclusion

Perceived barriers to fracture risk assessment and osteoporosis management in LTC have not changed recently, contributing in part to the ongoing care gap in osteoporosis management. Our findings highlight the importance to adapt guidelines to be applicable to the LTC environment, and to develop partnerships with stakeholders to facilitate their use in clinical practice.

Influence of recency and duration of glucocorticoid use on bone mineral density and risk of fractures: population-based cohort study

Although systemic glucocorticoids are commonly used, it is difficult to obtain accurate exposure history. In 50,000 patients, we confirmed that glucocorticoids were associated with reductions in bone mineral density (BMD) and increases in fracture and documented that recent and prolonged durations of exposure were particularly associated with adverse events-dose information did not improve risk prediction.

INTRODUCTION

Systemic glucocorticoid use, defined as ever having taken supra-physiologic doses for 90-days or more, is a risk factor for low BMD and fractures. This definition does not distinguish recent (vs remote) exposure.

METHODS

Within a population-based clinical BMD registry in Manitoba, Canada, we identified all adults over age 40 years tested between 1998 and 2007 and then undertook a cohort study. We identified all oral glucocorticoid dispensations from 1995 to 2009 and stratified exposure by timing ("recent" if within 12 months vs "remote") and duration (short [<90 days] vs prolonged [≥90 days]). Osteoporosis-related risk factors and treatments and major fractures were obtained using administrative health data.

RESULTS

A total of 12,818 of 52,070 (25%) subjects had used glucocorticoids prior to BMD testing; the most common exposure was remote short (n = 6453) vs recent prolonged (n = 2896) vs recent short (n = 2644) vs remote prolonged (n = 825). Compared to 39,252 never-users, only recent prolonged glucocorticoid use was significantly associated with femoral neck T-score (ANCOVA-adjusted difference -0.13, 95% CI -0.16 to -0.10, p < 0.001). There were 2,842 major (566 hip) fractures over median 5-year follow-up. Compared with never-users, only recent prolonged glucocorticoid use was significantly associated with BMD-independent increases in risk of incident major fracture (5.4 vs 7.7%, adjusted HR 1.25, 95% CI 1.07-1.45, p = 0.004) and hip fracture (1.1 vs 1.8%, adjusted HR 1.61, 95% CI 1.18-2.20, p = 0.003).

CONCLUSIONS

Recent and prolonged glucocorticoid use (but neither remote nor recent short courses) was independently associated with reduced BMD and increased risk of fractures. These findings should permit clinicians to identify a high-risk group of patients that might benefit from osteoporosis prevention.

Calcium and vitamin D intake and mortality: results from the Canadian Multicentre Osteoporosis Study (CaMos)

CONTEXT

Calcium and vitamin D are recommended for bone health, but there are concerns about adverse risks. Some clinical studies suggest that calcium intake may be cardioprotective, whereas others report increased risk associated with calcium supplements. Both low and high serum levels of 25-hydroxyvitamin D have been associated with increased mortality.

OBJECTIVE

The purpose of this study was to determine the association between total calcium and vitamin D intake and mortality and heterogeneity by source of intake.

DESIGN

The Canadian Multicentre Osteoporosis Study cohort is a population-based longitudinal cohort with a 10-year follow-up (1995-2007).

SETTING

This study included randomly selected community-dwelling men and women.

PARTICIPANTS

A total of 9033 participants with nonmissing calcium and vitamin D intake data and follow-up were studied.

EXPOSURE

Total calcium intake (dairy, nondairy food, and supplements) and total vitamin D intake (milk, yogurt, and supplements) were recorded.

OUTCOME

The outcome variable was all-cause mortality.

RESULTS

There were 1160 deaths during the 10-year period. For women only, we found a possible benefit of higher total calcium intake, with a hazard ratio of 0.95 (95% confidence interval, 0.89-1.01) per 500-mg increase in daily calcium intake and no evidence of heterogeneity by source; use of calcium supplements was also associated with reduced mortality, with hazard ratio of 0.78 (95% confidence interval, 0.66-0.92) for users vs nonusers with statistically significant reductions remaining among those with doses up to 1000 mg/d. These associations were not modified by levels of concurrent vitamin D intake. No definitive associations were found among men.

CONCLUSIONS

Calcium supplements, up to 1000 mg/d, and increased dietary intake of calcium may be associated with reduced risk of mortality in women. We found no evidence of mortality benefit or harm associated with vitamin D intake.

The disconnect between better quality of glucocorticoid-induced osteoporosis preventive care and better outcomes: a population-based cohort study

OBJECTIVE

The quality of glucocorticoid-induced osteoporosis (GIOP) care [defined by bone mineral density (BMD) testing or osteoporosis treatment] is suboptimal and has been targeted for improvement. The assumption that improvements in GIOP preventive care will lead to better outcomes has not been tested.

METHODS

We used linked healthcare databases to conduct a population-based study of all adults 20 years of age or older in Manitoba, Canada, who initiated longterm (> 90 days) systemic glucocorticoids (GC) between 1998 and 2008. High-quality GIOP care was defined by BMD testing or prescription osteoporosis treatment within 6 months. Outcomes were adjusted odds of major fractures within 1 year and 3 years.

RESULTS

We studied 15,285 subjects who had just begun to take GC; 5804 (38%) were 70 years of age or older, 9185 (58%) were women, and 4755 (30%) received 10 mg or more prednisone equivalents daily. Overall, 3898 (25%) subjects received a BMD test or osteoporosis treatment within 6 months. Within 1 year of starting GC, there had been 206 major fractures (1%) and within 3 years, 553 major fractures (4%). High-quality GIOP preventive care was not associated with a reduced risk of major fractures within 1 year (adjusted OR 1.6, 95% CI 1.2-2.1) or within 3 years (adjusted OR 1.3, 95% CI 1.1-1.6).

CONCLUSION

Three-quarters of those initiating GC received suboptimal osteoporosis care. Conventional administrative database analyses could not demonstrate that better GIOP preventive care was associated with reductions in medically attended fractures. Clinically rich databases and different analytic techniques are needed to better evaluate the effectiveness of GIOP preventive care.

Direct healthcare costs for 5 years post-fracture in Canada: a long-term population-based assessment

High direct incremental healthcare costs post-fracture are seen in the first year, but total costs from a third-party healthcare payer perspective eventually fall below pre-fracture levels. We attribute this to higher mortality among fracture cases who are already the heaviest users of healthcare ("healthy survivor bias"). Economic analyses that do not account for the possibility of a long-term reduction in direct healthcare costs in the post-fracture population may systematically overestimate the total economic burden of fracture.

INTRODUCTION

High healthcare costs in the first 1-2 years after an osteoporotic fracture are well recognized, but long-term costs are uncertain. We evaluated incremental costs of non-traumatic fractures up to 5 years from a third-party healthcare payer perspective.

METHODS

A total of 16,198 incident fracture cases and 48,594 matched non-fracture controls were identified in the province of Manitoba, Canada (1997-2002). We calculated the difference in median direct healthcare costs for the year pre-fracture and 5 years post-fracture expressed in 2009 Canadian dollars with adjustment for expected age-related healthcare cost increases.

RESULTS

Incremental median costs for a hip fracture were highest in the first year ($25,306 in women, $21,396 in men), remaining above pre-fracture baseline to 5 years in women but falling below pre-fracture costs by 5 years in men. In those who survived 5 years following a hip fracture, incremental costs remained above pre-fracture costs at 5 years ($12,670 in women, $7,933 in men). Incremental costs were consistently increased for 5 years after spine fracture in women. Total incremental healthcare costs for all incident fractures combined showed a large increase over pre-fracture costs in the first year ($137 million in women, $57 million in men), but fell below pre-fracture costs within 3-4 years. Elevated total healthcare costs were seen at year 5 in women after wrist, humerus and spine fractures, but these were somewhat offset by decreases in total healthcare costs for other fractures.

CONCLUSIONS

High direct healthcare costs post-fracture are seen in the first year, but total costs eventually fall below pre-fracture levels. Among those who survive 5 years following a fracture, healthcare costs remain above pre-fracture levels.

An interdisciplinary knowledge translation intervention in long-term care: study protocol for the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial

BACKGROUND

Knowledge translation (KT) research in long-term care (LTC) is still in its early stages. This protocol describes the evaluation of a multifaceted, interdisciplinary KT intervention aimed at integrating evidence-based osteoporosis and fracture prevention strategies into LTC care processes.

METHODS AND DESIGN

The Vitamin D and Osteoporosis Study (ViDOS) is underway in 40 LTC homes (n = 19 intervention, n = 21 control) across Ontario, Canada. The primary objectives of this study are to assess the feasibility of delivering the KT intervention, and clinically, to increase the percent of LTC residents prescribed ≥800 IU of vitamin D daily. Eligibility criteria are LTC homes that are serviced by our partner pharmacy provider and have more than one prescribing physician. The target audience within each LTC home is the Professional Advisory Committee (PAC), an interdisciplinary team who meets quarterly. The key elements of the intervention are three interactive educational sessions led by an expert opinion leader, action planning using a quality improvement cycle, audit and feedback reports, nominated internal champions, and reminders/point-of-care tools. Control homes do not receive any intervention, however both intervention and control homes received educational materials as part of the Ontario Osteoporosis Strategy. Primary outcomes are feasibility measures (recruitment, retention, attendance at educational sessions, action plan items identified and initiated, internal champions identified, performance reports provided and reviewed), and vitamin D (≥800 IU/daily) prescribing at 6 and 12 months. Secondary outcomes include the proportion of residents prescribed calcium supplements and osteoporosis medications, and falls and fractures. Qualitative methods will examine the experience of the LTC team with the KT intervention. Homes are centrally randomized to intervention and control groups in blocks of variable size using a computer generated allocation sequence. Randomization is stratified by home size and profit/nonprofit status. Prescribing data retrieval and analysis are performed by blinded personnel.

DISCUSSION

Our study will contribute to an improved understanding of the feasibility and acceptability of a multifaceted intervention aimed at translating knowledge to LTC practitioners. Lessons learned from this study will be valuable in guiding future research and understanding the complexities of translating knowledge in LTC.