Prevalence and costs of osteoporotic patients with subsequent non-vertebral fractures in the US

The Relation Between Osteoporosis and Bone Fractures and Health-Related Quality of Life in Post-menopausal Saudi Women in the Jazan Region: A Cross-Sectional Study

INTRODUCTION

Osteoporosis is a significant health concern, often leading to fragility fractures and severely impacting the quality of life in post-menopausal women. Studies evaluating the effects of osteoporosis and resultant fractures on health-related quality of life (HRQoL) in Saudi women are lacking. This study aimed to assess the relationship between osteoporosis and fracture and physical, psychological, social, and environmental HRQoL domains in post-menopausal Saudi women.

METHODS

In this cross-sectional study conducted in Jazan, Saudi Arabia, 158 post-menopausal Saudi women completed HRQoL surveys using the validated Arabic WHOQOL-BREF questionnaire. Data on socioeconomics, comorbidities, and fracture history were gathered. Descriptive statistics delineated sample characteristics. Analysis of variance (ANOVA) and post-hoc tests identified differences in HRQoL across socioeconomic and clinical categories. Multivariate regression analyses determined factors independently related to HRQoL.

RESULTS

Of 158 women surveyed, 39% had a history of osteoporotic fracture. Foot (35%), hand (31%), and vertebral (10%) fractures were the most frequent. Women over 70 had significantly lower physical HRQoL than those aged 45-55 (p<0.001). Unemployed and lower-income women showed poorer HRQoL across domains (p<0.01). Vertebral and hand fractures were negatively related to physical and psychological health (p<0.05). Chronic diseases like hypertension and rheumatoid arthritis reduced HRQoL (p<0.01). In regression analyses, older age, vertebral fracture, physical inactivity, long-term hormone therapy, and unemployment emerged as determinants of poorer HRQoL (p<0.05).

CONCLUSION

Osteoporosis and resultant fragility fractures, especially in vertebral and hand bones, led to substantial impairments in physical, social, psychological, and environmental HRQoL in Saudi women. Modifiable risk factors like physical inactivity and long-term hormone use also affected HRQoL. Targeted screening and multidomain interventions for disadvantaged women with osteoporosis are warranted to improve functioning and quality of life.

The Association of nutritional status and physical activity on osteoporotic refractures among older adults

BACKGROUND

This paper focuses on revealing the relationship between the Geriatric Nutritional Risk Index (GNRI) and Activity of Daily Living (ADL) with osteoporotic refracture.

METHODS

Data from 1068 inpatients with osteoporotic fractures were analyzed. Binary logistic regression, Cox proportional hazard regression and Kaplan-Meier curves were performed for osteoporosis characteristics and its risk factors. Receiver operating characteristic (ROC) curve was developed to predict the cut-off value.

RESULTS

The study showed that older age, lower ADL and lower GNRI were independent risk factors for osteoporotic fracture with OR of 1.039, 0.946, 0.892 and HR of 1.033, 0.967, 0.947 respectively. According to the results of ROC, the predictive accuracy of GNRI was high with an area under ROC (AUC) of 0.715, sensitivity of 76.6%, specificity of 53.5% and a threshold value of 99.65.

CONCLUSION

Older age, lower ADL and lower GNRI were independent risk factors for osteoporotic refracture.

The imminent risk of a fracture-existing worldwide data: a systematic review and meta-analysis

The overall incidence of imminent fracture after a prior fragility fracture was 7.58% in the first year and 11.58% in the first 2 years. Approximately half of re-fractures occurred in the first 2 years after a fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly, with immediate care and a secondary fracture prevention to prevent the high imminent risk of a fracture.

INTRODUCTION

Imminent fractures refer to the fractures that occur within 2 years of an initial fracture. It is well known that the risk of a subsequent fracture is not constant with time and occurs shortly after the initial one. This systematic review and meta-analysis aimed to present the existing data on imminent fracture worldwide.

METHODS

Literature search was conducted in Pubmed, Embase, and Web of Science databases until 26 October 2021 for studies reporting the incidence of imminent osteoporotic fractures among people aged 50 years or older. The overall incidence of imminent fracture was pooled and subgroup analyses of index fracture sites and regions on incidence of imminent fracture were performed, with the 95% confidence interval (CI) being calculated. Percentage of imminent fracture occurring in follow-up period was calculated and pooled by meta-analysis. Hazard ratio (HR) was used to estimate the gender differences on the imminent risk of fracture.

RESULTS

A total of 1446 articles were identified. Nineteen observational studies were eligible for our systematic review, in which 18 were used for quantitative analysis. Pooled overall incidence of imminent fracture in the first year after an osteoporotic fracture was 7.58% (95% CI 5.84 to 9.31%) and cumulative incidence in the first 2 years was 11.58% (95% CI 8.94 to 14.21%). Subgroup analysis showed that in the first 2 years, the pooled incidence in Asia was 7.30% (95% CI 3.42 to 11.18%), whilst incidence in Europe/North America was 13.17% (95% CI 10.14 to 16.20%). In included studies with follow-up period of more than 5 years, pooled imminent fracture percentage in the first 2 years was 47.24% (95% CI 26.18 to 68.30%). Hazard ratio (HR) on gender showed that women had an overall slight increase in risk of imminent fractures (HR 1.18, 95% CI 1.11 to 1.25).

CONCLUSION

The incidence of imminent fracture is high globally at 11.58%. Approximately half of all refractures occur in the first 2 years after an index fragility fracture. Older patients that have suffered from a fragility fracture should be treated promptly. Also, immediate care and secondary fracture prevention are necessary to prevent the high imminent risk of a fracture, especially within the first 2 years.

The association of coffee consumption with the risk of osteoporosis and fractures: a systematic review and meta-analysis

To elucidate the association of coffee and bone health would help fracture risk reduction via dietary intervention. Although those who had higher coffee consumption were less likely to have osteoporosis, the associations between coffee consumption and fracture risk need further investigations with better study designs.

INTRODUCTION

The associations between coffee consumption and the risk of osteoporosis and fracture remain inconclusive. We aimed to better quantify these associations by conducting meta-analyses of observational studies.

METHODS

Relevant studies were systematically searched on PubMed, Web of Science, Cochrane library, and Embase Database up to November 25, 2021. The odds ratio (OR) or relative risk (RR) with 95% confidence intervals (CI) was pooled and a dose-response analysis was performed.

RESULTS

Four studies with 7114 participants for osteoporosis and thirteen studies with 391,956 participants for fracture incidence were included in the meta-analyses. High versus low coffee consumption was associated with a lower risk of osteoporosis [pooled OR (95% CI): 0.79 (0.65-0.92)], while it was non-significantly associated with fracture incidence [pooled OR (95% CI): 0.86 (0.67-1.05) at hip and 0.89 (0.42-1.36) at non-hip]. A non-linear association between the level of coffee consumption and hip fracture incidence was shown (P = 0.004). The pooled RR (95% CI) of hip fracture risk in those who consumed 1, 2-3, 4, and ≥ 9 cups of coffee per day was 0.92 (0.87-0.97), 0.89 (0.83-0.95), 0.91 (0.85-0.98), and 1.10 (0.76-1.59), respectively. The significance in the association between coffee consumption and the hip fracture incidence decreased in those studies that had larger sample size, higher quality, and more adjustments.

CONCLUSIONS

A dose-dependent relationship may exist between coffee consumption and hip fracture incidence. The effect of high versus low coffee consumption was influenced by study designs. Further studies with dedicated designs are needed to confirm the independent effects of coffee consumption on bone health.

Efficacy of the Combination of Teriparatide and Denosumab in the Treatment of Postmenopausal Osteoporosis: A Meta-Analysis

Aim: Evidence on the efficacy of combination treatment of teriparatide and denosumab for osteoporosis remains controversial. We aim to compare the efficacy between the combination treatment and monotherapy among patients with postmenopausal osteoporosis.

Methods and results: We systematically searched PubMed, EMBASE, the Cochrane Library, and Web of Science up to 26 January 2022, for relevant studies. This meta-analysis reviewed all randomized controlled trials (RCTs) that reported on the combination treatment of teriparatide and denosumab in patients with postmenopausal osteoporosis. The articles were examined individually by two reviewers, and the relevant data was extracted. We combined weighted mean difference (WMD) for bone mineral density (BMD) using random- or fixed- effect models and conducted subgroup analyses. Sensitivity analyses were performed, and possible publication bias was also assessed. Overall, combination treatment enhanced the mean percent change of bone mineral density in lumbar spine than monotherapy (WMD = 2.91, 95%CI: 1.983.83; p = 0.00). And, combination treatment has been beneficial for enhancing the mean percent change of BMD in hip (WMD = 3.19, 95%CI: 2.25∼4.13; p = 0.00). There was no significant difference between combination treatment and monotherapy in terms of the adverse events (RR = 0.81, 95%CI: 0.45∼1.45; p = 0.472).

Conclusion: The meta-analysis indicates that combination treatment led to greater BMD at the lumbar spine and hip in comparison to monotherapy, without an increased incidence of adverse events.

Systematic Review Registration: (https://inplasy.com/), identifier (Inplasy Protocol 2734).

Self-reported sleep characteristics and risk for incident vertebral and hip fracture in women

OBJECTIVE

To examine the relationships between self-reported sleep characteristics and risk of incident vertebral fracture and hip fracture in women.

DESIGN

Longitudinal cohort study.

SETTING

Nurses' Health Studies (NHS: 2002-2014, NHSII: 2001-2015).

PARTICIPANTS

Total 122,254 female registered nurses (46,129 NHS, 76,125 NHSII) without prior history of fracture.

EXPOSURE

Sleep was characterized by 4 sleep-related domains-sleep duration, sleep difficulty, snoring, and excessive daytime sleepiness-assessed by self-reported questionnaires.

OUTCOMES

Self-reports of vertebral fracture were confirmed by medical record review and hip fracture was assessed by biennial questionnaires.

RESULTS

Over 12-14 years of follow-up, 569 incident vertebral fracture cases (408 in NHS, 161 in NHSII) and 1,881 hip fracture cases (1,490 in NHS, 391 in NHSII) were documented. In the pooled analysis, the multivariable-adjusted HR (95% CI) for vertebral fracture was 1.20 (0.86, 1.66) for sleep duration ≤5 hours vs. 7 hours and 0.82 (0.60, 1.12) for ≥9 vs. 7 hours; 1.63 (0.93, 2.87) for sleep difficulties all-the-time vs. none/little-of-the-time (p-trend = 0.005); 1.47 (1.05, 2.05) for snoring every night/week vs. never/occasionally (p-trend = 0.03), and 2.20 (1.49, 3.25) for excessive daytime sleepiness daily vs. never (p-trend < 0.001). In contrast, associations were not observed with hip fracture risk.

CONCLUSION

Poorer sleep characteristics were associated with risk of vertebral fracture. Our study highlights the importance of multiple dimensions of sleep in the development of vertebral fractures. Further research is warranted to understand the role of sleep in bone health that may differ by fracture site, as well as sleep interventions that may reduce the risk of fracture.

A Structural Equation Modelling Approach to Determine Factors of Bone Mineral Density in Korean Women

BACKGROUND

no studies have assessed the associations of nutrient intake, physical activity, age, and body mass index (BMI) with bone mineral density (BMD) using structural equation modelling (SEM) in Korean women. The aim of this study was to examine the effects of nutrient intakes, physical activity, and body mass index (BMI) on BMD in Korean premenopausal and postmenopausal women, with the SEM approach, based on the fourth and fifth Korea National Health and Nutrition Examination Surveys (KNHANES) 2008-2011.

METHODS

SEM analysis was performed with 4160 women (2863 premenopausal women and 1297 postmenopausal women) aged 30-75 years in order to investigate total, direct, or mediating effects of nutrient intake, physical activity, age, and BMI on BMD. Model sensitivity to external misspecification and statistical significance of SEM was determined by phantom variables and bootstrapping. Reliability assessment of the SEM was done by Cronbach's alpha.

RESULTS

a direct effect of minerals (potassium, calcium, and phosphorus) on BMD (total femur, femoral neck, lumbar spine, and whole body) was observed in premenopausal and postmenopausal women (p = 0.045 and p = 0.048, respectively). Age and BMI showed a total effect on BMD in premenopausal and postmenopausal women (p = 0.002, respectively).

CONCLUSIONS

our study suggests that mineral intake (potassium, calcium, and phosphorus), age, and BMI are major contributors to BMD in Korean premenopausal and postmenopausal women aged 30-75 years.

Estimating the future clinical and economic benefits of improving osteoporosis diagnosis and treatment among women in Japan: a simulation projection model from 2020 to 2040

Impact of increased osteoporosis diagnosis and treatment among postmenopausal women (PMW) on reduction in fractures and associated costs in Japan from 2020 to 2040 was modeled.

INTRODUCTION

Japan is currently home to the world's oldest population and the 65 + years demographic is expected to grow to 35% by 2040. Thus, identifying strategies to reduce clinical and economic burden associated with osteoporosis among this at-risk population is critical.

METHODS

A microsimulation model was developed to project osteoporotic annual fracture incidence and costs among PMW 2020-2040. Fracture risk was estimated using a simplified Fracture Risk Assessment Tool (FRAX). Fracture estimates were based on annualized FRAX risk and treatment impact. Published literature informed inputs for direct and indirect fracture costs, DXA screening costs, and treatment costs and efficacy. Japan's current screening and treatment rates were compared against 50% increases to (1) case finding (screening rate and subsequent treatment rate) and (2) treatment rate among those at highest fracture risk.

RESULTS

From 2020 to 2040, 21.6 million fractures are projected costing US $410.2 billion. Increased case finding scenario resulted in the prevention of 456.9 thousand primary and 340.9 thousand second + fractures saving US $4.25 billion. Increased treatment scenario led to 500.5 thousand and 435.5 thousand fewer primary and second + fractures, respectively, and reduced economic burden by $3.1 billion.

CONCLUSION

Improvements to rates of osteoporosis screening and preventive treatment in Japan's aging population through disease awareness campaigns and post-fracture care programs, among others, will likely reduce osteoporosis-associated clinical and economic burden.

The clinical and economic burden after an osteoporosis fracture in France: a nationwide population-based study

Osteoporosis-related fragility fractures increase the risk of subsequent fractures and are associated with substantial morbidity and mortality. Emphasis should be placed on the prevention of recurrent fractures, which will decrease both the clinical burden on patients and the economic burden on the health system.

INTRODUCTION

Fragility fractures are associated with increased morbidity and mortality. Quantifying the clinical and economic burden of subsequent fractures following an initial osteoporosis-related fracture is a key to informing public health policies.

METHODS

A retrospective cohort study, using the national French health insurance claims database. Males and females ≥ 50 years, with a hospital discharge diagnosis of osteoporosis with fracture or a relevant fragility fracture (hip, vertebrae, femur, pelvis, wrist/hand, forearm, humerus/clavicle) between 2011 and 2014, were included and followed until death or end of 2016, whichever came first. Index fracture was the first qualifying hospitalization; subsequent fractures were defined as those occurring either at a different site from the index fracture or at the same site ≥ 90 days apart. Costs abstracted included hospitalization, external consultation, outpatient visits, and treatment.

RESULTS

A total of 544,426 participants (132,148 [24.3%] males and 412,278 [75.7%] females), of whom 16,110 (12.2%) males and 73,538 (17.8%) females had at least one subsequent fracture during follow-up, were included. Incidence of subsequent fracture was highest in the first year following index fracture. During follow-up, 161,179 patients died; mortality was highest among those with a hip fracture at index (29,971 (51.6%) males and 65,254 (39.6%) females). Total mean costs per patient in the year following index fracture were highest for males and females with a hip fracture (€18,585 and €15,754, respectively).

CONCLUSION

Subsequent fractures among osteoporotic participants with an initial fracture result in increased clinical mortality and high healthcare resource use. Emphasis should be placed on the prevention of recurrent fractures.

Estimating the future clinical and economic benefits of improving osteoporosis diagnosis and treatment among women in China: a simulation projection model from 2020 to 2040

Annual osteoporotic fractures is projected to increase by 135% from 6.9 M (2020) to 16.2 M (2040), increasing the economic burden by 121% from $29.9B (2020) to $65.9B (2040).

INTRODUCTION

Globally, aging populations drive significant increases in osteoporosis prevalence. In China, the number of women aged ≥ 65 years is expected to more than double from 2020 (91.5 M) to 2040 (183.6 M). Using a microsimulation model, impact of increased diagnosis and treatment of postmenopausal women (PMW) with osteoporosis on anticipated reduction in fractures and associated costs in China from 2020 to 2040 was projected.

METHODS

A microsimulation model was developed to project annual incidence and costs of osteoporotic fractures among PMW in China from 2020 to 2040. Fracture risk was estimated using the simplified Fracture Risk Assessment Tool (FRAX). Fractures estimates were based on annualized FRAX risk and impact of treatment. Published literature informed inputs for direct and indirect fracture costs, DXA screening costs, and treatment costs and efficacy. China's current screening and treatment rates were compared against 50% increases to (i) case finding (screening rate and subsequent treatment rate) and (ii) treatment rate among those at highest fracture risk.

RESULTS

From 2020 to 2040, 241.7 M osteoporotic fractures are projected to cost $997B. Increased treatment scenario prevented 24.6 M fractures and saved $56B. Increased case finding scenario prevented 26 M fractures and saved $61.7B.

CONCLUSION

Osteoporosis underdiagnosis and undertreatment among the aging Chinese population will considerably burden patients, caregivers, and society. Policy changes to increase screening and treatment rates may result in significant cost savings and clinical benefits.

Estimating the future clinical and economic benefits of improving osteoporosis diagnosis and treatment among women in South Korea: a simulation projection model from 2020 to 2040

Using a microsimulation model, the impact of increased diagnosis and treatment of postmenopausal women with osteoporosis on anticipated reduction in fractures and associated costs in South Korea from 2020 to 2040 was projected.

INTRODUCTION

The economic burden of osteoporosis was US $5.1B in 2011 in South Korea. Osteoporosis is expected to strain resources in South Korea as the population most susceptible to osteoporotic fracture, females > 50 years old, is projected to increase by 32% from 2020 to 2040.

METHODS

A microsimulation model was developed to project annual incidence and costs of osteoporotic fractures among postmenopausal women from 2020 to 2040. Fracture risk was estimated using the simplified Fracture Risk Assessment Tool (FRAX). The fracture estimates were based on annualized FRAX risk and impact of treatment. Korean National Health Insurance data informed treatment and case-finding rates in the reference case. Two scenarios were evaluated: 50% increases to (i) case finding (screening rate and subsequent treatment rate) and (ii) treatment rate among those at highest risk.

RESULTS

Among individuals modeled in the reference case from 2020 to 2040, 41.2 M fractures at a cost of US $263.6B were projected. Increased treatment scenario prevented 4.4 M fractures and saved US $13.5B. Increased case-finding scenario prevented 4.0 M fractures and saved US $11.1B.

CONCLUSION

Implementation of policies to enable increasing case finding or treatment may result in fewer fractures and substantial cost savings across the healthcare system. These results highlight the importance of early screening, diagnosis, and preventive treatment.

The effect of table olive wastewater extract administration on the adult ovariectomised rat model of osteoporosis

Recent efforts for alternative non-pharmaceutical treatments for postmenopausal osteoporosis are focused on nutritional measures. The aim of this study was to investigate the effect of table olive wastewater extract (OE) administration on bone mineral density (BMD) and biomechanical strength in ovariectomised rats. Thirty mature 9-month-old female Wistar rats were separated into three groups of ten: Control, Ovariectomised (OVX) and OVX + OE. BMD was measured before ovariectomy, 3 and 6 months afterwards. At the end of the study, blood, both femurs and tibias, internal organs and abdominal fat were collected. After 3 months, the percentage changes from baseline of the total and proximal tibial BMD of the OVX + OE group were both higher compared with the OVX group (P < 0·005). Similar results were found after 6 months, when the percentage changes from baseline of the total and proximal tibial BMD of the OVX + OE group were both higher compared with the OVX group (P < 0·005). Biomechanical testing of the femurs did not reveal any statistically significant difference between the groups. Body weights throughout the study, organs' and abdominal fat ratios to final body weight and blood results (alanine aminotransferase (ALT), gamma-glutamyltransferase (γ-GT), total cholesterol, HDL-cholesterol, LDL-cholesterol, Ca and P) were within normal limits and did not show any significant difference between the treated and untreated groups. As a conclusion, the administration of OE for 6 months protected tibial BMD loss in comparison with the untreated OVX group without causing adverse effects.

Economic burden of subsequent fracture in osteoporosis patients in South Korea

OBJECTIVES

This study aimed to assess the economic burden of subsequent fracture in osteoporosis patients with incident fracture.

METHODS

The authors conducted a retrospective cohort analysis of the South Korean national health insurance claims data. Study subjects included osteoporosis patients aged ≥50 with incident fracture (July 1, 2014-June 30, 2015). Fracture-related 1-year healthcare cost was evaluated after incident fracture for patients with and without subsequent fracture, defined as a fracture occurring within 2 years from incident fracture at a different site or at the same site after 6-months washout period. Per-patient-per-month (PPPM) cost was calculated by dividing each patient's cumulative healthcare cost until subsequent fracture with time-to-subsequent-fracture. For the patients without subsequent fracture, PPPM cost equaled 1-year monthly cost. A generalized linear model (GLM) was used to estimate the ratio of increase in healthcare cost to assess the economic impact of subsequent fracture.

RESULTS

A total of 73,717 osteoporosis patients with incident fracture were identified, consisting of 52.1% vertebral, 1.9% hip, and 46.0% non-vertebral-non-hip fractures. Subsequent fracture occurred in 17.9% of patients with average time-to-subsequent-fracture of 256 days. Patients with subsequent fracture had significantly higher 1-year healthcare cost after incident fracture than those without subsequent fracture ($4,307 vs $1,721) and the difference was greater in PPPM cost ($930 vs $141). GLM analysis showed that having subsequent fracture increased both 1-year healthcare cost and PPPM cost by 1.91-fold (95% CI = 1.87-1.95) and 6.14-fold (95% CI = 5.99-6.28), respectively.

CONCLUSIONS

Subsequent fracture imposes a substantial burden on osteoporosis patients and, therefore, more efforts are needed for preventing subsequent fracture among osteoporosis patients.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Obstructive Sleep Apnea and Risk for Incident Vertebral and Hip Fracture in Women

Recent studies suggest a positive association between obstructive sleep apnea (OSA), a disorder associated with intermittent hypoxia and sleep fragmentation, and derangements in bone metabolism. However, no prospective study to date has investigated the association between OSA and fracture risk in women. We conducted a prospective study examining the relation between OSA and risk of incident vertebral fracture (VF) and hip fracture (HF) in the Nurses' Health Study. History of physician-diagnosed OSA was assessed by self-reported questionnaires. A previous validation study demonstrated high concordance between self-reports and medical record identification of OSA. OSA severity was further categorized according to the presence or absence of self-reported sleepiness. Self-reports of VF were confirmed by medical record review. Self-reported HF was assessed by biennial questionnaires. Cox proportional-hazards models estimated the hazard ratio for fracture according to OSA status, adjusted for potential confounders, including BMI, physical activity, calcium intake, history of osteoporosis, and falls, and use of sleep medications. Among 55,264 women without prior history of fracture, physician-diagnosed OSA was self-reported in 1.3% in 2002 and increased to 3.3% by 2012. Between 2002 and 2014, 461 incident VF cases and 921 incident HF cases were documented. The multivariable-adjusted hazard ratio (HR) for confirmed VF for women with history of OSA was 2.00 (95% CI, 1.29-3.12) compared with no OSA history, with the strongest association observed for OSA with daytime sleepiness (HR 2.86; 95% CI, 1.31-6.21). No association was observed between OSA history and self-reported HF risk (HR 0.83; 95% CI, 0.49-1.43). History of OSA is independently associated with higher risk of confirmed VF but did not have a statistically significant association with self-reported HF in women. Further research is warranted in understanding the role of OSA and intermittent hypoxia in bone metabolism and health that may differ by fracture site. © 2020 American Society for Bone and Mineral Research (ASBMR).

The burden and undertreatment of fragility fractures among senior women

Using a large population database, we showed that fragility fractures were highly prevalent in senior women and were associated with significant physical disability. However, treatment rates were low because osteoporosis treatment was not prescribed or not agreed to by the majority of women with prevalent fragility fractures.

PURPOSE

The purpose of the study is to estimate prevalence of fragility fractures (FF), risk factors, and treatment rates in senior women and to assess impact of FF on physical function and quality of life.

METHODS

Women aged 65 years and older from the EpiReumaPt study (2011-2013) were evaluated. Rheumatologists collected data regarding FF, clinical risk factors for fractures, and osteoporosis (OP) treatment. Health-related quality of life (EQ5D) and physical function (HAQ) were analyzed. Peripheral dual-energy X-ray absorptiometry was performed. FF was defined as any self-reported low-impact fracture that occurred after 40 years of age. Prevalence estimates of FF were calculated.

RESULTS

Among 3877 subjects evaluated in EpiReumaPt, 884 were senior women. The estimated prevalence of FF was 20.7%. Lower leg was the most frequent fracture site reported (37.8%) followed by wrist (18.6%). Only 7.1% of the senior women reporting a prevalent FF were under treatment for OP, and 13.9% never had treatment. OP treatment was not prescribed in 47.7% of FF women, and 23.4% refused treatment. Age (OR = 2.46, 95% CI 1.11-5.47), obesity (OR = 2.05, 95% CI 1.14-3.70), and low wrist BMD (OR = 2.29; 95% CI 1.20, 4.35; p = 0.012) were positively associated with prevalent FF. A significantly higher proportion of women in the lowest quintile of wrist bone mineral density reported FF (OR = 2.29, 95% CI 1.20-4.35). FF were associated with greater physical disability (β = 0.33, 95% CI 0.13-0.51) independent of other comorbidities.

CONCLUSION

FF was frequently reported among senior women as an important cause of physical disability. However, the prevalence of OP treatment was low, which constitutes a public health problem in this vulnerable group.

Treatment costs and cost drivers among osteoporotic fracture patients in Japan: a retrospective database analysis

This study estimated the direct medical costs of osteoporotic fractures from a large claim database in Japan. We further identified several comorbidities which drove the treatment costs. The results would contribute to health economic analysis as well as understanding of individual financial burden in Japan.

INTRODUCTION

The purposes of this study were to estimate treatment costs of osteoporotic fractures and to investigate the cost drivers.

METHODS

Male and female patients aged 50 years and older with a hip, vertebral, or non-hip/non-vert (NHNV) fracture between April 2008 and December 2016 were analyzed from claim database. Two types of costs were estimated. The incremental yearly costs of fractures and comorbidity treatments (total medical costs) were calculated by subtracting pre-fracture costs from post-fracture costs. The costs exclusive for fracture treatments (fracture treatment costs) were estimated by summing up the costs of fracture treatments within 1 year after fracture. The associations between comorbidities and costs were examined with a generalized linear model.

RESULTS

Total 12,898 patients were identified (83% was female). The total medical costs of fractures were $14,592 for male-hip, $15,691 for female-hip, $4268 for male-vertebral, $3819 for female-vertebral, $3790 for male-NHNV, and $4259 for female-NHNV. The fracture treatment costs were $4506 for male-hip, $5427 for female-hip, $1022 for male-vertebral, $1044 for female-vertebral, $1035 for male-NHNV, and $1408 for female NHNV. Three comorbidities were associated with increasing fracture treatment costs whereas four comorbidities were associated with decreasing fracture treatment costs. Five comorbidities were associated with increasing total medical costs whereas one comorbidity was associated with decreasing total medical costs.

CONCLUSIONS

Yearly treatment costs were increased considerably after fracture. Several comorbidities were considered to be cost drivers for osteoporotic fracture treatment. The cost estimates with different patient profile would support conducting health economic analysis in the future.

Prevalence and Cost of Subsequent Fractures Among U.S. Patients with an Incident Fracture

BACKGROUND

The prevalence and cost of subsequent fractures among patients with an incident fracture are not well defined.

OBJECTIVE

To assess the prevalence of, and costs associated with, subsequent fractures in the year after an incident fracture.

METHODS

This was a retrospective claims database analysis using data from Humana Medicare Advantage claims (Medicare group) and Optum Insight Clinformatics Data Mart commercial claims (commercial group). Patients included in the study had a claim for a qualifying fracture occurring between January 2008 and December 2013 (index fracture), were continuously enrolled in the health plan for ≥ 1 year before and after the index fracture, and were aged ≥ 65 years in the Medicare group or ≥ 50 years in the commercial group at the time of the index fracture. Subsequent fractures were identified by ICD-9-CM codes and were defined as the second fracture occurring ≥ 3 to ≤ 12 months after the index fracture (≥ 6 to ≤ 12 months for fractures at the same site as the index fracture). Rates of subsequent fractures were calculated as the number of patients who had a subsequent fracture divided by the total sample size. After propensity matching of demographic and clinical variables, we determined the total medical and pharmacy costs accrued within 1 year of the index fracture by patients with and without a subsequent fracture. Health care costs were compared between patients with and without a subsequent fracture using McNemar's test.

RESULTS

A total of 45,603 patients were included in the Medicare group, and 54,145 patients were included in the commercial group. In the Medicare group, 7,604 (16.7%) patients experienced a subsequent fracture. The proportion of patients with a subsequent fracture was highest among patients with multiple index fractures (26.2%, n = 905), followed by those with hip (25.5%, n = 1,280) and vertebral (20.2%, n = 1,908) index fractures. In the commercial group, 6,256 (11.6%) patients experienced a subsequent fracture. The proportion of patients with a subsequent fracture paralleled those observed in the Medicare group: 24.5% (n = 808) in patients with multiple index fractures, 22.0% (n = 525) in those with hip fracture, and 14.5% (n = 841) in those with vertebral fracture. For vertebral, hip, and nonhip nonvertebral fractures, subsequent fractures were most frequently of the same type as the index fracture. The mean total health care cost (sum of medical and pharmacy costs) in the year following the incident fracture for the Medicare group was $27,844 and differed significantly between patients with and without a subsequent fracture ($34,897 vs. $20,790; P < 0.001). The mean total health care cost in the year following the incident fracture for the commercial group was $29,316 and also differed significantly between patients with and without a subsequent fracture ($39,501 vs. $19,131; P < 0.001).

CONCLUSIONS

Among patients with an incident fracture, those who experienced a subsequent fracture in the following year had significantly higher health care costs than those who did not. A subsequent fracture is most likely to be of the same type as the initial fracture.

DISCLOSURES

This study was funded by Merck & Co. Other than through the employer relationships disclosed here, Merck & Co did not have a role in the study design, data collection, interpretation of the data, in writing of the manuscript, or in the decision to submit the manuscript for publication. Weaver and Marvos are employees of Merck & Co. Sajjan was an employee of Merck & Co. and owned stock in the company at the time of the study. Lewiecki has received consulting and/or speaker honoraria from Merck, AbbVie, AgNovos Healthcare, Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Radius Health, Shire, and TheraNova. Lewiecki has received research grant support from Merck, Amgen, and Eli Lilly and Company and serves as a board member for the National Osteoporosis Foundation, the International Society for Clinical Densitometry, and the Osteoporosis Foundation of New Mexico. Harris has received consulting honoraria from Merck, Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Gilead Sciences, Primus Pharmaceuticals, and Radius Health. Study concept and design were contributed by Weave and Sajjan. Lewiecki collected the data, and data interpretation was performed by all the authors. The manuscript was written and revised by Weaver, Lewiecki, and Harris.

Cement Calcaneoplasty: An Innovative Method for Treating Nonunion in Calcaneal Insufficiency Fracture

Insufficiency type stress fractures are common in older patients with osteoporosis. Persistent pain after nonunion of these fractures can be disabling, with the management options often limited. We aimed to assess the suitability of fluoroscopic-guided injection of bone cement into a persistently symptomatic nonuniting calcaneal insufficiency fracture. To the best of our knowledge, this technique has not previously been described in the published data. After local subcutaneous anesthesia, the midpoint of the fracture site was accessed by trocar insertion under radiographic guidance, and bone cement was injected directly into the site. A preprocedure visual analog scale pain score of 90 of 100 was recorded. This had improved to 0 of 100 at the 12-month follow-up point after the procedure. The aim of the present case report was to raise awareness of percutaneous calcaneoplasty, which we believe to be a safe and well-tolerated technique for the management of osteoporotic insufficiency fracture of the calcaneus. We propose that this technique be considered when conservative methods aimed at promoting fracture healing have failed.

Characteristics of hip fracture patients with and without muscle atrophy/weakness: predictors of negative economic outcomes

OBJECTIVE

Hip fractures have negative humanistic and economic consequences. Predictors and sub-groups of negative post-fracture outcomes (high costs and extensive healthcare utilization) were identified in patients with and without muscle atrophy/weakness (MAW).

METHODS

Truven Health MarketScan data identified patients ≥50 years old with inpatient hospitalizations for hip fracture. Patients had ≥12 months of continuous healthcare insurance prior to and following index hospitalization and no hip fracture diagnoses between 7 days and 1 year prior to admission. Predictors and sub-groups of negative outcomes were identified via multiple logistic regression analyses and classification and regression tree (CART) analyses, respectively.

RESULTS

Post-fracture 1-year all-cause healthcare costs (USD$31,430) were higher than costs for the prior year ($18,091; p < 0.0001). Patients with MAW had greater post-fracture healthcare utilization and costs than those without MAW (p < 0.05). Greater post-fracture costs were associated with a higher number of prior hospitalizations and emergency room visits, length of index hospitalization, Charlson Comorbidity Index (CCI), and discharge status; diagnosis of rheumatoid arthritis, osteoarthritis, or osteoporosis; and prior use of antidepressants, anticonvulsants, muscle relaxants, benzodiazepines, opioids, and oral corticosteroids (all p < 0.009). High-cost patient sub-groups included those with MAW and high CCI scores.

CONCLUSIONS

Negative post-fracture outcomes were associated with MAW vs no MAW, prior hospitalizations, comorbidities, and medications.

The potential economic benefits of improved postfracture care: a cost-effectiveness analysis of a fracture liaison service in the US health-care system

Fractures related to osteoporosis are associated with $20 billion in cost in the United States, with the majority of cost born by federal health-care programs, such as Medicare and Medicaid. Despite the proven fracture reduction benefits of several osteoporosis treatments, less than one-quarter of patients older than 65 years of age who fracture receive such care. A postfracture liaison service (FLS) has been developed in many health systems but has not been widely implemented in the United States. We developed a Markov state-transition computer simulation model to assess the cost-effectiveness of an FLS using a health-care system perspective. Using the model, we projected the lifetime costs and benefits of FLS, with or without a bone mineral density test, in men and women who had experienced a hip fracture. We estimated the costs and benefits of an FLS, the probabilities of refracture while on osteoporosis treatment, as well as the utilities associated with various health states from published literature. We used multi-way sensitivity analyses to examine impact of uncertainty in input parameters on cost-effectiveness of FLS. The model estimates that an FLS would result in 153 fewer fractures (109 hip, 5 wrist, 21 spine, 17 other), 37.43 more quality-adjusted life years (QALYs), and save $66,879 compared with typical postfracture care per every 10,000 postfracture patients. Doubling the cost of the FLS resulted in an incremental cost-effectiveness ratio (ICER) of $22,993 per QALY. The sensitivity analyses showed that results were robust to plausible ranges of input parameters; assuming the least favorable values of each of the major input parameters results in an ICER of $112,877 per QALY. An FLS targeting patients post-hip fracture should result in cost savings and reduced fractures under most scenarios.

Indirect costs account for half of the total costs of an osteoporotic fracture: a prospective evaluation

Data on direct and indirect costs of clinical fractures in 116 osteoporotic patients 50 years and older were prospectively collected using cost diaries. Indirect costs accounted for roughly half of the total costs, with a contribution of at least 81% of these costs in employed patients.

INTRODUCTION

The aim of this prospective study was to gain insight into the current total costs of clinical fractures in osteoporotic patients aged 50 years and older.

METHODS

In a study in the Netherlands, patients prospectively filled out cost diaries every 3 months, during 1 year after a clinical fracture. Primary analyses were performed on those patients with all four cost diaries returned. In-depth analyses of indirect costs were performed, dividing results for employed and unemployed patients. Sensitivity analyses using imputation techniques were performed on patients who returned two or three diaries

RESULTS

Of the 116 included patients, 69 completed all four diaries, 24 only two or three, and 23 patient completed one or no diaries. For all fractures, approximately 50% of the total costs were due to indirect costs; employed patients contributed for at least 81% of the indirect cost. Humerus fractures were most expensive with a total 1-year cost of €16.841 per patient. Indirect costs in the group with clinical spine fractures were highest (<euro>12.522), accounting for 89.1% of the total costs for this fracture.

CONCLUSION

Indirect costs account for roughly half of the total costs of clinical fractures, which are largely related to sick leave. When performing cost analyses in fracture patients, we advise a societal perspective in which indirect costs are also considered, and to apply a patient derived prospective data collection method to get a 'true' and complete image of the total costs due to clinical fractures.

Public health impact of osteoporosis

OBJECTIVE

To describe the public health impact of osteoporosis including the magnitude of the problem and important consequences of osteoporotic fractures.

METHODS

Literature review of key references selected by author.

RESULTS

Current demographic trends leading to an increased number of individuals surviving past age 65 will result in an increased number of osteoporotic fractures. Important consequences of osteoporotic fractures include an increased mortality that for hip fractures extends to 10 years after the fracture. Increased mortality risk also extends to major and minor fractures, especially, in those over 75 years. Hip and vertebral fractures have important functional consequences and reductions in quality of life. The economic impact of osteoporotic fractures is large and growing. Significant health care resources are required for all fractures.

CONCLUSIONS

To alleviate the public and private burden of osteoporosis related fractures, assessment of risk and reduction of individual risk is critical.

Awareness of osteoporosis and its relationship with calcaneus quantitative ultrasound in a large Chinese community population

Background

The People’s Republic of China has the largest population affected by osteoporosis in the world. However, no population-based survey of osteoporosis awareness in People’s Republic of China has been reported. This study investigated the level of basic awareness of osteoporosis in a large community in People’s Republic of China. The relationship between level of awareness and quantitative ultrasound (US) measurements at the calcaneus was also assessed.

Methods

A questionnaire was completed by 9983 men and women aged 40 years or older in Nanjing, People’s Republic of China, between June and December 2011. During this time, the study participants underwent quantitative US measurement. Data from 9049 of the subjects were included in the final analysis.

Results

The proportion of subjects who were aware of osteoporosis was very low. Only 30.7% had heard of osteoporosis, and only 18.5% had heard of osteoporotic fracture. In total, 52.9% of the subjects drank milk, 16.0% took calcium, 7.1% took vitamin D, and 47.2% were performing regular physical activity. Logistic regression showed that more highly educated older women had significantly better awareness of osteoporosis (P < 0.05). Subjects with a history of a previous osteoporotic fracture also had better awareness (P < 0.05) than subjects without such a history, except for those who drank milk. Similar to previous reports, female sex, old age, a low education level, and a personal history of osteoporotic fracture were significantly associated with a low quantitative US measurement (P < 0.001). Further, drinking milk and having not heard of osteoporosis were significantly associated with a higher quantitative US measurement (P < 0.05), while other indicators of osteoporosis awareness were not associated with quantitative US values (P > 0.05).

Conclusion

Awareness of osteoporosis in People’s Republic of China is very low. National awareness strategies should be implemented, especially for poorly educated young men.

Incidence of subsequent hip fractures is significantly increased within the first month after distal radius fracture in patients older than 60 years

BACKGROUND

Distal radius fracture is recognized as an osteoporosis-related fracture in aged population. If another osteoporosis-related fracture occurs in a short period, it represents a prolonged hospitalization and a considerable economic burden to the society.We evaluated the relationship between distal radius fracture and subsequent hip fracture within 1 year, especially in the critical time and age.

METHODS

We identified newly diagnosed distal radius fracture patients in 2000 to 2006 as an exposed cohort (N = 9,986). A comparison cohort (N = 81,227) was randomly selected from patients without distal radius fracture in the same year of exposed cohort. The subjects were followed up for 1 year since the recruited date.We compared the sociodemographic factors between two cohorts.Furthermore, the time interval following the previous distal radial fracture and the incidence of subsequent hip fracture was studied in detail.

RESULTS

The incidence of hip fracture within 1 year increased with age in both cohorts. The risk was 5.67 times (84.6 vs. 14.9 per 10,000 person-years) greater in the distal radial fracture cohort than in the comparison cohort. The multivariate Cox proportional hazard regression analyses showed the hazard ratios of hip fracture in relation to distal radial fracture was 3.45 (95% confidence interval = 2.59-4.61). The highest incidence was within the first month after distal radial fracture, 17-fold higher than the comparison cohort (17.9 vs. 1.05 per 10,000). Among comorbidities, age 9 60 years was also a significant factor associated with hip fracture (hazard ratio = 8.67, 95% confidence interval = 4.51-16.7).

CONCLUSIONS

Patients with distal radius fracture and age 960 years will significantly increase the incidence of subsequent hip fracture, especially within the first month.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level II.

A population-based study examining calcaneus quantitative ultrasound and its optimal cut-points to discriminate osteoporotic fractures among 9352 Chinese women and men

CONTEXT

No generally accepted thresholds for quantitative ultrasound (QUS) parameters to screen individuals at high risk of osteoporotic fractures have been defined.

OBJECTIVE

We sought to define appropriate cutoff points for osteoporotic fractures of calcaneus ultrasound according to participants' prevalent osteoporotic fractures.

DESIGN AND SETTING

This was a cross-sectional, population-based study conducted in Shanghai, China.

PARTICIPANTS

A total of 9352 Chinese women and men aged 40 and older were studied.

MAIN OUTCOME MEASURES

We measured calcaneus QUS (Achilles Express, GE Lunar) values and their relationships with osteoporotic fractures.

RESULTS

A prevalence of 14.9 and 12.2% of osteoporotic fractures was found in the women and men (P<0.001), respectively. Subjects with osteoporotic fractures had significantly lower QUS values than those without (P<0.001). One sd decline in the stiffness index (SI)-derived T-score was associated with a high risk of nonvertebral fracture [odds ratio (OR)=1.50; 95% confidence interval (CI), 1.39-1.62; P<0.001], clinical vertebral fracture (OR=1.49; 95% CI, 1.18-1.90; P<0.01), and multi-fractures (OR=1.98; 95% CI, 1.63-2.40; P<0.001). The receiver operating characteristic analysis showed that QUS could differentiate osteoporotic fractures in postmenopausal women and men, but not in premenopausal women. The optimal cutoff points for the SI-derived T-score to detect a high risk of nonvertebral fractures, clinical vertebral fractures, and multi-fractures were -1.25, -1.55, and -1.80 in postmenopausal women, respectively, and -1.30, -1.90, and -2.00 in males, respectively.

CONCLUSIONS

As a screening tool, the SI-derived T-score obtained from the Achilles QUS device for a postmenopausal woman or man that is less than -1.25 and -1.30, respectively, may indicate an increased risk of osteoporotic fractures and should be further evaluated by central DXA.