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Wang M, Seibel MJ. Secondary fracture prevention in primary care: a narrative review. Osteoporos Int 2024; 35:1359-1376. [PMID: 38652313 PMCID: PMC11281980 DOI: 10.1007/s00198-024-07036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/28/2024] [Indexed: 04/25/2024]
Abstract
The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.
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Affiliation(s)
- Mawson Wang
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia.
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia.
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia
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2
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Wang M, Seibel MJ. Approach to the Patient With Bone Fracture: Making the First Fracture the Last. J Clin Endocrinol Metab 2023; 108:3345-3352. [PMID: 37290052 PMCID: PMC10655538 DOI: 10.1210/clinem/dgad345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023]
Abstract
The global burden of osteoporosis and osteoporotic fractures will increase significantly as we enter a rapidly aging population. Osteoporotic fractures lead to increased morbidity, mortality, and risk of subsequent fractures if left untreated. However, studies have shown that the majority of patients who suffer an osteoporotic fracture are not investigated or treated for osteoporosis, leading to an inexcusable "osteoporosis care gap." Systematic and coordinated models of care in secondary fracture prevention known as fracture liaison services (FLS) have been established to streamline and improve the care of patients with osteoporotic fractures, and employ core principles of identification, investigation, and initiation of treatment. Our approach to the multifaceted care of secondary fracture prevention at a hospital-based FLS is illustrated through several case vignettes.
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Affiliation(s)
- Mawson Wang
- The University of Sydney, Bone Research Program, ANZAC Research Institute, Concord, NSW 2139, Australia
| | - Markus J Seibel
- The University of Sydney, Bone Research Program, ANZAC Research Institute, Concord, NSW 2139, Australia
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Li Q, Yang J, Tang Q, Feng Y, Pan M, Che M, Shi J, Zeng Y. Age-dependent gender differences in the diagnosis and treatment of osteoporosis during hospitalization in patients with fragility fractures. BMC Geriatr 2023; 23:728. [PMID: 37946131 PMCID: PMC10636910 DOI: 10.1186/s12877-023-04430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND There is a gender difference in the acceptance of osteoporosis diagnosis and treatment in patients after fragility fractures, but this difference is rarely assessed during hospitalization, and it is unclear whether these differences are age-dependent. This study aimed to evaluate the differences between male and female fragility fracture patients of different age groups who received the diagnosis and treatment of osteoporosis during hospitalization. METHODS 31,265 fragility fracture patients aged ≥ 50 years from the Fragility Fracture Management Database in a high-volume orthopedic hospital from December 2019 to February 2023 were included in this study. We compared the differences in the rates of men and women with fragility fracture who received the measurement of bone mineral density (BMD) and bone metabolism biochemical markers (BMBMs) and treatment with anti-osteoporosis medications (AOMs), and follow-up to the internal medicine clinic within 3 months after discharge, across all age groups and across different age stages (50-59, 60-69, 70-79, and ≥ 80 years). RESULTS The detection rates of female patients receiving BMD and BMBMs during hospitalization were 31.88% and 5.30%, respectively, compared with 22.23% and 2.69% for men. The rate of receiving any AOMs treatment was 44.63% for women and 31.60% for men. The follow-up rate of returning to the internal medicine clinic within 3 months after discharge was 9.79% for women compared to 3.00% for men. There was a significant difference between males compared to females (P < 0.0001). Analysis of patients by different age group revealed that differences in the diagnosis and treatment of osteoporosis were found only in patients under 80 years of age, while gender differences in the return to the internal medicine clinic for follow-up after discharge were present in all age groups. CONCLUSIONS Gender differences present in osteoporosis management in patients with fragility fracture during hospitalization, especially for patients under 80 years of age. This finding suggests that orthopedic surgeons neglect to manage osteoporosis in male patients with fragility fracture during hospitalization.
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Affiliation(s)
- Qingmei Li
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Jiancheng Yang
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Qinghua Tang
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Yan Feng
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Mingming Pan
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Maohong Che
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Jie Shi
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China
| | - Yuhong Zeng
- Department of Osteoporosis, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, NanShaomen, Beilin District, Xi'an, 710054, China.
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Aypak C, Bircan MA, Özdemir A. Anti-osteoporotic Drug Utilization Rates for Secondary Prevention Among Patients with Osteoporotic Fractures. Rambam Maimonides Med J 2022; 13:RMMJ.10473. [PMID: 35701156 PMCID: PMC9345764 DOI: 10.5041/rmmj.10473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Anti-osteoporotic drugs (AOD) are essential for secondary prevention of osteoporotic fracture (OF) in patients with established osteoporosis. However, data about AOD utilization rates are scarce among patients with OF. This study was therefore aimed at determining the AOD utilization rates among those particularly vulnerable patients. MATERIALS AND METHODS This cross-sectional study followed the medical records of patients with OF starting from their first OF diagnosis date. Each patient's preventive osteoporosis treatments (vitamin D, calcium+vitamin D) and AOD utilization rate were recorded for a 12-month period following OF diagnosis. RESULTS A total of 210 patients (168 females, mean age: 67.8±11.9 years; 42 males, mean age 62.4±16.1 years) were enrolled in the study. Of these, 65.7% (n=138) did not use any medication for primary protection against osteoporosis before OF diagnosis. The ratio of patients not using any type of medication for secondary prevention after OF increased from 26.5% to 51% during a 12-month period. In addition, by one year following diagnosis, AOD usage rate had decreased from 62.3% to 41.3%. CONCLUSION The AOD usage rates for secondary prevention of OF were insufficient, and cessation rates were high. Identification of factors associated with decreased AOD utility rates will provide important information for guiding patient follow-up in order to reduce the occurrence of OF.
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Affiliation(s)
- Cenk Aypak
- To whom correspondence should be addressed. E-mail:
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Galli S, Weiss D, Beck A, Scerpella T. Osteoporosis Care Gap After Hip Fracture - Worse With Low Healthcare Access and Quality. J Clin Densitom 2022; 25:424-431. [PMID: 34696980 DOI: 10.1016/j.jocd.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Despite the burden of osteoporosis-related fractures and availability of effective treatment, a substantial osteoporosis care gap persists. We evaluated this gap following fragility hip fracture, testing the hypothesis that patients who live in areas with low health care access or quality are less likely to undergo evaluation or treatment following hip fragility fracture. This retrospective analysis quantified osteoporosis evaluation and treatment just prior and for 12 mo following fragility hip fracture at an academic medical center in the upper Midwest. Initiation of pharmacologic therapy, Vitamin D screening and dual energy X-ray absorptiometry (DXA) scanning were measured. Each patient was assigned a value for 3 metrics of regional healthcare access and quality: (1) population per PCP ratio, (2) percent un-insured <65 yrs old, and (3) preventable hospitalization >65 yrs old. Generalized estimating equations, with county as a random effect, were used to assess the association of patient characteristics and/or heath care metrics with osteoporosis treatment at the time of admission and/or osteoporosis evaluation and treatment during hospitalization and post-discharge. A total of 585 patients were 80.7 ± 8.4 yrs of age at the time of hip fragility fracture; 68% were women. In 12 mo post-fracture, 17% underwent vitamin D screening, 12% received a DXA scan and 17% began a new bone anti-resorptive medication. Only in-hospital Vitamin D screening was more common in patients from counties with low healthcare access; all other pre- and post-fracture care was more common for patients with greater healthcare access and quality. Overall rates of initiating pharmacologic treatment and/or obtaining a Vitamin D screen or DXA scan following hip fragility fracture were very low and were worse in patients from counties with low access and quality of healthcare. These results remind the practitioner to diagnose and treat osteoporosis following hip fracture and suggests a role for targeting high-risk groups.
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Affiliation(s)
- Sara Galli
- Department of Orthopedic Surgery, Ochsner Medical Center, LA, USA
| | - Deena Weiss
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL
| | - Aaron Beck
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tamara Scerpella
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Liu BM, Vogler CM, Hilmer SN, Chang KP. Uptake of osteoporosis treatment recommended by an orthogeriatrics service after hip fracture: Retrospective cohort study of prevalence and potential barriers and enablers at a tertiary referral hospital in Sydney. Australas J Ageing 2022; 41:e196-e200. [PMID: 35165985 DOI: 10.1111/ajag.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The primary aim was to determine the 12-month period prevalence of and time to osteoporosis treatment following minimal trauma hip fractures in patients who were recommended treatment by an orthogeriatrics service. The secondary aim was to determine the factors associated with receiving treatment including the impact of osteoporosis clinic follow-up. METHODS A retrospective cohort study of patients with minimal trauma hip fractures admitted at a tertiary hospital in Sydney between 1 April 2017 and 31 March 2019 was performed. Baseline characteristics were collected from medical records. Osteoporosis treatment data were collected from patients and general practitioners. Univariate and multivariate logistic regression analyses were used to determine the factors associated with receiving osteoporosis treatment. RESULTS There were 189 participants who consented to participate with a mean age of 84.6 years. Most (76.7%) were females, 18.5% were nursing home residents, 70.9% had normal cognition, 20.6% were taking osteoporosis treatment prior to admission, 61.9% had osteoporosis treatment recommendations documented on the discharge summary, and 10.1% were followed up in the osteoporosis clinic. Ninety-eight patients (51.9%) received treatment within the first 12 months after fracture with a median time to treatment of 90 days. Factors associated with receiving osteoporosis treatment within 12 months on multivariate analysis included normal cognition (p = 0.03), taking osteoporosis treatment prior to admission (p < 0.001), including treatment recommendations in the discharge summary (p = 0.006) and osteoporosis clinic follow-up (p < 0.001). CONCLUSIONS Osteoporosis treatment after hip fracture remains suboptimal at this hospital. Patient and health service factors associated with treatment uptake could inform future quality improvement work.
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Affiliation(s)
- Bonnie Mengyuan Liu
- Geriatrics Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Constance Michelle Vogler
- Geriatrics Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Nicole Hilmer
- Geriatrics Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Philip Chang
- Geriatrics Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Zhuang H, Lin S, Li Y, Cai S, Wang P, Yu H, Lin J, Yao X, Xu H. Educational program for orthopedic surgeons' influences for osteoporosis. Open Med (Wars) 2021; 16:1438-1443. [PMID: 34676303 PMCID: PMC8483061 DOI: 10.1515/med-2021-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/29/2021] [Accepted: 08/27/2021] [Indexed: 12/02/2022] Open
Abstract
Background In this retrospective study, we studied the impact of educational osteoporosis program on the rates of bone mineral density (BMD) assessment and bone turnover markers (BTM) and drug medications in the patients with hip fracture. Methods This retrospective research enrolled 651 patients aged ≥50 years who experienced hip fractures from January 2013 to December 2015. We recorded whether patients had received BMD assessment, BTM measurement, and anti-osteoporosis therapy during the period of hospitalization. Orthopedic surgeons were classified into the trained group and the untrained group. The rates of BMD assessment, BTM measurement, and anti-osteoporosis medications in the patients with hip fracture were compared between the trained group and the untrained group. Results BMD assessment was performed in 109/220 patients in the trained group and 142/431 patients in the untrained group. BTM measurements were performed in 130 patients in the trained group and 124 patients in the untrained group. Forty eight patients in the trained group and 63 patients in the untrained group received bisphosphonate medications. Conclusions Although the rates of BMD assessment, BTM measurement, and bisphosphonate use in the patients after hip fractures are still insufficient, education programs help to improve the situation.
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Affiliation(s)
- Huafeng Zhuang
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Shufeng Lin
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Yizhong Li
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Siqing Cai
- Department of Radiology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian 362000, China
| | - Peiwen Wang
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Haiming Yu
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Jinkuang Lin
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Xuedong Yao
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
| | - Hao Xu
- Department of Orthopedics, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian 362000, China
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8
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Osteoporosis treatment rates after hip fracture 2011-2019 in Hawaii: Undertreatment of men after hip fractures. Osteoporos Sarcopenia 2021; 7:103-109. [PMID: 34632113 PMCID: PMC8486619 DOI: 10.1016/j.afos.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/22/2022] Open
Abstract
Objectives To investigate trends of osteoporosis treatment rates, and factors affecting osteoporosis treatment after hip fracture admission within a single health care system in Hawaii. Methods A retrospective chart review was conducted of patients aged 50 years or older and hospitalized for hip fractures between January 1, 2011 and December 31, 2019 at Hawaii Pacific Health, a large health care system in Hawaii. We collected data on basic demographics and osteoporosis medication prescription from electronic medical records. We evaluated trends of osteoporosis treatment rates and performed logistic regression to determine factors associated with osteoporosis treatment. Results The mean for treatment rates for osteoporosis from 2011 to 2019 was 17.2% (range 8.8%–26.0%). From 2011 to 2019 there was a small increase in treatment rates from 16.3% in 2011 to 24.1% in 2019. Men were less likely to receive osteoporosis treatment after admission for hip fracture. Patients discharged to a facility were more likely to receive osteoporosis treatment. As compared to women, men who had a hip fracture were less likely to receive dual-energy X-ray absorptiometry scan, and osteoporosis medication before hip fracture admission. Conclusions The use of osteoporosis medication for secondary prevention after admission for hip fracture in Hawaii from 2011 to 2019 was low. However, there was a small increase in treatment rates from 2011 to 2019. Disparities in treatment of osteoporosis after hip fracture were noted in men. Significant work is needed to increase treatment rates further, and to address the disparity in osteoporosis treatment between men and women.
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Skjødt MK, Ernst MT, Khalid S, Libanati C, Cooper C, Delmestri A, Rubin KH, Javaid MK, Martinez-Laguna D, Toth E, Prieto-Alhambra D, Abrahamsen B. The treatment gap after major osteoporotic fractures in Denmark 2005-2014: a combined analysis including both prescription-based and hospital-administered anti-osteoporosis medications. Osteoporos Int 2021; 32:1961-1971. [PMID: 33721032 PMCID: PMC8510950 DOI: 10.1007/s00198-021-05890-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/11/2021] [Indexed: 12/11/2022]
Abstract
UNLABELLED This study demonstrates a substantial and persistent anti-osteoporosis treatment gap in men and women ≥50 years old who sustained major osteoporotic fracture(s) between 2005 and 2014 in Denmark. This was not substantially reduced by including hospital-administered anti-osteoporosis treatments. Strengthened post-fracture organization of care and secondary fracture prevention is highly needed. INTRODUCTION The purpose of this study was to evaluate the Danish anti-osteoporosis treatment gap from 2005 to 2014 in patients sustaining a major osteoporotic fracture (MOF), and to assess the impact of including hospital-administered anti-osteoporosis medications (AOM) on the treatment gap among these patients. METHODS In this retrospective, registry-based study, we included men and women aged 50 years or older and living in Denmark, who sustained at least one MOF between 2005 and 2014. We applied a repeated cross-sectional design to generate cohorts of patients sustaining a first MOF, hip, vertebral, humerus, or forearm fracture, respectively, within each calendar year. We evaluated the treatment gap as the proportion of patients within each cohort not receiving treatment with AOM within 1 year of the fracture. Hospital-administered AOM was identified by SKS code. RESULTS The treatment gap among MOF patients decreased from 85% in 2005 to 79% in 2014. The gap was smaller among hip and vertebral fracture patients as compared to humerus and forearm fracture patients, and it was smaller in women than in men. The use of hospital-administered AOM was relatively uncommon, with a maximum of 0.9% of MOF patients initiating hospital-administered AOM (in 2012). We observed substantial variations in this proportion between fracture types and gender. Hospital-administered AOM was most commonly used among vertebral fracture patients. CONCLUSION A significant treatment gap among patients sustaining a major osteoporotic fracture was present throughout our analysis, and including hospital-administered AOM did not significantly improve the treatment gap assessment. Improved secondary fracture prevention is urgently needed.
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Affiliation(s)
- M K Skjødt
- Department of Medicine, Hospital of Holbaek, Smedelundsgade 60, DK-4300, Holbaek, Denmark.
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark.
| | - M T Ernst
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - S Khalid
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
| | | | - C Cooper
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, England, UK
| | - A Delmestri
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
| | - K H Rubin
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - M K Javaid
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
| | - D Martinez-Laguna
- GREMPAL Research Group, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), CIBERFES, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain
| | - E Toth
- UCB Pharma, Anderlecht, Belgium
| | - D Prieto-Alhambra
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
| | - B Abrahamsen
- Department of Medicine, Hospital of Holbaek, Smedelundsgade 60, DK-4300, Holbaek, Denmark
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
- NDORMS, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, England, UK
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10
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Implementing a fracture follow-up liaison service: perspective of key stakeholders. Rheumatol Int 2019; 40:607-614. [PMID: 31501995 DOI: 10.1007/s00296-019-04413-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
Fracture liaison services (FLS) have been shown to prevent efficiently subsequent fragility fractures (FF). However, very few studies have examined their implementation in depth. The purpose of this research was to identify factors influencing the implementation of a FLS at three sites in Quebec, Canada. From 2013 to 2015, individual and group interviews focused on experiences of FLS stakeholders, including implementation committee members, coordinators, and orthopaedic surgeons and their teams. Emerging key implementation factors were triangulated with the FLS patients' clinico-administrative data. The Consolidated Framework for Implementation Research guided the analysis of perceived factors influencing four intervention outputs: investigation of FF risk (using the FRAX score), communication with the participant primary care provider, initiation of anti-osteoporosis medications (when relevant), and referral to organized fall prevention activities (either governmental or community based). Among the 454 FLS patients recruited to the intervention group, 83% were investigated for FF risk, communication with the primary care provider was established for 98% of the participants, 54% initiated medication, and 35% were referred to organized fall prevention activities. Challenges related to restricted rights to prescribe medication and access to organized fall prevention activities were reported. FLS coordinator characteristics to overcome those challenges included self-efficacy beliefs, knowledge of community resources, and professional background. This study highlighted the importance of enabling access to services for subsequent FF prevention, consolidating the coordinator's role to facilitate a more integrated intervention, and involving local leaders to promote the successful implementation of the FLS.
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11
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Narla RR, Hirano LA, Lo SHY, Anawalt BD, Phelan EA, Matsumoto AM. Suboptimal osteoporosis evaluation and treatment in older men with and without additional high-risk factors for fractures. J Investig Med 2019; 67:743-749. [PMID: 30723121 DOI: 10.1136/jim-2018-000907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2018] [Indexed: 01/05/2023]
Abstract
We compared osteoporosis case-finding, evaluation and treatment in groups of Older Men and Older Women with age alone as a significant risk for fracture and Older Men with Higher Risk (older men additionally having previous hip fracture, corticosteroid use or androgen deprivation therapy). We studied 13,704 older men and women (≥70 years old) receiving care at a Veterans Affairs medical center from January 2000 to August 2010 whose 10-year hip fracture risk was assessed by limited FRAX score. The main outcome measures were the proportion of patients who had bone mineral density (by dual-energy X-ray absorptiometry [DXA]) and serum 25-hydroxy vitamin D (25-OH D) measurements performed, and calcium/vitamin D or bisphosphonates prescribed. The proportion of men with a 10-year hip fracture risk ≥3% with age alone as a risk was 48% and 88% in men aged 75-79 and ≥80 years, respectively. Compared with Older Women, fewer Older Men underwent DXA (12% vs 63%, respectively) and 25-OH D measurements (18% vs 39%), and fewer received calcium/vitamin D (20% vs 63%) and bisphosphonate (5% vs 44%) prescriptions. In Older Men with Higher Risk category, the proportion of men with 10-year hip fracture risk ≥3% ranged from 69% to 95%. Despite a higher risk and expectation that this group would have greater case detection and screening, few Older Men with Higher risk underwent DXA screening (27%-36%) and 25-OH D measurements (23%-28%), and received fewer calcium/vitamin D (40%-50%) and bisphosphonate (13%-24%) prescriptions. Considering the known morbidity and mortality, our findings underscore the need for improved evaluation and management of osteoporosis in older men at high risk for fracture.
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Affiliation(s)
- Radhika Rao Narla
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington, USA.,Division of Endocrinology, Metabolism and Nutrition, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Lianne A Hirano
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Serena H Y Lo
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Bradley D Anawalt
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth A Phelan
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Alvin M Matsumoto
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Mo J, Huang K, Wang X, Sheng X, Wang Q, Fang X, Fan S. The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures. J Bone Joint Surg Am 2018; 100:e153. [PMID: 30562300 DOI: 10.2106/jbjs.17.01297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention. METHODS A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention. RESULTS Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model. CONCLUSIONS In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.
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Affiliation(s)
- Jian Mo
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China.,Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Kangmao Huang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xumeng Wang
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xinyu Sheng
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Qiang Wang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xiangqian Fang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Shunwu Fan
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
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Park YG, Nam KW, Kim SR, Park MS, Kim SJ, Ha YC. Improvement of Osteoporosis Medication after Multimodal Intervention in Patients with Hip Fracture: Prospective Multicenter Study. J Bone Metab 2018; 25:107-113. [PMID: 29900160 PMCID: PMC5995761 DOI: 10.11005/jbm.2018.25.2.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 01/22/2023] Open
Abstract
Background The authors had earlier conducted a retrospective cohort study from 2008 to 2011 in Jeju Island, among 945 hip fracture patients above 50 years of age. Of these 945 patients, 344 patients (36.4%) underwent a bone mineral density test and 218 patients (23.1%) received treatment for osteoporosis. The purpose of this study was to determine whether a patient education program could improve osteoporosis management after hip fracture. The data of the previous study was used for comparison. Methods From November 1, 2014 to September 30, 2015, 190 patients above 50 years of age who were admitted for hip fractures at six different hospitals, were enrolled in the present study. During the hospitalization period, patients underwent education sessions and were provided brochures. Patients were evaluated for diagnosis and treatment of osteoporosis at six months after discharge and were followed-up for at least a year. Results Of the 222 patients with hip fractures, 190 patients (37 men, 153 women) were enrolled at six hospitals in 2015. Dual energy X-ray absorptiometry was performed on 115 patients (60.5%) and 92 patients (48.4%) were prescribed medication for osteoporosis at the time of discharge. A total of 43.7% and 40.2% of the patients were found to be compliant with osteoporosis medication at 6 months and 12 months follow-up respectively. Conclusions This interventional multicenter study demonstrated that a patient education program in patients with hip fractures can improve compliance to osteoporosis medication up to 12 months of follow-up.
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Affiliation(s)
- Yong-Geun Park
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Sang-Rim Kim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Min-Suk Park
- Department of Orthopedic Surgery and Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Sang-Jae Kim
- Department of Orthopedic Surgery and Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
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Luc M, Corriveau H, Boire G, Filiatrault J, Beaulieu MC, Gaboury I. Patient-Related Factors Associated with Adherence to Recommendations Made by a Fracture Liaison Service: A Mixed-Method Prospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15050944. [PMID: 29747415 PMCID: PMC5981983 DOI: 10.3390/ijerph15050944] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/02/2018] [Accepted: 05/04/2018] [Indexed: 01/06/2023]
Abstract
A Fracture Liaison Service (FLS) has been calculated to be a cost-effective model of care for patients with fragility fracture (FF). Cost-effectiveness can be achieved when adherence to bone health recommendations from FLS staff is high. This prospective study combined participants’ telephone longitudinal survey data (intervention group, n = 354) and interviews with 16 individuals from FLS in three health regions of the province of Quebec (Canada). Participants were recruited between January 2013 and April 2015. Regression models were fit to examine the relationship between participant-related factors and adherence at 12 months to osteoporosis medication, vitamin D supplementation, and participation in physical activity. Participants acknowledging FF as a consequence of osteoporosis were more likely to adhere to medication (odds ratio (OR) 2.5; p = 0.001) and vitamin D supplementation (OR 2.3; p = 0.01). Paradoxically, the same participants were less prone to engage in physical activity (OR 0.5, p = 0.01). Qualitative interviews suggested that feedback from FLS coordinators helped participants understand the underlying cause of their FF. This study highlighted the key roles of FLS staff in helping patients to recognize FF as a sign of underlying bone disease and encouraging adherence to care recommendations.
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Affiliation(s)
- Mireille Luc
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
| | - Hélène Corriveau
- School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
| | - Gilles Boire
- Division of Rheumatology, Department of Medicine, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
| | - Johanne Filiatrault
- School of Rehabilitation, Université de Montréal, Montreal, QC H3C 3J7, Canada.
| | - Marie-Claude Beaulieu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
| | - Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
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15
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Weaver J, Sajjan S, Lewiecki EM, Harris ST. Diagnosis and Treatment of Osteoporosis Before and After Fracture: A Side-by-Side Analysis of Commercially Insured and Medicare Advantage Osteoporosis Patients. J Manag Care Spec Pharm 2018. [PMID: 28650253 PMCID: PMC10398230 DOI: 10.18553/jmcp.2017.23.7.735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although treatment for osteoporosis is recommended by U.S. clinical guidelines, a lack of diagnosis and treatment is common among patients with osteoporotic fractures. OBJECTIVE To determine the rates of osteoporosis diagnosis and treatment before and after various types of fractures. METHODS This was a retrospective claims analysis using data from the 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 (the 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. Fragility fractures and osteoporosis diagnoses were identified from ICD-9-CM codes. Treatment for osteoporosis included oral and injectable therapies identified by National Drug Code numbers and Healthcare Common Procedure Coding System codes. Diagnosis and treatment rates were assessed during the 1-year periods before and after the index fracture. All analyses were conducted by fracture type (vertebral, hip, nonhip/nonvertebral [NHNV], and multiple), with stratification by age and sex. No comparisons were made between the Medicare and Commercial groups; rather, McNemar tests were used to compare prefracture versus postfracture diagnosis and treatment rates within each group. RESULTS For inclusion in the Medicare group, 45,603 patients were identified, and 54,145 patients were identified for the Commercial group. In the prefracture period, the osteoporosis diagnosis rates ranged from 12.0% (NHNV) to 21.5% (vertebral) in the Medicare group and from 5.3% (NHNV) to 12.1% (vertebral) in the Commercial group. In the postfracture period, diagnosis rates significantly increased (P < 0.001)-and nearly doubled-for all fracture types but did not exceed 42.1% (vertebral) in the Medicare group and 27.7% (vertebral) in the Commercial group. Pre-index treatment rates were similarly low, ranging from 9.4% (hip) to 16.6% (vertebral) among Medicare patients, and 7.5% (NHNV) to 14.4% (vertebral) in Commercial patients. Osteoporosis treatment rates improved significantly in the postfracture year, ranging from 12.5% (NHNV) to 26.5% (vertebral) among Medicare patients, and 8.3% (NHNV) to 21.4% (vertebral) in Commercial patients. Larger increases in diagnosis rates and smaller increases in treatment rates were observed in stratified analyses of men and women and of different age groups, with women and older patients having higher overall rates of diagnosis and treatment before and after fracture. CONCLUSIONS In men and women, osteoporosis diagnosis rates were low before the index fracture and improved substantially after the fracture, yet still remained low overall (under 50%). Osteoporosis treatment rates among patients experiencing a fracture were low before the index fracture and improved only minimally afterwards. DISCLOSURES This study was funded by Merck & Co. Other than through the employer relationship 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 is an employee 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 & Co., AbbVie, AgNovos Healthcare, Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Radius Health, Shire, and TheraNova, along with research grant support from Merck & Co., 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 & Co., Alexion Pharmaceuticals, Amgen, Eli Lilly and Company, Gilead Sciences, Primus Pharmaceuticals, and Radius Health. Study concept and design were contributed by Weaver and Sajjan. Sajjan collected the data, and data interpretation was performed by all the authors. The manuscript was written and revised by Weaver, Lewiecki, and Harris.
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Affiliation(s)
- Jessica Weaver
- 1 Center for Observational and Real-World Evidence, Merck & Co., Kenilworth, New Jersey
| | - Shiva Sajjan
- 1 Center for Observational and Real-World Evidence, Merck & Co., Kenilworth, New Jersey
| | - E Michael Lewiecki
- 2 New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico
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16
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Danan ER, Krebs EE, Ensrud K, Koeller E, MacDonald R, Velasquez T, Greer N, Wilt TJ. An Evidence Map of the Women Veterans' Health Research Literature (2008-2015). J Gen Intern Med 2017; 32:1359-1376. [PMID: 28913683 PMCID: PMC5698220 DOI: 10.1007/s11606-017-4152-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/08/2017] [Accepted: 07/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning. METHODS The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps. RESULTS We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials. CONCLUSIONS Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.
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Affiliation(s)
- Elisheva R Danan
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA. .,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Erin E Krebs
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kristine Ensrud
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Eva Koeller
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Roderick MacDonald
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Tina Velasquez
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Nancy Greer
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Timothy J Wilt
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Prescription of anti-osteoporosis medications after hospitalization for hip fracture: a multicentre Italian survey. Aging Clin Exp Res 2017; 29:1031-1037. [PMID: 27943127 DOI: 10.1007/s40520-016-0681-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 11/09/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Literature data indicate that the proportion of patients with recent hip fracture who receive a prescription for anti-osteoporotic drugs is low and does not seem to increase over time. This study aimed to obtain data on the prescription for anti-osteoporotic drugs in Italian patients discharged after a recent hip fracture and to assess which variables could have influenced the decision for prescribing osteoporosis medication. METHODS A total of four Italian centres located in four different geographical areas (Siena, Verona, Naples and Palermo) participated in this retrospective study. In each centre, experienced clinicians gathered the data of up to 200 consecutive patients discharged after a recent low-trauma hip fracture. The analysis was carried out on 697 patients (540 women and 157 men; mean age 81.9 ± 8.6 years). RESULTS The percentage of patients who were receiving any type of treatment for osteoporosis before the hip fracture was 8.8% (ranging from 2.4% in Naples to 17.4% in Verona). After the index hip fracture, only 23.2% of patients (namely 10.5% of men and 27.2% of women) received prescription for any pharmacological treatments for osteoporosis. Both female gender and previous use of medications for osteoporosis were positively associated with the likelihood of receiving prescription for anti-osteoporotic treatment at discharge. CONCLUSIONS This study showed that less than 25% of the elderly Italian patients discharged after a hip fracture received a prescription for any type of treatment for osteoporosis and highlights the urgent need for implementing new strategies in the management of hip fracture patients.
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LaFleur J, Rillamas-Sun E, Colón-Emeric CS, Knippenberg KA, Ensrud KE, Gray SL, Cauley JA, LaCroix AZ. Fracture Rates and Bone Density Among Postmenopausal Veteran and Non-Veteran Women From the Women's Health Initiative. THE GERONTOLOGIST 2017; 56 Suppl 1:S78-90. [PMID: 26768394 DOI: 10.1093/geront/gnv677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE OF THE STUDY Postmenopausal osteoporosis can impact quality-of-life even prefracture. To determine whether osteoporosis should be a greater concern in women Veterans versus non-Veterans, we compared fracture rates and bone mineral density (BMD) for Veterans and non-Veterans using Women's Health Initiative data. DESIGN AND METHODS In this cohort study, participants were women aged 50-79 years. Outcomes were hip, central body, and limb fractures occurring during up to 19 years of follow-up and hip, spine, and whole body BMD collected three times over a 6-year period in a participant subsample. Covariates comprised risk factors for fracture, including fall history and other components of the World Health Organization Fracture Risk Assessment Tool (FRAX). Cox Proportional Hazards models were used to examine fracture rates for Veterans compared with non-Veterans. RESULTS Of 161,808 women, 145,521 self-identified as Veteran (n = 3,719) or non-Veteran (n = 141,802). Baseline FRAX scores showed that Veterans had higher 10-year probabilities for any major fracture (13.3 vs 10.2; p < .01) and hip fracture (4.1 vs 2.2; p < .01) compared with non-Veterans. The age-adjusted rate of hip fracture per 1,000 person-years for Veterans was 3.3 versus 2.4 for non-Veterans (p < .01). After adjustment, the hazards ratio for hip fracture was 1.24 (95% confidence interval 1.03-1.49) for Veterans versus non-Veterans. Hazards ratios at other anatomic sites did not differ by Veteran status. Mean BMD at baseline and at Years 3 and 6 also did not differ by Veteran status at any site. IMPLICATIONS Women Veterans had an increased hip fracture rate not explained by differences in well-recognized fracture risk factors.
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Affiliation(s)
- Joanne LaFleur
- VA Salt Lake City Healthcare System, Utah. Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City.
| | - Eileen Rillamas-Sun
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Cathleen S Colón-Emeric
- Durham Center for Health Services Research and Durham Geriatric Research, Education and Clinical Center, Department of Veterans Affairs, North Carolina. Department of Medicine, Duke University, Durham, North Carolina
| | - Kristin A Knippenberg
- VA Salt Lake City Healthcare System, Utah. Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - Kristine E Ensrud
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minnesota. Department of Medicine, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Andrea Z LaCroix
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla
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19
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Utilization of osteoporosis medication after a fragility fracture among elderly Medicare beneficiaries. Arch Osteoporos 2016; 11:31. [PMID: 27696099 DOI: 10.1007/s11657-016-0285-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED Osteoporosis medications are recommended for elderly patients after a fragility fracture. However, we found substantial under-treatment in the post-fracture year, especially among patients who had not previously received such medications. Improved treatment of elderly patients experiencing fragility fractures is needed. INTRODUCTION Osteoporosis medications are recommended for elderly patients after a fragility fracture, but under-treatment is common. We determined osteoporosis medication use after fragility fractures and examined associated factors. METHODS Our cohort included elderly (age ≥66 years) Medicare-enrolled patients who sustained fragility fractures January 1, 2008-December 31, 2011. Osteoporosis medication prescriptions were determined in the 12 months after the index fracture. Using multivariate logistic models, we examined the association between post-fracture osteoporosis medication use and predictors. RESULTS Of 145,185 patients with fragility fractures (mean age 80.9 ± 7.8 years; 91.2 % white; 81.3 % female), 29.9 % sustained hip, 31.8 % vertebral, and 38.4 % non-hip-non-vertebral fractures. Overall, 30.4 % of the cohort received an osteoporosis medication in the 12-month post-fracture period. Of patients not receiving an osteoporosis medication in the pre-index period (n = 108,344), 14.9 % of all patients, 16.3 % of women, and 10.3 % of men received one in the post-fracture period. Corresponding values for patients receiving an osteoporosis medication in the pre-index period (n = 36,841) were 76.2, 76.5, and 72.2 %. Odds of post-fracture osteoporosis medication use were 68 % higher for women than for men. Osteoporosis diagnosis (odds ratio, 1.55; P < 0.0001) and bone-mineral-density tests before an index fracture (odds ratio, 1.24; P < 0.001) were associated with post-fracture osteoporosis medication use. CONCLUSIONS Less than one third of our cohort received an osteoporosis medication in the post-fracture year, when risk of a second fragility fracture is highest. In those not already previously treated with an osteoporosis medication, only about 1 in 7 patients received treatment.
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Osuna PM, Ruppe MD, Tabatabai LS. FRACTURE LIAISON SERVICES: MULTIDISCIPLINARY APPROACHES TO SECONDARY FRACTURE PREVENTION. Endocr Pract 2016; 23:199-206. [PMID: 27849385 DOI: 10.4158/ep161433.ra] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A well-recognized gap exists between evidence-based recommendations for post-fracture care and actual clinical practice, demonstrated by the high percentage of fragility fracture patients who are neither diagnosed nor treated for osteoporosis. Our purpose is to review fracture liaison service (FLS) models and to evaluate national and international experiences in secondary fracture prevention. METHODS We performed a systematic search of publication databases (MEDLINE, SCOPUS) and included randomized controlled trials, meta-analyses, and review articles using the following keywords: Fracture liaison services, Secondary prevention of fracture, Post-fracture healthcare gap, and fragility fractures. References were included from 2001-2015. We subsequently performed reference searches of retrieved articles and available literature was reviewed. RESULTS The efficacy of secondary fracture prevention programs correlates strongly with their intensity. Type A FLS Models are most successful in initiating diagnostic and treatment plans for fragility fracture patients. Adoption of FLS programs improves care by lowering mortality and refracture rates while also lowering healthcare costs. The quality of evidence supporting associations between FLS programs and improved outcomes was moderately strong due to the availability of longitudinal data from nationalized health systems. CONCLUSION As our population ages and challenges to the healthcare system loom ever larger, it is imperative that we fund and champion fracture liaison services. The fracture liaison service has recently emerged as a novel clinical approach that uses coordinated, multidisciplinary care to improve post-fracture outcomes and reduce recurrent fractures. These programs are simple, targeted, high-yield and have the potential to protect our most vulnerable patients. ABBREVIATIONS DXA = dual-energy x-ray absorptiometry FLS = fracture liaison service NCQA = National Committee of Quality Assurance NHS = National Health Service PCP = primary care physician PQRS = Physician Quality Reporting System QCDR = Qualified Clinical Data Registry.
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Edmonds SW, Cram P, Lou Y, Jones MP, Roblin DW, Saag KG, Wright NC, Wolinsky FD. Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial. BMC Musculoskelet Disord 2016; 17:369. [PMID: 27562713 PMCID: PMC5000520 DOI: 10.1186/s12891-016-1227-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge. Methods The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates. Results At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point. Conclusions A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care. Trial registration Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.
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Affiliation(s)
- Stephanie W Edmonds
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 5231 Westlawn, IA 52242, Iowa City, IA, USA. .,College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - Peter Cram
- Department of Medicine, University of Toronto Division of General Internal Medicine, Toronto, ON, Canada.,University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Yiyue Lou
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Michael P Jones
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA, USA.,Iowa City Veterans Affairs Health System, Iowa City, IA, USA
| | - Douglas W Roblin
- Kaiser Permanente, Atlanta, GA, USA.,School of Public Health, Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - Kenneth G Saag
- Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicole C Wright
- School of Public Health, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fredric D Wolinsky
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, 5231 Westlawn, IA 52242, Iowa City, IA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA.,College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa, IA, USA
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22
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Rinat B, Rubin G, Orbach H, Giwnewer U, Rozen N. Can orthopedic surgeons help create a better head start for osteoporosis treatment after hip fracture? Medicine (Baltimore) 2016; 95:e4141. [PMID: 27399130 PMCID: PMC5058859 DOI: 10.1097/md.0000000000004141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Treatment for osteoporosis in the community in patients who were operated for hip fracture appears to be suboptimal at best. Evidence regarding treatment beyond the 1st year after surgery is scarce. We examined the association between discharge recommendations for treatment of osteoporosis in patients suffering from hip fractures and treatment beyond the 1st year. METHODS AND MATERIALS We performed a retrospective observational cohort study in patients age 50 to 90 years operated for osteoporotic hip fractures between the years 2008 and 2014. We investigated the correlation between discharge recommendations and rates of osteoporosis treatment postdischarge 1 to 7 years, and the influence of osteoporosis diagnosis upon treatment. Exclusion criteria besides age included high-energy trauma, pathologic or periprosthetic fractures, and patients deceased within 1-year postsurgery. RESULTS A total of 602 patient files were examined. Univariate analysis showed that, of 283 patients who were prescribed dietary supplementation of vitamin D and calcium, a significantly higher percentage of patients received treatment if they had a recommendation (50.3% vs 36.1%, P = 0.0005), were diagnosed (43.8% vs 14.4%, P < 0.0001), or were of female gender (84.1% vs 57.3%, P < 0.0001). Multivariate analysis showed that the odds ratio (OR) for receiving treatment compared with the control group (patients without a recommendation and a diagnosis) was higher among patients who had both a recommendation and a treatment (OR = 5.4, P < 0.0001) than the group with a diagnosis only (OR = 4.75, P < 0.0001) or a recommendation only (OR = 2.06, P = 0.0006). CONCLUSIONS A formal recommendation for osteoporosis treatment in the discharge letters of patients who suffered hip fragility fractures increases treatment rate of osteoporosis in the community compared with patients without a recommendation. Patients who receive such a recommendation but also have a formal coded diagnosis of osteoporosis in their medical files have an even higher chance of receiving treatment in the community. Our observations may assist in amplifying the overall treatment rates, which are still undoubtedly low.
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Affiliation(s)
- Barak Rinat
- Orthopedic Department, Emek Medical Center, Afula
| | - Guy Rubin
- Orthopedic Department, Emek Medical Center, Afula
- Faculty of Medicine, Technion, Haifa, Israel
| | - Hagay Orbach
- Orthopedic Department, Emek Medical Center, Afula
| | | | - Nimrod Rozen
- Orthopedic Department, Emek Medical Center, Afula
- Faculty of Medicine, Technion, Haifa, Israel
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23
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Yoshii I, Satake Y, Kitaoka K, Komatsu M, Hashimoto K. Relationship between dementia degree and gait ability after surgery of proximal femoral fracture: Review from Clinical Pathway with Regional Alliance data of rural region in Japan. J Orthop Sci 2016; 21:481-486. [PMID: 27075586 DOI: 10.1016/j.jos.2016.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/12/2016] [Accepted: 03/11/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Proximal femoral fracture (PFF) is one of the most serious injury-related problems in developed countries. Functional prognosis after operation for PFF is unsatisfactory, as a considerable number of patients cannot perform similar gait function before fracture. Postoperative gait function is a key in performing activities of daily living (ADL). It is well known that PFF patients with dementia result in worse prognosis compared to without dementia. It is believed that dementia affects gait function after operation. However, it is still unclear whether lost function recovers after dementia level improves. METHODS Relationship between ADL and dementia of PFF patients after surgery was investigated using data of Clinical Pathway with Regional Alliance system. Functional Independence Measurement (FIM), revised version of Hasegawa's Dementia Scale (HDS-R), motivation for rehabilitation (MR), and gait status (GS) measured in acute and recovery institute (A-I and R-I) of 266 patients were analyzed with linear regression analysis. Degrees of patients' dementia were classified into three groups with HDS-R for ten points increment partition, and their average FIM and GS in R-I for groups were compared statistically with ANOVA. FIM gain and GS gain from A-I to R-I were compared statistically with chi-square test. RESULTS FIM and HDS-R demonstrated significant regression with each of all other parameters (p < 0.01) for both A-I and R-I. The group with lowest HDS-R score demonstrated significant lower FIM gain and lower GS gain than groups with higher scores (p < 0.01). However, patients who demonstrated improvement in HDS-R at R-I demonstrated significant better GS gain (p < 0.05) even in the group with lowest HDS-R at A-I. CONCLUSIONS These results show that there is a very close correlation between patients' gait function and dementia and that it is necessary to control a patient's status not only for physical condition but also for mental status after PFF operation.
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Affiliation(s)
- Ichiro Yoshii
- In Yoshii Hospital from Medical Corporation Genyu, 6-7-5 Nakamura-Ohashidori, Shimanto-City, 787-0033 Kochi Prefecture, Japan.
| | - Yoshinori Satake
- Department of Orthopaedic Surgery, Kochi Prefectural Aki General Hospital, 3-33Hoheicho, Aki, 784-0027 Kochi Prefecture, Japan
| | - Kenichi Kitaoka
- Department of Orthopaedic Surgery, Kochi Prefectural Hata Kenmin Hospital, 3-1 Yoshina, Yamada-cho, 788-0785 Kochi Prefecture, Japan
| | - Makoto Komatsu
- Department of Orthopaedic Surgery, Kochi Prefectural Hata Kenmin Hospital, 3-1 Yoshina, Yamada-cho, 788-0785 Kochi Prefecture, Japan
| | - Kyuichi Hashimoto
- Department of Orthopaedic Surgery, Otsuki Hospital, 603 Hokotsuti, Otsuki, 788-0311 Kochi Prefecture, Japan
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24
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Abstract
UNLABELLED Osteoporosis treatment rates within 2 years following an index event (fragility fracture, osteoporotic bone mineral density (BMD) T-score, or osteoporosis ICD-9 codes) were determined from 2005 to 2011. Most patients were not treated. Fracture patients had the lowest treatment rate. Low treatment rates also occurred in patients that were male, black, or had non-commercial insurance. INTRODUCTION Clinical recognition of osteoporosis (osteoporotic BMD, assignment of an ICD-9 code, or the occurrence of fragility fractures) provides opportunities to treat patients at risk for future fracture. METHODS A cohort of 36,965 patients was identified from 2005 to 2011 in the Indiana Health Information Exchange, with index events after age 50 of either non-traumatic fractures, an osteoporosis ICD-9 code, or a BMD T-score ≤ -2.5. Patients with osteoporosis treatment in the preceding year were excluded. Medication records during the ensuing 2 years were extracted to identify osteoporosis treatments, demographics, comorbidities, and co-medications. Predictors of treatment were evaluated in a multivariable logistic regression model. RESULTS The cohort was 78 % female, 11 % black, 91 % urban-dwelling, and 53 % commercially insured. The index events were as follows: osteoporosis diagnosis (47 % of patients), fragility fracture (44 %), and osteoporotic T-scores (9 %). Within 2 years after the index event, 23.3 % received osteoporosis medications (of which, 82.2 % were oral bisphosphonates). Treatment rates were higher after osteoporosis diagnosis codes (29.3 %) or osteoporotic T-score (53.9 %) than after fracture index events (10.5 %) (p < 0.001). Age had an inverted U-shaped effect for women with highest odds around 60-65 years. Women (OR 1.86) and non-black patients (OR 1.52) were more likely to be treated (p < 0.001). Patients with public (versus commercial) insurance (OR 0.86, p < 0.001) or chronic comorbidities (ORs about 0.7-0.9, p < 0.001) were less likely to be treated. CONCLUSION Most osteoporosis treatment candidates remained untreated. Men, black patients, and patients with fracture or chronic comorbidities were less likely to receive treatment, representing disparity in the recognition and treatment of osteoporosis.
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Affiliation(s)
- Z Liu
- Department of Biostatistics, Indiana University Schools of Medicine and Public Health, Health Information and Translational Sciences Building, 410 W 10th Street, Suite 3000, Indianapolis, IN, 46202-5111, USA.
| | - J Weaver
- Merck & Co, Whitehouse Station, New Jersey, NJ, 08889, USA
| | - A de Papp
- Merck & Co, Whitehouse Station, New Jersey, NJ, 08889, USA
| | - Z Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - J Martin
- Regenstrief Institute, Indianapolis, IN, USA
| | - K Allen
- Regenstrief Institute, Indianapolis, IN, USA
| | - S Hui
- Regenstrief Institute, Indianapolis, IN, USA
| | - E A Imel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Yong JHE, Masucci L, Hoch JS, Sujic R, Beaton D. Cost-effectiveness of a fracture liaison service--a real-world evaluation after 6 years of service provision. Osteoporos Int 2016; 27:231-40. [PMID: 26275439 DOI: 10.1007/s00198-015-3280-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/05/2015] [Indexed: 11/24/2022]
Abstract
UNLABELLED The cost-effectiveness of a less intensive fracture liaison service is unknown. We evaluated a fracture liaison service that had been educating and referring patients for secondary prevention of osteoporotic fractures for 6 years. Our results suggest that a less intensive fracture liaison service, with moderate effectiveness, can still be worthwhile. INTRODUCTION Fragility fractures are common among older patients; the risk of re-fracture is high but could be reduced with treatments; different versions of fracture liaison service have emerged to reduce recurrent osteoporotic fractures. But the cost-effectiveness of a less intensive model is unknown. The objective of this study was to assess the cost-effectiveness of the Ontario Fracture Clinic Screening program, a fracture liaison service that had been educating and referring fragility fracture patients across Ontario, Canada to receive bone mineral density testing and osteoporosis treatments since 2007. METHODS We developed a Markov model to assess the cost-effectiveness of the program over the patients' remaining lifetime, using rates of bone mineral density testing and osteoporosis treatment and cost of intervention from the program, and supplemented it with the published literature. The analysis took the perspective of a third-party health-care payer. Costs and benefits were discounted at 5 % per year. Sensitivity analyses assessed the effects of different assumptions on the results. RESULTS The program improved quality-adjusted life-years (QALYs) by 4.3 years and led to increased costs of CAD $83,000 for every 1000 patients screened, at a cost of $19,132 per QALY gained. The enhanced model, the Bone Mineral Density (BMD) Fast Track program that includes ordering bone mineral density testing, was even more cost-effective ($5720 per QALY gained). CONCLUSIONS The Ontario Fracture Clinic Screening program appears to be a cost-effective way to reduce recurrent osteoporotic fractures.
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Affiliation(s)
- J H E Yong
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - L Masucci
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - J S Hoch
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - R Sujic
- Musculoskeletal Health & Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
| | - D Beaton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
- Musculoskeletal Health & Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Yu J, Goldshtein I, Shalev V, Chodick G, Ish-Shalom S, Sharon O, Modi A. Association of gastrointestinal events and osteoporosis treatment initiation in newly diagnosed osteoporotic Israeli women. Int J Clin Pract 2015; 69:1007-14. [PMID: 26278464 PMCID: PMC5042045 DOI: 10.1111/ijcp.12676] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The objective was to examine the association of gastrointestinal (GI) events and osteoporosis treatment initiation patterns among postmenopausal women following an osteoporosis diagnosis from an Israeli health plan. METHODS This retrospective analysis of claims records included women aged ≥ 55 years with ≥ 1 osteoporosis diagnosis (date of first diagnosis was index date). Osteoporosis treatment initiation was defined as use of osteoporosis therapy (oral bisphosphonates or other) during 12 months postindex. GI events (diagnosis of GI conditions) were reported for 12 months preindex and postindex (from index to treatment initiation or 1 year postindex, whichever occurred first). The association of postindex GI events (yes/no) with the initiation of osteoporosis treatment (yes/no) and with type of therapy initiated (oral bisphosphonate vs. other) were examined with logistic regression and Cox proportional hazard regression (as sensitivity analysis). RESULTS Among 30,788 eligible patients, 17.5% had preindex GI events and 13.0% had postindex GI events. About 70.6% of patients received no osteoporosis therapy within 1 year of diagnosis, 24.9% received oral bisphosphonates and 4.5% received other medications. Postindex GI events were associated with lower odds of osteoporosis medication initiation (85-86% reduced likelihood; p < 0.01). Upon treatment initiation, postindex GI was not significantly associated with the type of osteoporosis therapy initiated, controlling for baseline GI events and patient characteristics. CONCLUSIONS Among newly diagnosed osteoporotic women from a large Israeli health plan, 70.6% did not receive osteoporosis treatment within 1 year of diagnosis. The presence of GI events was associated with reduced likelihood of osteoporosis treatment initiation.
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Affiliation(s)
- J Yu
- Merck & Co, Inc., Kenilworth, NJ, USA
| | - I Goldshtein
- Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - V Shalev
- Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - G Chodick
- Medical Division, Maccabi Healthcare Services, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | | | - O Sharon
- Merck Sharp & Dohme Co. Ltd., Petah Tikya, Israel
| | - A Modi
- Merck & Co, Inc., Kenilworth, NJ, USA
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27
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LaFleur J, DuVall SL, Willson T, Ginter T, Patterson O, Cheng Y, Knippenberg K, Haroldsen C, Adler RA, Curtis JR, Agodoa I, Nelson RE. Analysis of osteoporosis treatment patterns with bisphosphonates and outcomes among postmenopausal veterans. Bone 2015; 78:174-85. [PMID: 25896952 DOI: 10.1016/j.bone.2015.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 03/24/2015] [Accepted: 04/14/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE Adherence and persistence with bisphosphonates are frequently poor, and stopping, restarting, or switching bisphosphonates is common. We evaluated bisphosphonate change behaviors (switching, discontinuing, or reinitiating) over time, as well as fractures and costs, among a large, national cohort of postmenopausal veterans. METHODS Female veterans aged 50+ treated with bisphosphonates during 2003-2011 were identified in Veterans Health Administration (VHA) datasets. Bisphosphonate change behaviors were characterized using pharmacy refill records. Patients' baseline disease severity was characterized based on age, T-score, and prior fracture. Cox Proportional Hazard analysis was used to evaluate characteristics associated with discontinuation and the relationship between change behaviors and fracture outcomes. Generalized estimating equations were used to evaluate the relationship between change behaviors and cost outcomes. RESULTS A total of 35,650 patients met eligibility criteria. Over 6800 patients (19.1%) were non-switchers. The remaining patients were in the change cohort; at least half displayed more than one change behavior over time. A strong, significant predictor of discontinuation was ≥5 healthcare visits in the prior year (11-23% more likely to discontinue), and discontinuation risk decreased with increasing age. No change behaviors were associated with increased fracture risk. Total costs were significantly higher in patients with change behaviors (4.7-19.7% higher). Change-behavior patients mostly had significantly lower osteoporosis-related costs than non-switchers (22%-118% lower). CONCLUSIONS Most bisphosphonate patients discontinue treatment at some point, which did not significantly increase the risk of fracture in this majority non-high risk population. Bisphosphonate change behaviors were associated with significantly lower osteoporosis costs, but significantly higher total costs.
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Affiliation(s)
- J LaFleur
- Pharmacotherapy Outcomes Research Center, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, USA; VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - S L DuVall
- Pharmacotherapy Outcomes Research Center, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, USA; VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - T Willson
- Pharmacotherapy Outcomes Research Center, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, USA; VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - T Ginter
- VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - O Patterson
- VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - Y Cheng
- Pharmacotherapy Outcomes Research Center, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, USA; VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - K Knippenberg
- Pharmacotherapy Outcomes Research Center, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, USA
| | - C Haroldsen
- VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - R A Adler
- Hunter Holmes McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23224, USA
| | - J R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 1825 University Boulevard, Birmingham, AL 35294-2182, USA
| | - I Agodoa
- Amgen, Inc., 1 Amgen Center Drive, Thousand Oaks, CA 91320, USA
| | - R E Nelson
- VA Salt Lake City Heath Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
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Abstract
Gender differences exist in the presentation of musculoskeletal disease, and recognition of the differences between men and women's burden of disease and response to treatment is key in optimizing care of orthopaedic patients. The role of structural anatomy differences, hormones, and genetics are factors to consider in the analysis of differential injury and arthritic patterns between genders.
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Wilk A, Sajjan S, Modi A, Fan CPS, Mavros P. Post-fracture pharmacotherapy for women with osteoporotic fracture: analysis of a managed care population in the USA. Osteoporos Int 2014; 25:2777-86. [PMID: 25112720 PMCID: PMC4221620 DOI: 10.1007/s00198-014-2827-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/25/2014] [Indexed: 12/14/2022]
Abstract
UNLABELLED Pharmacologic therapy is recommended to reduce future fracture risk. We examined osteoporosis medications dispensed to older women after first fracture. Only 23 % received therapy during the first year post-fracture. Prior osteoporosis therapy, a prior osteoporosis diagnosis, and older age were good predictors of post-fracture osteoporosis therapy. INTRODUCTION Pharmacologic therapy is recommended after osteoporotic fracture to reduce future fracture risk. The objective of this retrospective study was to examine osteoporosis therapy dispensed to women post-fracture. METHODS We identified women ≥50 years old in a large administrative claims database from 2003 to mid-2012 who were continuously enrolled 2 years before (baseline) and 1 year after first osteoporotic fracture. Exclusions were Paget's disease or malignant neoplasm. Pre- and post-fracture osteoporosis therapies (oral and parenteral) were assessed overall and by fracture site. RESULTS A total of 47,171 women of mean (SD) age of 63 (10) years were eligible; fractures included 8 % hip, 17 % vertebral, 73 % non-hip/non-vertebral, and 3 % multiple fracture sites. Only 18 % received osteoporosis therapy within 90 days and 23 % within 1 year post-fracture. Overall, 19 % of women had a prior osteoporosis diagnosis; 20 % had received osteoporosis therapy during baseline. Of 37,649 (80 %) women without baseline therapy, only 9 % initiated pharmacologic therapy within 1 year. The adjusted odds ratio (OR) of therapy within 1 year post-fracture was significantly greater for women who had received baseline osteoporosis therapy (versus none) and who had vertebral (OR 12.7, 95 % confidence interval (CI) 11.2-14.5), hip (15.2, 12.5-18.7), or non-hip/non-vertebral fracture (34.4, 31.7-37.3). Other significant predictors included pre-fracture osteoporosis diagnosis (1.6, 1.4-1.7) and older age (OR range, 1.3-1.7). Treatment adherence was significantly better among women with baseline osteoporosis diagnosis. CONCLUSIONS The substantial post-fracture treatment gap represents an important unmet need for women with osteoporotic fractures. Fracture liaison or adherence programs could lead to improved post-fracture treatment rates.
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Affiliation(s)
- A. Wilk
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - S. Sajjan
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
| | - A. Modi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
| | | | - P. Mavros
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
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30
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Kim SR, Park YG, Kang SY, Nam KW, Park YG, Ha YC. Undertreatment of osteoporosis following hip fractures in jeju cohort study. J Bone Metab 2014; 21:263-8. [PMID: 25489575 PMCID: PMC4255047 DOI: 10.11005/jbm.2014.21.4.263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 09/18/2014] [Accepted: 10/23/2014] [Indexed: 11/16/2022] Open
Abstract
Background Osteoporosis treatment following hip fracture is well known to not enough. We previously performed intervention study for orthopaedic surgeon's education and reported twofold increase in osteoporosis detection and treatment rate observed between 2005 and 2007. This follow-up observational study was conducted to find out the rate in which a diagnostic workup and treatment for osteoporosis were done in patients with hip fracture. Methods Medical records and radiographs in patients who were older than 50 years and diagnosed as having femoral neck or intertrochanteric fractures at 8 hospitals in Jeju island, South Korea from 2008 to 2011 were reviewed. The numbers of patients who were studied with bone densitometry and who were treated for osteoporosis after the diagnosis of hip fracture were analyzed. Results Nine hundred forty five hip fractures (201 in 2008, 257 in 2009, 265 in 2010, and 304 in 2011) occurred in 191 men and 754 women during the study periods. The mean age of the patients was 79.7 years. The mean rate of osteoporosis detection using dual energy X-ray absorptiometry was 36.4% (344/945 hips) (ranged from 24.2% in 2009 to 40.5% in 2011). The mean initiation rate of osteoporosis treatment was 23.1% (218/945 hips) (ranged from 20% in 2009 to 29% in 2008). Conclusions Detection and treatment rate of osteoporosis following hip fracture during follow-up periods was still not enough. Additional intervention studies are required to further improvement of osteoporosis treatment rates after hip fracture.
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Affiliation(s)
- Sang-Rim Kim
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Korea
| | - Yong-Geun Park
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Korea
| | - Soo Yong Kang
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Jeju National University School of Medicine, Jeju, Korea
| | - Yong-Gum Park
- General Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
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Laurent M, Antonio L, Sinnesael M, Dubois V, Gielen E, Classens F, Vanderschueren D. Androgens and estrogens in skeletal sexual dimorphism. Asian J Androl 2014; 16:213-22. [PMID: 24385015 PMCID: PMC3955330 DOI: 10.4103/1008-682x.122356] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Bone is an endocrine tissue expressing androgen and estrogen receptors as well as steroid metabolizing enzymes. The bioactivity of circulating sex steroids is modulated by sex hormone-binding globulin and local conversion in bone tissue, for example, from testosterone (T) to estradiol (E2) by aromatase, or to dihydrotestosterone by 5α-reductase enzymes. Our understanding of the structural basis for gender differences in bone strength has advanced considerably over recent years due to increasing use of (high resolution) peripheral computed tomography. These microarchitectural insights form the basis to understand sex steroid influences on male peak bone mass and turnover in cortical vs trabecular bone. Recent studies using Cre/LoxP technology have further refined our mechanistic insights from global knockout mice into the direct contributions of sex steroids and their respective nuclear receptors in osteoblasts, osteoclasts, osteocytes, and other cells to male osteoporosis. At the same time, these studies have reinforced the notion that androgen and estrogen deficiency have both direct and pleiotropic effects via interaction with, for example, insulin-like growth factor 1, inflammation, oxidative stress, central nervous system control of bone metabolism, adaptation to mechanical loading, etc., This review will summarize recent advances on these issues in the field of sex steroid actions in male bone homeostasis.
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Affiliation(s)
- Michaël Laurent
- Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine; Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, KU Leuven; Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
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32
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Modi A, Sajjan S, Gandhi S. Challenges in implementing and maintaining osteoporosis therapy. Int J Womens Health 2014; 6:759-69. [PMID: 25152632 PMCID: PMC4140231 DOI: 10.2147/ijwh.s53489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the United States, an estimated 19% of older men and 30% of older women are at elevated risk of osteoporotic fracture and considered to be eligible for treatment. The burden of osteoporosis is similar in Europe and is projected to rise worldwide, with aging populations and increasing fracture rates accompanying urbanization. Notwithstanding its high prevalence, osteoporosis is often underdiagnosed and undertreated. Moreover, even when the diagnosis is made and the decision is taken to treat, there are remaining challenges in implementing therapy for osteoporosis. Several patient populations are particularly challenging for clinicians to treat and require further study with regard to osteoporosis therapy. These include the very elderly, who face challenges relating to adherence; men, in whom osteoporosis remains under-recognized; patients with glucocorticoid-induced osteoporosis or renal impairment, who are at increased risk of fracture; patients with preexisting gastrointestinal problems who cannot tolerate existing orally administered osteoporosis therapies; and high-risk patients who show inadequate response to therapy. Moreover, poor adherence and poor persistence with osteoporosis medications are common and result in an increased risk of fracture, higher medical costs, and increased hospitalizations. Once the decision to institute therapy is made, patient education about osteoporosis and fracture risk should be provided. This is particularly important for men, who may not be aware that osteoporosis can be a concern. Secondary prevention programs, including fracture liaison services and bone therapy groups, can help to improve adherence to therapy. Further study is needed to guide the treatment of men, the very elderly, patients with glucocorticoid-induced osteoporosis and renal impairment, high-risk patients not well-controlled despite therapy, and patients with preexisting gastrointestinal conditions. Moreover, therapies are needed that are viewed as effective and safe by both physicians and patients, and as convenient to take by patients.
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Affiliation(s)
- Ankita Modi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - Shiva Sajjan
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - Sampada Gandhi
- School of Public Health, Rutgers University, Piscataway, NJ, USA
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Ganda K, Schaffer A, Pearson S, Seibel MJ. Compliance and persistence to oral bisphosphonate therapy following initiation within a secondary fracture prevention program: a randomised controlled trial of specialist vs. non-specialist management. Osteoporos Int 2014; 25:1345-55. [PMID: 24445732 DOI: 10.1007/s00198-013-2610-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/16/2013] [Indexed: 11/27/2022]
Abstract
UNLABELLED Following initiation of oral bisphosphonate therapy through a secondary fracture prevention program, 2-year treatment compliance and persistence remained high and were similar in patients randomised to follow-up by either the program or primary care physician. Thus, community-based and specialist management are equally effective in supporting compliance and persistence with anti-osteoporotic treatments. INTRODUCTION The purpose of this study was to determine whether management by a secondary fracture prevention (SFP) program (aka "fracture liaison service") results in better compliance and persistence to oral bisphosphonate therapy than follow-up by the primary care physician, after initiation within an SFP program. METHODS This prospective RCT included 102 patients with incident osteoporotic fractures referred to a SFP program in Sydney, Australia. Following oral bisphosphonate therapy initiation, patients were randomised to either 6-monthly follow-up with the SFP program (group A) or referral to their primary care physician with a single SFP program visit at 24 months (group B). Compliance and persistence to treatment were measured using pharmaceutical claims data. Predictors of compliance and persistence and associations between compliance and persistence, and changes in bone mineral density (BMD) or bone resorption marker, urinary deoxypyridinoline over 24 months were analysed. RESULTS The median medication possession ratio at 24 months was 0.78 (IQR, 0.50-0.93) in group A and 0.79 (IQR, 0.48-0.96) in group B (p = 0.68). Persistence at 24 months was also similar in both groups (64 vs. 61%, respectively; p = 0.75). After adjusting for confounders, patients in group A were not more likely to be compliant (OR, 1.06; 95% CI, 0.46-2.47) or persistent (HR, 0.83; 95% CI, 0.27-1.67) than those randomised to group B. Time-based changes in BMD or bone turnover were not associated with compliance or persistence. CONCLUSION Compliance and persistence to oral bisphosphonate therapy remain high amongst patients initiated within an SFP program, with community-based and SFP program management being equally effective in maintaining therapeutic compliance and persistence over 2 years. These results indicate that one of the main functions of an SFP program may be the initiation of therapy rather than continuous patient monitoring.
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Affiliation(s)
- K Ganda
- Bone Research Program, ANZAC Research Institute, The University of Sydney, Hospital Road, Concord, NSW, 2139, Australia,
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Scarvell JM, Van Twest MS, Stanton SF, Burski G, Smith PN. Prevalence of undisclosed osteoporosis in patients with minimal trauma fractures: a prospective cohort study. PHYSICIAN SPORTSMED 2013; 41:38-43. [PMID: 23703516 DOI: 10.3810/psm.2013.05.2011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite epidemiologic evidence for the presence of osteoporosis in patients with minimal trauma fractures, screening programs have not been routinely established in Australian ambulatory care clinics. Our study assessed the prevalence of osteoporosis and osteopenia in patients at a tertiary care hospital to gather local data to support policy change that favors bone mineral density screening. Our prospective observational study enrolled 115 patients, aged > 40 years, who had experienced a minimal trauma fracture. Inclusion criteria required that the patient had no history of testing for osteoporosis or metabolic bone disease/major pathology. The patients were recruited over a 6-month period. Eleven participants were excluded and 7 participants withdrew from the study, with a total of 97 patients completing the study. Participants were assessed for osteoporosis risk via bone mineral density measurement by dual-energy x-ray absorptiometry and blood screening for bone mineral levels, 25-hydroxyvitamin D, and parathyroid hormone levels. In our study patients, the prevalence of previously undiagnosed osteoporosis was 19%, undiagnosed osteopenia, 50%, and the standard bone mineral density was 32%. The most common risk factors for osteoporosis/osteopenia were smoking (22%), alcohol intake (16%), and corticosteroid use (9%). In 67% of patients, 25-hydroxyvitamin D level was in the low clinical range in 51% of patients, magnesium levels were in the high range and 18% of patients had elevated serum parathyroid levels. At month 12 of our study, 80 participants were available for follow-up: 2 patients had sustained a second fracture (1 was minimal trauma); 6 patients had required further surgery (3 fracture fixations, 3 for removal of internal fixation devices); 26 patients continued treatment regimens with calcium and 25-hydroxyvitamin D supplementation; and 28 patients had been prescribed bisphosphonates, with 22 patients complying with the prescription. The high prevalence of previously undiagnosed low bone mass in our study patient population, each of whom had experienced minimal trauma falls, provides impetus for the provision of osteoporosis screening programs and corresponding treatment as needed.
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Affiliation(s)
- Jennie M Scarvell
- Trauma and Orthopaedic Research Unit, Canberra Hospital, Woden, ACT, Australia.
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Lim SY, Lim JH, Nguyen D, Okamura R, Amiri HM, Calmes M, Nugent K. Screening for osteoporosis in men aged 70 years and older in a primary care setting in the United States. Am J Mens Health 2013; 7:350-4. [PMID: 23440083 DOI: 10.1177/1557988313478826] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Osteoporosis in men is an underrecognized and undertreated condition. Despite the National Osteoporosis Foundation recommending osteoporosis screening in men aged 70 years and older since 2008, screening rates in the United States remain undefined. In our study, we analyzed dual-energy X-ray absorptiometry (DXA) screening rates in a primary care setting. Overall, screening rates were low (11.3%). Although there was an increase with age in both the 10-year osteoporotic and 10-year hip fracture probabilities, no association was found between increased age and bone mineral density testing using DXA. Only 23.2% of patients were prescribed bone protective treatments. The performance of DXA screening strongly predicted prescription of bone protective treatment. Increased age raised the likelihood of bone protective treatment prescriptions; however, smokers were less likely to be prescribed these medications. As the population in the United States ages, an increased awareness of this major public health problem is warranted.
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Affiliation(s)
- Sian Yik Lim
- Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 2013; 24:393-406. [PMID: 22829395 DOI: 10.1007/s00198-012-2090-y] [Citation(s) in RCA: 269] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures, despite the availability of effective treatments. We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures. We searched eight medical literature databases to identify reports published between 1996 and 2011, describing models of care for secondary fracture prevention. Information extracted from each publication included study design, patient characteristics, identification strategies, assessment and treatment initiation strategies, as well as outcome measures (rates of bone mineral density (BMD) testing, osteoporosis treatment initiation, adherence, re-fractures and cost-effectiveness). Meta-analyses of studies with valid control groups were conducted for two outcome measures: BMD testing and osteoporosis treatment initiation. Out of 574 references, 42 articles were identified as analysable. These studies were grouped into four general models of care-type A: identification, assessment and treatment of patients as part of the service; type B: similar to A, without treatment initiation; type C: alerting patients plus primary care physicians; and type D: patient education only. Meta-regressions revealed a trend towards increased BMD testing (p = 0.06) and treatment initiation (p = 0.03) with increasing intensity of intervention. One type A service with a valid control group showed a significant decrease in re-fractures. Types A and B services were cost-effective, although definition of cost-effectiveness varied between studies. Fully coordinated, intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and/or education only.
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Affiliation(s)
- K Ganda
- Department of Endocrinology and Metabolism, Bone Research Program, ANZAC Research Institute, The University of Sydney, Concord, NSW, 2139, Australia.
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Abstract
Osteoporosis is now recognized as a major threat to health in aging men. Morbidity and mortality, particularly following hip fracture, are substantial. Although trabecular bone loss starts in early adulthood, loss of cortical bone only seems to occur from midlife onwards. Declining bioavailable estradiol levels plays an integral role in male age-associated bone loss. Both pharmacologic and supportive care interventions are important for optimal care in men at an increased fracture risk.
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Affiliation(s)
- Matthew T Drake
- Department of Medicine, Division of Endocrinology, College of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Nelson RE, Nebeker JR, Sauer BC, LaFleur J. Factors associated with screening or treatment initiation among male United States veterans at risk for osteoporosis fracture. Bone 2012; 50:983-8. [PMID: 22266156 DOI: 10.1016/j.bone.2011.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 11/04/2011] [Accepted: 11/21/2011] [Indexed: 11/16/2022]
Abstract
Male osteoporosis continues to be under-recognized and undertreated in men. An understanding of which factors cue clinicians about osteoporosis risk in men, and which do not, is needed to identify areas for improvement. This study sought to measure the association of a provider's recognition of osteoporosis with patient information constructs that are available at the time of each encounter. Using clinical and administrative data from the Veterans Health Administration system, we used a stepwise procedure to construct prognostic models for a combined outcome of osteoporosis diagnosis, treatment, or a bone mineral density (BMD) test order using time-varying covariates and Cox regression. We ran separate models for patients with at least one primary care visit and patients with only secondary care visits in the pre-index period. Some of the strongest predictors of clinical osteoporosis identification were history of gonadotropin-releasing hormone (GnRH) agonist exposure, fragility fractures, and diagnosis of rheumatoid arthritis. Other characteristics associated with a higher likelihood of having osteoporosis risk recognized were underweight or normal body mass index, cancer, fall history, and thyroid disease. Medication exposures associated with osteoporosis risk recognition included opioids, glucocorticoids, and antidepressants. Several known clinical risk factors for fracture were not correlated with osteoporosis risk including smoking and alcohol abuse. Results suggest that clinicians are relying on some, but not all, clinical risk factors when assessing osteoporosis risk.
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Affiliation(s)
- Richard E Nelson
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.
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