A population-based analysis of the post-fracture care gap 1996-2008: the situation is not improving

Opportunistic Assessment of Hip Fracture Risk Based on Chest CT

OBJECTIVE

Hip fracture (HF) has been described as the "last fracture of life" in the elderly, so the assessment of HF risk is extremely important. Currently, few studies have examined the relationship between imaging data from chest computed tomography (CT) and HF. This study demonstrated that pectoral muscle index (PMI) and vertebral body attenuation values could predict HF, aiming to opportunistically assess the risk of HF in patients without bone mineral density (BMD) based on chest CT for other diseases.

METHODS

In the retrospective study, 800 participants who had both BMD and chest CT were enrolled from January 2021 to January 2024. After exclusion, 472 patients were finally enrolled, divided into the healthy control (HC) group and the HF group. Clinical data were collected, and differences between the two groups were compared. A predictive model was constructed based on the PMI and CT value of the fourth thoracic vertebra (T4HU) by logistic regression analysis, and the predictive effect of the model was analyzed by using the receiver operating characteristic (ROC) curve. Finally, the clinical utility of the model was analyzed using decision curve analysis (DCA) and clinical impact curves.

RESULTS

Both PMI and T4HU were lower in the HF group than in the HC group (p < 0.05); low PMI and low T4HU were risk factors for HF. The predictive model incorporating PMI and T4HU on the basis of age and BMI had excellent diagnostic efficacy with an area under the curve (AUC) of 0.865 (95% confidence interval [CI]: 0.830-0.894, p < 0.01), sensitivity and specificity of 0.820 and 0.754, respectively. The clinical utility of the model was validated using calibration curves and DCA. The AUC of the predictive model incorporating BMD based on age and BMI was 0.865 (95% CI: 0.831-0.895, p < 0.01), with sensitivity and specificity of 0.698 and 0.711, respectively. There was no significant difference in diagnostic efficacy between the two models (p = 0.967).

CONCLUSIONS

PMI and T4HU are predictors of HF in patients. In the absence of dual-energy x-ray absorptiometry (DXA), the risk of HF can be assessed by measuring the PMI and T4HU on chest CT examination due to other diseases, and further treatment can be provided in time to reduce the incidence of HF.

Secondary fracture prevention in primary care: a narrative review

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.

High and very high risk of osteoporotic fracture in Colombia, 2003-2022: identifying diagnostic and treatment gaps

This study examined the clinical characteristics and refracture rates of Colombian patients with high- and very high-risk osteoporosis. This reveals osteoporosis diagnoses and treatment gaps. Only 5.3% of the patients were diagnosed with osteoporosis at discharge and 70.5% had refractures. This finding underscores the need for national policies to enhance osteoporosis prevention and treatment.

PURPOSE

This study aimed to assess the clinical features and refracture rates among patients with high- and very-high-risk osteoporosis in Colombia, highlighting diagnostic and treatment gaps.

METHODS

A retrospective observational study was conducted using the medical records of patients aged ≥ 50 years who experienced fragility fractures between 2003 and 2022. Clinical and demographic characteristics at the time of the initial fracture were analyzed, as well as the subsequent imminent risk (refracture rate) and the diagnosis and treatment gap.

RESULTS

303.982 fragility fractures occurred, and only 5.3% of patients were diagnosed with osteoporosis upon discharge. The most prevalent index fractures were forearm, vertebral, rib, and hip. Only 17.8% of the cohort had a matched osteoporosis diagnosis, indicating a low healthcare capture. Among the diagnosed patients, 10.08% were classified as high- and very high-risk of fracture, predominantly women with a mean age of 73 years. Comorbidities included diabetes, Sjögren's syndrome, and heart failure. The prevalence of osteoporosis has increased significantly from 2004 to 2022, possibly due to improved detection methods, an aging population, or a combination of both. Despite this increase, treatment delay was evident. Refractures affected 70.5% of the patients, with forearm, hip, humerus, and vertebral fractures being the most common, with a mean time of refracture of 7 months.

CONCLUSION

Significant delays were observed in the diagnosis and treatment of fragility fractures. Colombia's government and health system must address osteoporosis by implementing national policies that prioritize osteoporosis and fragility fracture prevention and reduce delays in diagnosis and treatment.

Vertebral HU value and the pectoral muscle index based on chest CT can be used to opportunistically screen for osteoporosis

BACKGROUND

Existing studies have shown that computed tomography (CT) attenuation and skeletal muscle tissue are strongly associated with osteoporosis; however, few studies have examined whether vertebral HU values and the pectoral muscle index (PMI) measured at the level of the 4th thoracic vertebra (T4) are strongly associated with bone mineral density (BMD). In this study, we demonstrate that vertebral HU values and the PMI based on chest CT can be used to opportunistically screen for osteoporosis and reduce fracture risk through prompt treatment.

METHODS

We retrospectively evaluated 1000 patients who underwent chest CT and DXA scans from August 2020-2022. The T4 HU value and PMI were obtained using manual chest CT measurements. The participants were classified into normal, osteopenia, and osteoporosis groups based on the results of dual-energy X-ray (DXA) absorptiometry. We compared the clinical baseline data, T4 HU value, and PMI between the three groups of patients and analyzed the correlation between the T4 HU value, PMI, and BMD to further evaluate the diagnostic efficacy of the T4 HU value and PMI for patients with low BMD and osteoporosis.

RESULTS

The study ultimately enrolled 469 participants. The T4 HU value and PMI had a high screening capacity for both low BMD and osteoporosis. The combined diagnostic model-incorporating sex, age, BMI, T4 HU value, and PMI-demonstrated the best diagnostic efficacy, with areas under the receiver operating characteristic curve (AUC) of 0.887 and 0.892 for identifying low BMD and osteoporosis, respectively.

CONCLUSIONS

The measurement of T4 HU value and PMI on chest CT can be used as an opportunistic screening tool for osteoporosis with excellent diagnostic efficacy. This approach allows the early prevention of osteoporotic fractures via the timely screening of individuals at high risk of osteoporosis without requiring additional radiation.

The Suitable Population for Opportunistic Low Bone Mineral Density Screening Using Computed Tomography

Objective

To explore the suitable population of CT value for predicting low bone mineral density (low-BMD).

Methods

A total of 1268 patients who underwent chest CT examination and DXA within one-month period retrospectively analyzed. The CT attenuation values of trabecular bone were measured in mid-sagittal plane from thoracic vertebra 7 (T7). Receiver operating characteristic (ROC) curves were used to evaluate the ability to diagnose low-BMD.

Results

The AUC for diagnosing low BMD was larger in women than in men (0.894 vs 0.744, p < 0.05). The AUC increased gradually with the increase of age but decreased gradually with the increase in height and weight (p < 0.05). In females, when specificity was adjusted to approximately 90%, a threshold of 140.25 HU has a sensitivity of 69.3%, which is higher than the sensitivity of 36.5% in males for distinguishing low-BMD from normal. At the age of 70 or more, when specificity was adjusted to approximately 90%, a threshold of 126.31 HU has a sensitivity of 76.1%, which was higher than that of other age groups.

Conclusion

For patients who had completed chest CTs, the CT values were more effective in predicting low-BMD in female, elderly, lower height, and lower weight patients.

Development and Validation of a Feature-Based Broad-Learning System for Opportunistic Osteoporosis Screening Using Lumbar Spine Radiographs

RATIONALE AND OBJECTIVES

Osteoporosis is primarily diagnosed using dual-energy X-ray absorptiometry (DXA); yet, DXA is significantly underutilized, causing osteoporosis, an underdiagnosed condition. We aimed to provide an opportunistic approach to screen for osteoporosis using artificial intelligence based on lumbar spine X-ray radiographs.

MATERIALS AND METHODS

In this institutional review board-approved retrospective study, female patients aged ≥50 years who received both X-ray scans and DXA of the lumbar vertebrae, in three centers, were included. A total of 1180 cases were used for training and 145 cases were used for testing. We proposed a novel broad-learning system (BLS) and then compared the performance of BLS models using radiomic features and deep features as a source of input. The deep features were extracted using ResNet18 and VGG11, respectively. The diagnostic performances of these BLS models were evaluated with the area under the curve (AUC), sensitivity, and specificity.

RESULTS

The incidence rate of osteoporosis in the training and test sets was 35.9% and 37.9%, respectively. The radiomic feature-based BLS model achieved higher testing AUC (0.802 vs. 0.654 vs. 0.632, both P = .002), sensitivity (78.2% vs. 56.4% vs. 50.9%), and specificity (82.2% vs. 74,4% vs. 75.6%) than the two deep feature-based BLS models.

CONCLUSION

Our proposed radiomic feature-based BLS model has the potential to expand osteoporosis screening to a broader population by identifying osteoporosis on lumbar spine X-ray radiographs.

Women's perspectives regarding osteoporosis, fracture risk, and pharmacologic treatment: a cross-sectional study

We assessed women's perspectives regarding early preventative therapy for osteoporosis. More than a third of early menopausal women were concerned about bone loss and future fractures, and approximately half were willing to take an intravenous or oral bisphosphonate around the time of menopause to preserve bone health.

PURPOSE

Bisphosphonate medications can prevent the substantial bone loss that occurs during early menopause, but little is known about whether women would accept bisphosphonate treatment at this time in their life, when imminent fracture risk is low. We assessed women's perspectives regarding bone loss, fracture risk, and preventative pharmacotherapy in early menopause.

METHODS

In this cross-sectional study, Canadian women aged ≥ 45 years were recruited via Facebook advertisement to complete an electronic survey. Primary outcome was the proportion of early menopausal respondents (≤ 5 years since final menstrual period) who were worried about bone loss and fractures. Secondary outcomes were the proportion of early menopausal women willing to accept pharmacologic intervention aimed at preventing either bone loss or future fractures. We compared responses between early menopausal women and older women (> 5 years since final menstrual period).

RESULTS

2033 women responded to the Facebook advertisement, 1195 eligible women (aged: 45 to 89 years) started the survey, and 966 completed it. Among early menopausal respondents (N = 98), 38 (42%) were worried about future fractures and 9 of 25 (36%) who had a prior bone mineral density scan were worried about their results. A total of 42 (47%) were willing to start medication to prevent fractures, and 48 (54%) would start medication to prevent bone loss. Responses were comparable between early menopausal women and older women.

CONCLUSION

Menopausal women are concerned about bone loss and fractures. Many women would consider early menopausal pharmacotherapy, with the goals of preserving bone health and lowering their risk of fractures.

Positive correlation between the proximal femur Hounsfield units from routine CT and DXA results

To determinate the correlation between the proximal femur Hounsfield unit (HU) value and dual-energy X-ray absorptiometry (DXA) results, and to identify its feasibility for opportunistic screening osteoporosis. A total of 680 patients underwent computed tomography (CT) containing proximal femur and DXA test within 6 months between 2010 and 2020 in our hospital. The CT HU value of four axial slices of the proximal femur were measured. The measurements were compared with the DXA results by Pearson correlation coefficient. Receiver operator characteristic curve were generated to identify the best cutoff for diagnosing osteoporosis. These 680 consecutive patients included 165 male and 515 female; the average age was 63.66 ± 11.36 years old, the mean interval time between two examinations was 45.43 days. The most representative CT HU value measurement was the 5-mm slice measurement. The average CT HU value was 59.3 ± 36.5 HU, and the differences among the three DXA defined bone mineral density (BMD) categories were significant (all p < 0.001). The Pearson correlation analysis showed that the proximal femur CT values had strong positive correlation with femoral neck T-score, femoral neck BMD and total hip BMD (r = 0.777, r = 0.748, r = 0.746, respectively; all p < 0.001). The area under the curve for CT value for diagnosing osteoporosis was 0.893 (p < 0.001), the best cutoff was 67 HU with 84% sensitivity, 80% specificity, 92% positive predictive value and 65% negative predictive value. Proximal femur CT values had good positive correlation with DXA results, which could be used to opportunistic screening for potential osteoporosis patient.

Hounsfield Unit for Evaluating Bone Mineral Density and Strength: Variations in Measurement Methods

OBJECTIVE

To assess the consistency and accuracy of various measurements of the Hounsfield unit (HU) in lumbar vertebrae.

METHODS

The study reviewed lumbar spine computed tomography images of 60 postmenopausal women aged >50 years. A total of 240 vertebrae were measured and analyzed for the variations of HU values in different sections and regions. Investigated the relationship between HU values of the lumbar spine under different measurements and dual-energy X-ray absorptiometry results and the ability to identify patients with osteoporosis.

RESULTS

HU values measured in midsagittal (r = 0.763), midcoronal (r = 0.768), and midaxial (r = 0.786) sections exhibited a strong positive correlation with dual-energy X-ray absorptiometry T-scores. HU values measured in midsagittal and midaxial sections of the vertebral body were in good agreement (P > 0.1), but decreased in the midcoronal (P < 0.001). HU values in the middle of the vertebral body were significantly higher than in the near end plate (P < 0.001). HU values varied between L1 and L4 vertebrae, but all had a good ability to identify osteoporosis and did not differ significantly in screening ability (P > 0.05).

CONCLUSIONS

An averaged HU value in axial multilevel is a comprehensive assessment of vertebral bone density. Using the HU value of the lumbar spine can help identify patients with osteoporosis, and the screening ability does not differ significantly across vertebral segments.

Hounsfield units on abdominal computed tomography: a new tool for predicting osteoporosis

BACKGROUND

Osteoporosis can cause bone fractures and disability, but early diagnosis faces challenges. Our proposed diagnostic indicators offer a new approach for early detection, which benefits early identification.

PURPOSE

To determine the most appropriate threshold for predicting osteoporosis in patients with each section of vertebral body.

MATERIAL AND METHODS

A retrospective analysis of 210 patients, including 646 vertebrae, who had both abdominal computed tomography (CT) and dual-energy X-ray absorptiometry (DXA) within six months. The correlation between DXA T-score and CT Hounsfield units (HU) values was tested by Pearson. The area under the curve (AUC) was calculated using the threshold obtained from the regression equation.

RESULTS

The thresholds matching the T-score of -2.5 were 85, 95, 85, and 90 HU for the upper axial plane of the vertebral body (Lau), the middle axial plane of the vertebral body (Lam), the lower axial plane of the vertebral body (Lad), and the mid-sagittal plane of the vertebral body (Lsm), respectively. Defining osteoporosis using CT as Lau ≤ 85, Lam ≤ 95, Lad ≤ 85, or Lsm ≤ 90 HU had a specificity of 88.1% (116/134) and sensitivity of 90.8% (69/76) for distinguishing DXA osteoporosis of the lumbar spine in 210 patients. T-score ≤-2.5 defined as Lau ≤85 or Lam ≤95 or Lad ≤85 or Lsm ≤90 HU had a specificity of 85.9% (275/320) and sensitivity of 82.8% (270/326) for DXA T-score ≤-2.5 in 646 lumbar vertebrae.

CONCLUSION

CT HU values obtained based on different sections of the vertebral body in abdominal CT can be used as a supplementary measure to assess osteoporosis.

The axial and sagittal CT values of the 7th thoracic vertebrae in screening for osteoporosis and osteopenia

AIM

To evaluate the difference in computed tomography (CT) attenuation value of different planes of the 7th thoracic vertebra and investigate the efficacy of axial and sagittal vertebral CT measurements in predicting osteoporosis.

MATERIALS AND METHODS

Patients who underwent routine chest CT and dual-energy X-ray absorptiometry (DXA) within 1 month were included in this retrospective study. The CT attenuation values of different planes were compared. Logistic regression and receiver operating characteristic (ROC) were used to analyse the difference of each plane in the diagnosis of osteoporosis.

RESULTS

The study included 1,338 patients (mean age of 61.9±11.9; 54% female). The CT attenuation values decreased successively in the normal group, osteopenia group, and osteoporosis group. The paired t-test results showed that the mid-axial measurements were greater than mid-sagittal measurements, with a mean difference of 9 HU, the difference was statistically significant (p<0.001, 95% confidence interval [CI] = 7.8-10.1). For each one-unit reduction in mid-sagittal CT attenuation value, the risk of osteopenia or osteoporosis increased by 3.6%. To distinguish osteoporosis from non-osteoporosis (osteopenia + normal), the sensitivity was 90% and the specificity was 52.4% at the mid-sagittal threshold of 113.7 HU.

CONCLUSIONS

The CT attenuation values of mid-sagittal plane have higher diagnostic efficacy than axial planes in predicting osteoporosis. For patients with a sagittal CT attenuation value of <113.7 HU in the T7, further DXA examination is warranted.

Exploring the osteoporosis treatment gap after fragility hip fracture at a Tertiary University Medical Center in Thailand

BACKGROUND

(1) To evaluate the prescription rate of anti-osteoporosis medication, and (2) to identify factors associated with patients not receiving anti-osteoporosis medication or, when prescribed, not persisting with medication 1 year after hip fracture treatment.

METHODS

We retrospectively reviewed the medical records of all fragility hip fracture patients admitted to the orthopedic unit of the Faculty of Medicine Siriraj Hospital, Mahidol University, between July 1, 2016, and December 31, 2019. We identified patients who did not receive anti-osteoporosis medication both 6 months and 1 year after fracture treatment. Patients who did not receive the medication 1 year after their treatment were enrolled and interviewed using a no-treatment questionnaire.

RESULTS

In total, 530 patients with fragility hip fractures were eligible (mean age, 79.0 years), and most (74.5%) were women. Only 148 patients (31.6%) received anti-osteoporosis medication 1 year after hip fracture. Logistic regression analysis identified predictors for not receiving the medication: male sex (OR 1.8; 95% CI 1.1-3.0), Charlson comorbidity index score ≥ 5 (OR 1.5; 95% CI 1.0-2.3), and secondary school education or below (OR 2.0; 95% CI 1.2-3.3). The main reason for not receiving the medication was that healthcare providers neither discussed nor initiated pharmacological treatment for osteoporosis (48.2%). When the medication was prescribed, non-persistence primarily stemmed from transportation difficulties that resulted in patients missing follow-ups (50.0%).

CONCLUSIONS

Improved physician attitudes toward anti-osteoporosis medications might enhance the treatment rate. Developing a follow-up team and facilitating access to medications (eg, courier delivery to patients) would promote therapy compliance.

TRIAL REGISTRATIONS

The protocol for the first phase and second phase was approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021) and for the second phase, patients-informed consent forms used in the cross-sectional component were approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021). The research was registered with the Thai Clinical Trials Registry (TCTR number: 20210824002). The study was conducted in accordance with the Declaration of Helsinki. Each patient (or a relative/caregiver) provided informed consent in writing or by telephone to participate in this second study phase.

An Orthopaedic Surgeon Led Osteoporosis (OSLO) Model of Care reduces early recurrent fracture rates and improves treatment compliance in patients treated for osteoporotic fractures

This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) in improving care of patients with primary osteoporotic fractures. The OSLO-MOC has shown to be effective in improving osteoporotic medication initiation and compliance and reducing secondary fracture rates in patients.

PURPOSE

This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) as compared to a Case Manager Led Osteoporosis Model of Care (CMLO-MoC) in reducing early osteoporotic re-fracture rates and treatment compliance in patients.

METHODS

This was a single centre, retrospective, comparative cohort study of all patients screened and treated for secondary osteoporotic fracture prevention from the 2008 to 2018 at an orthopaedic surgical unit. From the 2008 to 2013, patients were recruited under the CMLO-MoC and from 2014 to 2018, under the OSLO-MOC. Logistics regression analysis was used to identify significant predictors such as OSLO-MOC implementation, gender, ethnicity, marital status and education level for patient recruitment, treatment compliance and secondary fracture rates at 12-month follow-up.

RESULTS

Over a 10-year period, 7388 patients were screened of which 2855 patients were eligible for analysis. A total of 1234 patients were recruited under CMLO-MoC and 1621 patients under OSLO-MOC. Implementation of the OSLO-MOC was associated with greater patient recruitment, OR 1.26 (95%CI 1.06-1.49, P = 0.007). Of the 2855 patients recruited, OSLO-MOC implementation, OR 2.61 (95%CI 2.03-3.36, P < 0.001), and a higher level of education, OR 1.428 (95%CI 1.02-1.43, P = 0.037), were associated with improved compliance to medication at 12 months. OSLO-MOC implementation was the only factor associated with reduced risk of secondary fractures at 12 months, OR 0.14 (95%CI 0.03-0.66, P = 0.013).

CONCLUSION

The OSLO-MOC has shown to be effective in reducing the rate of re-fracture and osteoporotic medication initiation and compliance of patients.

LEVEL OF EVIDENCE

IV.

Routine chest CT combined with the osteoporosis self-assessment tool for Asians (OSTA): a screening tool for patients with osteoporosis

INTRODUCTION

The osteoporosis self-assessment tool for Asians (OSTA) is a common screening tool for osteoporosis. The seventh thoracic CT (CT-T7) Hounsfield unit (HU) measured by chest CT correlates with osteoporosis. This study aimed to investigate the diagnostic value of OSTA alone, CT-T7 alone, or the combination of OSTA and CT-T7 in osteoporosis.

MATERIALS AND METHODS

In this study, 1268 participants were grouped into 586 men and 682 women. We established multiple linear regression models by combining CT-T7 and OSTA. Receiver operating characteristic (ROC) curves were used to evaluate the ability to diagnose osteoporosis.

RESULTS

In the male group, the mean age was 59.02 years, and 108 patients (18.4%) had osteoporosis. In the female group, the mean age was 63.23 years, and 308 patients (45.2%) had osteoporosis. By ROC curve comparison, the CT-T7 (male, AUC = 0.789, 95% CI 0.745-0.832; female, AUC = 0.835, 95% CI 0.805-0.864) in the diagnosis of osteoporosis was greater than the OSTA (male, AUC = 0.673, 95% CI 0.620-0.726; female, AUC = 0.775, 95% CI 0.741-0.810) in both the male and female groups (p < 0.001). When OSTA was combined with CT, the equation of multiple linear regression (MLR) was obtained as follows: female = 3.020-0.028*OSTA-0.004*CT-T7. In the female group, it was found that the AUC of MLR (AUC = 0.853, 95% CI 0.825-0.880) in the diagnosis of osteoporosis was larger than that of CT-T7 (p < 0.01). When the MLR was 2.65, the sensitivity and specificity were 53.9% and 90%, respectively.

CONCLUSION

For a patient who has completed chest CT, CT-T7 (HU) combined with OSTA is recommended to identify the high-risk population of osteoporosis, and it has a higher diagnostic value than OSTA alone or CT-T7 alone, especially among females. For a female with MLR greater than 2.65, further DXA examination is needed.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort

BACKGROUND

Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture.

METHODS

A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery.

RESULTS

In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race.

INTERPRETATION

Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

Prediction of osteoporosis and osteopenia by routine computed tomography of the lumbar spine in different regions of interest

Background

We aimed to investigate the utility of Hounsfield units (HU) obtained from different regions of interest in opportunistic lumbar computed tomography (CT) to predict osteoporosis coupling with data of dual-energy X-ray absorptiometry (DXA).

Methods

A total of 100 patients who attended a university hospital in Shanghai, China, and had undergone CT and DXA tests of the lumbar spine within 3 months were included in this retrospective review. Images were reviewed on axial sections, and regions of interest (ROI) markers were placed on the round, oval, anterior, left, and right of the L1–L4 vertebra to measure the HU. The mean values of CT HU were then compared to the bone mineral density (BMD) measured by DXA. Receiver operator characteristic curves were generated to determine the threshold for diagnosis and its sensitivity and specificity values.

Results

The differences in CT HU of different ROI based on DXA definitions of osteoporosis, osteopenia, and normal individuals were statistically significant (p < 0.01). The HU values of the different ROI correlated well with the BMD values (Spearman coefficient all > 0.75, p < 0.01). The threshold for diagnosing osteoporosis varies from 87 to 111 HU in different ROIs, and the threshold for excluding osteoporosis or osteopenia is 99–125 HU.

Conclusion

This is the first study on osteoporosis diagnosis of different ROI with routine CT lumbar scans. There is a strong correlation between CT HU of different ROI in the lumbar spine and BMD, and HU measurements can be used to predict osteoporosis.

The Economic Burden of Severe Osteoporotic Fractures in the French Healthcare Database: The FRACTOS Study

Osteoporosis carries a high medical, economic, and societal burden principally because of the risk of severe fractures. The objective of this cost-of-illness study was to describe health resource utilization and associated costs in all patients aged ≥50 years hospitalized for a severe osteoporotic fracture over a 6-year period (2009 to 2014) in France. Data were extracted from the French national healthcare database (SNDS) on all health care resource utilization between the index date (date of hospitalization for first fracture during the enrollment period) and study end (December 31, 2016) or until the patient died. Costing was restricted to direct costs and determined from the payer perspective. Variables related to costs were identified through multivariate logistic regression analysis. A total of 356,895 patients were included (median follow-up 39.1 months). In the year after the index fracture, 36,622 patients (10.5%) were rehospitalized for a fracture-related reason. Only 18,474 (5.3%) underwent bone densitometry and 58,220 (16.7%) received a specific treatment. The total annual per capita osteoporosis-related cost in the year after the index severe osteoporotic fracture was €18,040 (from €8598 for multiple ribs to €21,085 for hip fracture) of which €17,905 was incurred by fracture-related costs. The cost incurred by management of osteoporosis was €135. Over years 2 to 5, the mean annual per capita costs of fracture treatment (€806, mostly attributable to the treatment of refractures) continued to dominate those of osteoporosis management (€99). Total annual cost of care was €1260 million (year 2014). Variables associated with higher cost were older age, male sex, site of fracture, a history of prior osteoporotic fracture, and the number of refracture events. The 5-year cost of severe osteoporotic fractures to the French health care system is high and mostly attributable to the treatment of refractures. Improved fracture prevention measures in patients with osteoporosis is crucial to reduce the economic burden of the disease. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

A micro-costing analysis of post-fracture care pathways: results from the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

This study identified the costs and health-related quality of life impacts of several post-fracture multidisciplinary care pathways specific to individual skeletal site (hip, distal forearm, vertebrae, humerus). These care pathways may assist healthcare providers in allocating resources for osteoporotic fractures in more effective and cost-efficient ways.

INTRODUCTION

This micro-costing study was undertaken to provide the estimated healthcare costs of several fracture site-specific health service use pathways associated with different trajectories of health-related quality of life (HRQoL) 12-months post-fracture.

METHODS

The study included 4126 adults aged ≥ 50 years with a fragility fracture (1657 hip, 681 vertebrae, 1354 distal forearm, 434 humerus) from the International Costs & Utilities Related to Osteoporotic fractures Study (ICUROS). ICUROS participants were asked to recall the frequency and duration (where applicable) of their health and community care service use at 4- and 12-month follow-up visits. Patient-level costs were identified and aggregated to determine the average cost of healthcare use related to the fracture in each care pathway (presented in Australian 2021 dollars). Mean cost differences were calculated and analysed using a one-way analysis of variance (ANOVA) and post hoc Bonferroni correction to determine any statistically significant differences.

RESULTS

The total direct cost of fractures was estimated at $89564, $38926, $18333, and $38461AUD per patient for hip, vertebral, wrist, and humeral participants, respectively. A Kruskal-Wallis test yielded a statistically significant difference in cost values between most care pathways (p < 0.001). Of the 20 care pathways, those associated with recovery of HRQoL had lower mean costs per patient across each fracture site.

CONCLUSIONS

This study identified the costs and HRQoL impacts of several multidisciplinary care pathways for individual fracture sites based on the health service utilization of an international cohort of older adults. These care pathways may assist healthcare providers in allocating resources for fragility fractures in more effective and cost-efficient ways.

Anti-osteoporotic Drug Utilization Rates for Secondary Prevention Among Patients with Osteoporotic Fractures

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.

Screening for osteoporosis using L1 vertebral density on abdominal CT in an Australian population

AIM

To assess the utility of osteoporosis screening using abdominal computed tomography (CT) versus dual-energy X-ray absorptiometry (DXA) T-scores as the reference.

MATERIALS AND METHODS

Patients ≥30 years undergoing abdominal CT and DXA within 12 months were assessed retrospectively. Bone mineral density (BMD) was measured using axial CT attenuation at L1, correlating with DXA T-scores. Sensitivity, specificity, area under the curve (AUC), and odds ratio (OR) were calculated.

RESULTS

The study cohort comprised 407 CT-DXA pairs (58.2% women). The prevalence of osteoporosis was 11.8%. L1 density and T-score were significantly correlated in both women (r=0.35, p<0.001) and men (r=0.15, p=0.04). The AUC to distinguish osteoporosis from osteopenia and normal BMD was 0.64 (95% CI: 0.56-0.71). In women, a threshold of 190 HU detected T-scores ≤ -2.5 with a negative predictive value (NPV) of 94.4% (OR=4.4, p<0.01). In the entire cohort, a threshold of 180 HU detected T-scores ≤ -2.5 with a NPV of 96.2% (OR=4.7, p<0.01).

CONCLUSIONS

CT L1 attenuation correlates with L1 DXA T-scores. Density values < 190 and 180 HU increased the probability of an osteoporosis diagnosis in Australian women and the overall cohort, respectively. Opportunistic screening for osteoporosis using abdominal CT is feasible, enabling identification of at-risk subjects for formal DXA imaging, thereby improving treatment initiation and reducing fracture risk.

Barriers and Expectations for Patients in Post-Osteoporotic Fracture Care in France: The EFFEL Study

OBJECTIVES

This study aimed to quantify the relative importance of barriers to better secondary prevention of osteoporotic fractures and of care expectations expressed by patients with osteoporotic fractures in France.

METHODS

A qualitative exploration of potential barriers to care and expectations was undertaken through a systematic literature review and in-depth patients interviews. A list of 21 barriers and 21 expectations was identified. These were presented to 324 subjects with osteoporotic fractures, identified in a representative sample of the French population, in the form of best-worst scaling questionnaires. Patients rated the relative importance of the attributes, and arithmetic mean importance scores were calculated and ranked. A Bayesian hierarchical model was also performed to generate a relative importance score. Latent class analysis was performed to identify potential subgroups of patients with different response profiles.

RESULTS

A total of 7 barriers were rated as the most important, relating to awareness of osteoporosis and coordination of care. The highest-ranked barrier, "my fracture is not related to osteoporosis," was significantly more important than all the others (mean importance score 0.45; 95% confidence interval 0.33-0.56). A similar ranking of attributes was obtained with both the arithmetic and the Bayesian approach. For expectations, no clear hierarchy of attributes was identified. Latent class analysis discriminated 3 classes of respondents with significant differences in response profiles (the educated environmentalists, the unaware, and the victims of the system).

CONCLUSIONS

Better quality of care of osteoporosis and effective secondary fracture prevention will require improvements in patient education, training of healthcare professionals, and coordination of care.

Osteoporosis in 10 years time: a glimpse into the future of osteoporosis

Patients living with osteoporosis are projected to increase dramatically in the next decade. Alongside the forecasted increased societal and economic burden, we will live a crisis of fractures. However, we will have novel pharmacological treatment to face this crisis and, more importantly, new optimized treatment strategies. Fracture liaison services will be probably implemented on a large scale worldwide, helping to prevent additional fractures in high-risk patients. In the next decade, novel advances in the diagnostic tools will be largely available. Moreover, new and more precise fracture risk assessment tools will change our ability to detect patients at high risk of fractures. Finally, big data and artificial intelligence will help us to move forward into the world of precision medicine. In the present review, we will discuss the future epidemiology and costs of osteoporosis, the advances in early and accurate diagnosis of osteoporosis, with a special focus on biomarkers and imaging tools. Then we will examine new and refined fracture risk assessment tools, the role of fracture liaison services, and a future perspective on osteoporosis treatment.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

The treatment gap after major osteoporotic fractures in Denmark 2005-2014: a combined analysis including both prescription-based and hospital-administered anti-osteoporosis medications

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.

Regional and gender-specific analyses give new perspectives for secular trend in hip fracture incidence

In this study, we found that regional disparity in incidence of hip fractures has converged. Also, annual hip fracture risk ratios between genders have systematically diminished over time.

INTRODUCTION

Several studies have reported secular trends in hip fracture incidence, but knowledge about the possible causes is limited. We studied potential explanations by examining spatio-temporal epidemiology of the fractures and estimating relative risks between genders.

METHODS

This observational study was based on all inpatient hospital discharges in 1972-2018 in Finland. We divided the data by gender, 5-year age groups and Finnish sub-regions and estimated gender and age standardized spatio-temporal rates of hip fractures by using a Bayesian age-period-cohort model.

RESULTS

In 1972, women's hip fracture incidence was 1.2-1.3 times higher in western and coastal Finland compared to eastern and inland areas. Also, women had approximately 1.7 times higher average risk to get a hip fracture compared to men. Today, the hip fracture differences between the areas have converged to insignificant and the relative risk between genders has diminished to 1.2. Age-specific relative risks indicate greater hip fracture risk for younger men and older women, and the women's risk increases beyond the risk of men at age 65 which is ten years later than in the beginning of the study period.

CONCLUSION

Incidence of hip fracture has converged significantly between regions and genders. Especially factors related with socioeconomic development and increased frailty and longevity seem to be important. The hip fracture incidence rate ratio between women and men has systematically decreased in time, and more attention should be paid to hip fracture risk in men in the future.

Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process

OBJECTIVES

To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool.

DESIGN

A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels.

SETTING AND PARTICIPANTS

A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members.

METHODS

Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17).

RESULTS

In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions.

CONCLUSIONS AND IMPLICATIONS

An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.

Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study

Group medical visits for osteoporosis can improve access to care while being highly accepted by patients. In this study, a similar proportion of women planned to initiate pharmacotherapy after attending a group or traditional one-on-one osteoporosis consultation, indicating that the group consultation model does not produce unexpected treatment decisions.

INTRODUCTION

Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation.

METHODS

In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician.

RESULTS

We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009).

CONCLUSION

Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.

Refracture and mortality following hospitalization for severe osteoporotic fractures: The Fractos Study

Severe osteoporotic fractures (hip, proximal humerus, pelvic, vertebral and multiple rib fractures) carry an increased risk of mortality. This retrospective cohort study in the French national healthcare database aimed to estimate refracture and mortality rates after severe osteoporotic fractures at different sites, and to identify mortality‐related variables. A total of 356,895 patients hospitalized for severe osteoporotic fracture between 2009 and 2014 inclusive were analyzed. The cohort was followed for 2 to 8 years up to the study end or until the patient died. Data were extracted on subsequent hospitalizations, refracture events, treatments, comorbidities of interest and survival. Time to refracture and survival were described using Kaplan‐Meier analysis by site of fracture and overall. Mortality risk factors were identified using a Cox model. Hip fractures accounted for 60.4% of the sample (N = 215,672). In the 12 months following fracture, 58,220 patients (16.7%) received a specific osteoporosis treatment, of whom 21,228 were previously treatment‐naïve. The 12‐month refracture rate was 6.3% (95% confidence interval [CI], 6.2%–6.3%), ranging from 4.0% (95% CI, 3.7%–4.3%) for multiple rib fractures to 7.8% (95% CI, 7.5%–8.1%) for pelvic fractures. Twelve‐month all‐cause mortality was 12.8% (95% CI, 12.7%–12.9%), ranging from 5.0% (95% CI, 4.7%–5.2%) for vertebral fractures to 16.6% (95% CI, 16.4%–16.7%) for hip fractures. Osteoporosis‐related mortality risk factors included fracture site, previous osteoporotic fracture (hazard ratio 1.21; 95% CI, 1.18–1.23), hip refracture (1.74; 95% CI, 1.71–1.77), and no prior osteoporosis treatment (1.24; 95% CI, 1.22–1.26). Comorbid cancer (3.15; 95% CI, 3.09–3.21) and liver disease (2.54; 95% CI, 2.40–2.68) were also strongly associated with mortality. In conclusion, severe osteoporotic fractures, including certain non‐hip nonvertebral fractures, carry a high burden in terms of mortality and refracture risk. However, most patients received no anti‐osteoporotic treatment. The findings emphasize the importance of better management of patients with severe fractures, and of developing effective strategies to reduce fracture risk in patients with osteoporosis. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Bone densitometry categories as a salient distracting feature in the modern clinical pathways of osteoporosis care: A retrospective 20-year cohort study

BACKGROUND

It is unknown as to what factors typically drive osteoporosis therapy decisions in real-world practice.

METHODS

Retrospective, 20-year cohort study within the government health system of Manitoba including all women having bone densitometry (BMD) tests between 1996 and 2017. Osteoporosis prescription data was linked to registry data on fractures, clinical risk factors and BMD tests. We defined 6 possible treatment decisions by prescription data: no treatment, starting, stopping, continuing, drug hiatus and re-starting. For each decision, we tested the association between salient patient factors (age, glucocorticoid use, recent fracture, BMD hip or spine T-score ≤ -2.5, FRAX major osteoporotic fracture probability ≥20%) using multivariable logistic regression. The factors were rank-ordered by decreasing Wald χ² statistic to determine the relative importance.

RESULTS

There were 64,181 women, 33.8% of whom started osteoporosis therapy. For patients who begin therapy after a first BMD, the rank-ordered multivariable logistic regression factor most strongly associated was the T-score ≤ -2.5 [OR of 7.59(95%CI 7.19-8.01, p < 0.001)]. This was followed by glucocorticoid use [OR 2.89(95%CI 2.59-3.22, p < 0.001)]. Increasing age and recent fracture (within 2 years) were weak predictors of therapy and high FRAX score associated with reduced odds of therapy [OR 0.80 (95%CI 0.74-0.88, p < 0.001)]. T-scores were the strongest factor predicting therapy stop/continuation/re-starting; age and prior fracture had weak or no associations.

CONCLUSIONS

Despite recommendations for fracture-risk-based approach to osteoporosis therapy, BMD T-score continues to be the dominant factor in actual practice. Age, prior fracture or global fracture risk are much less associated; it is possible that BMD T-score categories are therefore acting as a clinically salient distracting factor.

Osteoporosis Screening Is Often Indicated but Overlooked Prior to Rotator Cuff Repair

Purpose

To (1) report the percentage of patients undergoing rotator cuff repair (RCR) who were appropriately screened with dual-energy X-ray absorptiometry testing prior to surgery, if indicated, and (2) determine the percentage of patients properly prescribed osteoporosis medications within 6 months of surgery.

Methods

Consecutive patients aged 50 years or older who underwent elective RCR at a single tertiary-care center over a 1-year period were reviewed. Fracture risk was estimated using the Fracture Risk Assessment Tool (FRAX) with and without bone mineral density. The U.S. National Osteoporosis Foundation (NOF) criteria for screening and treatment were applied. Patients with acute fractures or revision surgery were excluded.

Results

Of the 218 patients included, 129 were women (58.1%). The mean age was 61.5 ± 7.2 years. One hundred thirty-one RCRs (60.1%) occurred within 3 months of injury. A total of 69 patients (31.7%) met the NOF criteria for bone mineral density screening. Of these patients, 23 (33.3%) were appropriately screened with a dual-energy X-ray absorptiometry scan. Primary care providers initiated bone health assessment in 18 of the 23 appropriately screened patients, with orthopaedic providers initiating the workup in 3 patients (13.0%). Thirty-two patients (14.7%) met the NOF criteria for pharmacologic management of osteoporosis. Of these patients, 5 (15.6%) were treated. Patients meeting the medication criteria were older (69.1 ± 7.7 years vs 60.2 ± 6.3 years, P < .001), had a lower body mass index (28.8 ± 6.1 vs 31.5 ± 6.5, P = .028), and had chronic rotator cuff tears (P = .015).

Conclusions

Patients aged 50 years or older undergoing RCR are often not appropriately screened for osteoporosis. Even when appropriately screened, only 15.6% of patients meeting the indications for pharmacologic intervention for bone health optimization were prescribed appropriate medications. Although bone health optimization may or may not affect surgical timing, patient encounters related to rotator cuff tears can be used as an opportunity for providers to initiate osteoporosis screening and treatment protocols.

Level of Evidence

Level IV, therapeutic case series.

Low-Energy Pelvic Ring Fractures: A Care Conundrum

Introduction:

A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care.

Results:

Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population.

Conclusions:

Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

Opportunistic screening for osteoporosis and osteopenia by routine computed tomography scan: A heterogeneous, multiethnic, middle-eastern population validation study

PURPOSE

We aimed define thresholds for HU values observed on opportunistic CT scans that suggest abnormal bone mineral density (BMD) in a heterogeneous Middle Eastern population.

METHODS

Consecutive patients who had undergone CT and dual-energy X-ray absorptiometry (DXA) test of the lumbar spine within 6 months were included in this retrospective study. Hounsfield units (HU) on lateral lumbar spine CT and BMD at the spine and hip on DXA were compared. Potential HU thresholds suggestive of abnormal BMD were established using receiver operating characteristic (ROC) analysis.

RESULTS

246 patients (mean age of 64 ± 11.6 years; 83 % female) were included. On DXA, 27 % had osteoporosis, 56 % had osteopenia, and 17 % had normal BMD. To distinguish osteoporosis from non-osteoporosis (osteopenia, normal BMD), a threshold of HU160 had sensitivity 95 % and the balanced threshold was HU121 (sensitivity 74 %, specificity 61 %). To distinguish normal from abnormal BMD (osteoporosis, osteopenia), a threshold of HU110 had specificity 93 % and the balanced threshold was HU149 (sensitivity 76 %, specificity 74 %).

CONCLUSIONS

In a heterogeneous Middle-Eastern population, our study supports the reported correlation between HU values on lumbar spine CT and BMD on DXA. In this population, HU > 160 correlates with low probability of osteoporosis on DXA, and screening examination is not warranted unless a vertebral fracture is detected; for HU ≤ 110 there is high probability of abnormal (osteoporosis or osteopenia) BMD, DXA examination is warranted; Finally, for HU 110-160, there is an intermediate chance of abnormal BMD, DXA examination may be warranted in specific patients with other risk factors.

Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service

OBJECTIVE

Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis.

METHODS

We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record.

RESULTS

We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008).

CONCLUSIONS

Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.

Group medical consultation for osteoporosis: a prospective pilot study of patient experience in Canadian tertiary care

BACKGROUND

Delivery of patient-centred care is limited by physician time. Group medical consultations may save physician time without compromising patient experience.

AIM

To assess patient experience and specialist physician time commitment in a group consultation for osteoporosis.

DESIGN AND SETTING

Prospective pilot study at a tertiary osteoporosis centre in Canada between May 2016 and June 2019.

METHOD

The authors evaluated women referred for osteoporosis who chose a 2-hour group consultation instead of a one-to-one consultation. Group consultations were led by an osteoporosis nurse and specialist physician, and consisted of individualised fracture risk assessment and education regarding osteoporosis therapies, followed by a decision-making exercise to choose a treatment plan. Patients then followed up with their GPs to implement this plan. Patient experience was assessed via a questionnaire immediately and 3 months post-consultation, at which time GP satisfaction and patient treatment status were also surveyed.

RESULTS

Of 560 referrals received, 18 patients declined osteoporosis specialist assessment, 54 could not be contacted, 303 attended a one-to- one consultation, and 185 attended a group consultation. Mean participant age was 62.8 years (standard deviation [SD] 5.8) and the Fracture Risk Assessment Tool (FRAX) 10-year osteoporotic fracture risk was 13.0 (SD 7.0)%. Immediately post-consultation, 104 (97.2%) patients were satisfied and 102 (95.3%) felt included in decision making. Satisfaction was reported by 95/99 (96.0%) patients and 27/36 (75.0%) GPs. Treatment plans had been enacted by 90 (90.1%) patients. For a matched number of individual consultations, each group session conferred a specialist physician time savings of 5.5 hours.

CONCLUSION

Group consultations represent a satisfactory and time-efficient alternative to one-to-one consultations for select patients with osteoporosis.

Secular trends in the initiation of therapy in secondary fracture prevention in Europe: a multi-national cohort study including data from Denmark, Catalonia, and the United Kingdom

This paper demonstrates a large post-fracture anti-osteoporosis treatment gap in the period 2005 to 2015. The gap was stable in Denmark at around 88-90%, increased in Catalonia from 80 to 88%, and started to increase in the UK towards the end of our study. Improved post-fracture care is needed.

INTRODUCTION

Patients experiencing a fragility fracture are at high risk of subsequent fractures, particularly within the first 2 years after the fracture. Previous studies have demonstrated that only a small proportion of fracture patients initiate therapy with an anti-osteoporotic medication (AOM), despite the proven fracture risk reduction of such therapies. The aim of this paper is to evaluate the changes in this post-fracture treatment gap across three different countries from 2005 to 2015.

METHODS

This analysis, which is part of a multinational cohort study, included men and women, aged 50 years or older, sustaining a first incident fragility fracture. Using routinely collected patient data from three administrative health databases covering Catalonia, Denmark, and the United Kingdom, we estimated the treatment gap as the proportion of patients not treated with AOM within 1 year of their first incident fracture.

RESULTS

A total of 648,369 fracture patients were included. Mean age 70.2-78.9 years; 22.2-31.7% were men. In Denmark, the treatment gap was stable at approximately 88-90% throughout the 2005 to 2015 time period. In Catalonia, the treatment gap increased from 80 to 88%. In the UK, an initially decreasing treatment gap-though never smaller than 63%-was replaced by an increasing gap towards the end of our study. The gap was more pronounced in men than in women.

CONCLUSION

Despite repeated calls for improved secondary fracture prevention, an unacceptably large treatment gap remains, with time trends indicating that the problem may be getting worse in recent years.

Coding and prescription rates of osteoporosis are low among distal radius fracture patients in Japan

INTRODUCTION

This study aimed to clarify the coding and prescription rates for osteoporosis in distal radius fracture patients and to investigate the associated factors to help prevent subsequent osteoporotic fracture.

MATERIALS AND METHODS

Between 2014-2015, among 294,374 eligible individuals (42% female) aged 50-75 years in a health insurance claims database, we identified 192 individuals (mean age: 59.8 years, 74% female), counted the coding of distal radius fracture (International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) code: S525, S526), and determined if the patient had been assigned the code for osteoporosis and been prescribed osteoporosis medications. Logistic regression was performed to identify factors related to each rate.

RESULTS

The osteoporosis coding rate and osteoporosis medication prescription rate were 17.2% (n = 33) and 10.9% (n = 21), respectively. Most codes were assigned ≤ 3 months after injury (88%) at the distal radius fracture treatment facilities (84.8%). Patients who were assigned the code for osteoporosis or treated with osteoporosis medications were older (p = 0.08, p = 0.02, respectively), female (p = 0.05, p = 0.06, respectively) and having comorbidity (p = 0.02, p = 0.07, respectively). After adjustment, being female and having comorbidity remained the independent factors for the assignment of the code for osteoporosis (OR: 3.30, 95%, CI: 1.08-10.07, OR: 2.77, 95% CI: 1.24-6.12, respectively). No factor remained significant for the osteoporosis prescription. Active vitamin D analogues were most frequently prescribed medication (67%) followed by bisphosphonates (48%).

CONCLUSION

The overall coding and prescription rates for osteoporosis after distal radius fracture were low, which suggested that physician adherence to the osteoporosis guideline was low.

Performance of a Fracture Liaison Service in an Orthopaedic Setting: A Report of Key Indicators and Improvement of Longitudinal Outcomes

BACKGROUND

Many Fracture Liaison Services (FLSs) have been successfully implemented, but very few incorporate systematic longitudinal follow-up. The objective of this study was to report on the performance of such an FLS using key performance indicators and longitudinal clinical outcomes.

METHODS

An FLS was implemented in 2 outpatient orthopaedic clinics. Men and women who were ≥40 years of age and had a recent fragility fracture were recruited. Participants were evaluated, treated when appropriate, and systematically followed over a 2-year period. Clinical data including chart review and questionnaires were collected. Medical services and hospitalization claims data were retrieved from administrative databases. The primary outcomes were the following key performance indicators: the numbers of investigated and treated patients, follow-up attendance, and the incidence of subsequent fractures. Secondary outcomes were the changes in bone turnover markers and quality of life, physical capacity, and pain scores between baseline and follow-up visits.

RESULTS

A total of 532 subjects with a mean age of 63.4 years were recruited; 85.7% were female. Bone mineral density results were collected for 472 subjects (88.7%) and a prescription for anti-osteoporosis medication was given to 86.6% of patients. Overall, 83.6% of patients attended at least 1 follow-up visit. The subsequent fracture incidence rate was 2.6 per 100 person-years (23 fractures). The mean level of type-I collagen C-telopeptide (CTX-1), a bone resorption marker, decreased >35%. Clinically important improvements of functional capacity scores (by 14.4% to 63.7%) and pain level (by 19.3% to 35.7%) were observed over time; however, the increase in quality-of-life scores was not clinically important (by 3% to 15.2%).

CONCLUSIONS

In this FLS, the rates of investigation, treatment, and participation were >80% over a 2-year period. The subsequent fragility fracture incidence rate was <3 per 100 person-years. These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective. A randomized controlled trial is needed to support these results.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Establishing baseline absolute risk of subsequent fracture among adults presenting to hospital with a minimal-trauma-fracture

Background

One in three women and one in five men are expected to experience a minimal-trauma-fracture after the age of 50-years, which increases the risk of subsequent fracture. Importantly, timely diagnosis and optimal treatment in the form of a fracture liaison service (FLS), has been shown to reduce this risk of a subsequent fracture. However, baseline risk of subsequent fracture among this group of FLS patients has not been well described. Therefore, this study aims to estimate absolute risk of subsequent fracture, among women and men aged 50-years or more, presenting to hospital with a minimal-trauma-fracture.

Methods

Women and men aged 50-years or more with a minimal-trauma-fracture, presenting to hospitals across the South Western Sydney Local Health District between January 2003 and December 2017 were followed to identify subsequent fracture presentations to hospital. Absolute risk of subsequent fracture was estimated, by taking into account the competing risk of death.

Results

Between January 2003 and December 2017–15,088 patients presented to the emergency departments of the five hospitals in the SWSLHD (11,149, women [74%]), with minimal-trauma-fractures. Subsequent fractures identified during the follow-up period (median = 4.5 years [IQR, 1.6–8.2]), occurred in 2024 (13%) patients. Death during the initial hospital stay, or during a subsequent hospital visit was recorded among 1646 patients (11%). Women were observed to have 7.1% risk of subsequent fracture after 1-year, following an initial fracture; and, the risk of subsequent fracture after 1-year was 6.2% for men. After 5-years the rate among women was 13.7, and 11.3% for men, respectively. Cumulative risk of subsequent fracture when initial fractures were classified as being at proximal or distal sites are also presented.

Conclusion

This study has estimated the baseline risk of subsequent fracture among women and men presenting to hospital with minimal trauma fractures. Importantly, this information can be used to communicate risk to patients deciding to attend an osteoporosis refracture prevention clinic, and highlight the need for screening, and initial of treatment when indicated, once a minimal-trauma-fracture has occurred.

Diagnostic efficacy of routine contrast-enhanced abdominal CT for the assessment of osteoporosis in the Turkish population

Background/aim

This study aimed to evaluate the diagnostic efficacy of vertebral Hounsfield unit (HU) values on routine contrast- enhanced abdominal computed tomography (CT) scans for the assessment of osteoporosis using dual-energy X-ray absorptiometry (DXA) T-scores as a reference standard.

Materials and methods

A total of 111 consecutive patients who underwent contrast-enhanced abdominal CT examination for any indication and DXA within a 6-month period were retrospectively analyzed. The CT attenuation values of trabecular bone in HUs were measured in axial and sagittal planes from lumbar vertebrae 1–4 (L1–L4). The correlation between the DXA T-scores and HU values measured on the CT scans was evaluated by Pearson’s correlation test. Areas under the curves (AUCs) were calculated by receiver operating characteristic analysis for diagnostic proficiency, and threshold values were determined. Paired t-test and Bland–Altman plot test were used to evaluate the correlation between axial and sagittal HU values.

Results

There was a strong correlation between the DXA T-scores and HU values of all the lumbar vertebrae (P < 0.001). The highest correlation was for the L3 vertebra; L3 was thus chosen for additional analyses. The mean axial and sagittal L3 attenuations were 133.7 HU and 131.9 HU, respectively. The axial measurements were not significantly different from the sagittal measurements, with a mean difference of 1.8 HU (P > 0.05). The L3 axial CT attenuation threshold for 90% sensitivity was 170 HU and that for 90% specificity was 102 HU for distinguishing osteoporosis from osteopenia and normal bone mineral density (BMD). To distinguish the low BMD group from the normal group, the L3 axial CT attenuation threshold for approximately 90% sensitivity was 102 HU and for 90% specificity was 165 HU.

Conclusion

The HUs derived from routine contrast-enhanced abdominal CT scans can be used for the evaluation of osteoporosis, without additional radiation exposure and cost.

Age at hip fracture and life expectancy in Denmark - Secular trends over two decades

BACKGROUND

Recent improvements in the health of the oldest old coexist with a decline in hip fracture rates, in particular in women. We speculated that increased longevity with decreasing hip fracture rates would result in a delay in hip fracture. We conducted an analysis of time trends in the age at hip fracture, by type and gender, for the past two decades using national data.

STUDY POPULATION AND METHODS

We used data from the Danish Hospital Discharge Register (1996-2017) to analyse the age distribution of femoral neck (FN) and pertrochanteric fractures (PT), allowing only the first fracture at each of these two sites to contribute to the analysis in each calendar year. Demographics for the background population at risk including life expectancy tabulations, were also obtained.

RESULTS

The average age at FN fracture in women increased slowly but significantly by 0.035years - or 12.8 days - per calendar year [0.035, 95% CI (0.016; 0.054), p<0.001], resulting in an increase from 79.6 to 80.4 years. There were no significant changes in the age at FN fracture in men or the age at PT fracture in women and men. Further, increases in life expectancy were considerably faster than any change observed in the age at hip fracture. In 1996, the average age at FN or PT fracture exceeded the average life expectancy in both men and women whereas the opposite was the case from 2009 and onwards in men and 2015 and onwards in women.

CONCLUSION

This study demonstrates a significant change in the demographics of hip fractures in Denmark over the past two decades. We observed a significant increase in the age at FN fracture in women but not in men, with no significant increase in the age at IT fracture and PT fracture. This developed much more slowly, however, than the increase in life expectancy in both sexes observed over the same period of time. Taken together, these changes resulted in a large decrease in the female to male incidence rate ratio from 2.6 and 2.5 (FN and PT, respectively) to 1.9 and 1.7.Additional effort is required to prevent hip fractures to ensure that the increasing life expectancy is matched by a similar increase in hip-fracture free life expectancy.

At Odds About the Odds: Women's Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds

BACKGROUND

Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values.

OBJECTIVE

We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds.

DESIGN AND PARTICIPANTS

This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center.

INTERVENTION

A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated¹ their 10-year MOF and hip fracture risk using FRAX and² their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation.

MAIN MEASURES

We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%).

KEY RESULTS

Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105).

CONCLUSIONS

Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.

A population-based study of postfracture care in Manitoba, Canada 2000/2001-2014/2015

We previously found that population-based postfracture notification, which informed primary care physicians of their patient's recent fracture and suggested assessment for osteoporosis, led to an improvement in postfracture care in the context of a randomized controlled trial ( ClinicalTrials.gov identifier NCT00594789, fractures from late 2007 to mid-2010). Since June 2010, a province-wide postfracture notification program was implemented. This study was to (1) determine whether this program has resulted in sustained improvement in postfracture care and (2) test factors associated with receiving osteoporosis care.

METHODS

A retrospective matched cohort study was performed using population-based health administrative data in Manitoba, Canada. We selected individuals aged 50+ years with an incident major osteoporosis fracture (MOF; N = 18,541) in fiscal years 2000/2001 to 2013/2014 and controls without a MOF (N = 92,705) matched (5:1) on age, sex, and residential area. The Cochran-Armitage test tested for a linear trend in osteoporosis care outcomes for cases and controls. Logistic regressions were used to test characteristics associated with the likelihood of receiving osteoporosis care.

RESULTS

The percentage of individuals receiving DXA testing and/or osteoporosis medication increased in fracture cases (p < 0.001), but decreased in controls (p < 0.001). Odds ratios for osteoporosis care in years following the postfracture notification program were approximately double of those prior to the clinical trial. In addition to prior MOF (OR 9.03, 95% CI 8.60-9.48), factors associated with osteoporosis care included lower income (OR   0.72, 95% CI 0.67-0.78), glucocorticoid use (OR   4.37, 95% CI 3.72-5.14), diabetes diagnosis (OR =  0.74, 95% CI 0.68-0.80), and Charlson Comorbidity Index (indexes 1-2: OR 1.27, 95% CI 1.20-1.34; indexes 3-5: OR 1.26, 95% CI 1.13-1.40).

CONCLUSIONS

Adopting a population-based postfracture notification program led to sustained improvements in postfracture care.

[Hounsfield units as a measure of bone density-applications in spine surgery]

Despite today's good diagnostic and therapeutic options for osteoporosis, the number of unidentified cases is very high and therapy is therefore usually inadequate. Frequently, the diagnosis of osteoporosis is made only after the occurrence of a fracture. The reason for this, apart from the costs incurred as well as the additional radiation exposure of the diagnostics, is certainly the limited availability of dual energy X‑ray absorptiometry (DEXA) as well as quantitative computed tomography (q-CT). In search of an alternative technique, Hounsfield units (HU) of the clinical CT examination proved to be ground-breaking: the results of previous investigations demonstrated a reliable correlation between the T values of the DEXA measurement and the HU of the same vertebral body. Due to the widespread use of clinical CT scans of the thorax and the abdomen for a variety of indications, it is expected that the number of unidentified cases of osteoporosis can be significantly reduced-without additional costs and radiation exposure associated with osteoporosis screening. In addition to osteoporosis diagnostics, the calculated HU may also provide better preoperative planning as well as predicting the further course of the disease. Thus, the risk for vertebral body fractures, screw loosening and cage sintering after ventral fusion operations can be sufficiently predicted. In this way, preoperative modifications to the surgical procedure can be made to reduce the risk of implant failure.

Implementing a fracture follow-up liaison service: perspective of key stakeholders

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.

Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues

Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.

Persistence and compliance to osteoporosis therapy in a fracture liaison service: a prospective cohort study

Persistence and compliance to osteoporosis medications aiming to prevent fragility fractures are essential for fracture prevention, but are suboptimal in the population. A Fracture Liaison Service with a systematic follow-up led to ongoing therapy and optimal drug compliance for more than half of treated patients over 2 years.

PURPOSE

Fracture Liaison Services (FLS) have the potential to improve persistence and compliance to osteoporosis therapy. We aimed to assess patterns of drug use in a high-level intervention FLS.

METHODS

Women and men (> 40 years) with a fragility fracture were recruited in a FLS, where osteoporosis therapy was prescribed if appropriate. Based on claims data, patients who filled their prescription in the 3-month period following baseline were selected. The 1- and 2-year persistence rates were measured using survival analysis. In non-persistent subjects, 1-year treatment re-initiation was measured. The 1- and 2-year compliance levels were measured, using the proportion of days covered (PDC > 80% = compliant). Regression analyses were performed to identify predictors of non-persistence/compliance.

RESULTS

Out of 332 subjects with complete drug insurance coverage, 297 (89.5%) were prescribed osteoporosis therapy by the FLS, and 275 (92.6%) were dispensed. Two hundred sixty participants (86.9% female; mean age 65.6 years) were selected for having filled a prescription inside 3 months after baseline. The 1- and 2-year persistence rates were 66.4% and 55.6%, respectively. Treatment re-initiation was observed in 56% of non-persistent patients. PDC was > 80% in 64.2% for 1 year and 62.5% for 2 years. Older and younger age, smoking, higher spine bone mineral density, lower major FRAX risk, and missing follow-up visits were predictors of non-persistence and/or non-compliance.

CONCLUSIONS

After 2 years in a high-level intervention FLS, more than half the treated participants were persistent and compliant to treatment. Comparative effectiveness studies must be undertaken to determine whether this intervention is an improvement over usual care.

Identification of Patients with Osteoporotic Vertebral Fractures via Simple Text Search of Routine Radiology Reports

Secondary fracture prevention programs mostly identify patients with symptomatic non-vertebral fractures, whereas asymptomatic vertebral fractures are usually missed. We here describe the development and validation of a simple method to systematically identify patients with radiographic vertebral fractures using simple text-based searching of free-text radiology reports. The study consisted of two phases. In the development phase (DP), twelve search terms were used to identify vertebral fractures in all X-ray and CT reports issued over a period of 6 months. Positive reports were manually reviewed to confirm whether or not a vertebral fracture had in fact been reported. The three search terms most effective in detecting vertebral fractures during the DP were then applied during the implementation phase (IP) over several weeks to test their ability to identify patients with vertebral fractures. The search terms 'Loss of Height' (LoH), 'Compression Fracture' (CoF) and 'Crush Fracture' (CrF) identified the highest number of imaging reports with a confirmed vertebral fracture. These three search terms identified 581 of 689 (84%) of all true vertebral fractures with a positive predictive value of 76%. Using these three terms in the IP, 126 reports were identified of which 100 (79%) had a vertebral fracture confirmed on manual review. Amongst a sample of 587 reports in week 1 of the IP, 7 (1.2%) were false negatives. Many patients with vertebral fractures can be identified via a simple text-based search of electronic radiology reports. This method may be utilised by secondary fracture prevention programs to narrow the 'care gap' in osteoporosis management.

Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study

Background

Osteoporosis prevention, diagnosis and treatment remain suboptimal.

Objectives

We conducted a qualitative study to understand barriers towards care initiation and levers to improve awareness and management of osteoporosis among general practitioners (GPs).

Methods

Semi-structured face-to face interviews were conducted with 16 GPs in the Rhône area of France to explore their knowledge and representations regarding osteoporosis. A thematic analysis of transcripts was performed to identify GPs’ perceptions on osteoporosis diagnosis, prevention, treatment and patients’ expectations.

Results

Interviewed GPs considered osteoporosis far less important than other chronic diseases. They questioned whether osteoporosis was a disease or normal aspect of ageing. They associated osteoporosis with fragility fractures, female sex, menopause, and old age but rarely with male sex. They regarded bone mineral density as the reference diagnostic test, but certain GPs indicated that they had difficulties to interpret the results and to know when to prescribe. Biphosphonates were mentioned as the reference treatment but some GPs expressed distrust about osteoporosis medications. Most of them did not think to screen for osteoporosis risk factors in their patients in a preventive medical approach. They mentioned the lack of time to implement prevention and were expecting clear and pragmatic guidelines, as well as information campaigns in general population to increase awareness on osteoporosis.

Conclusion

GPs tended to underestimate the salience of osteoporosis. Clear recommendations, better awareness of GPs and the general population could improve osteoporosis prevention and treatment.