Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender

Sex differences and predictors of anti-osteoporosis medication use in the 12 months after hip fracture surgery in adults 65 or older

PURPOSE

This study evaluates sex differences and predictors of anti-osteoporosis medication (AOM) use following a hip fracture, with a focus on older men who exhibit higher mortality rates post-fracture compared to women over the age of 65.

METHODS

Participants included 151 men and 161 women aged 65 and older with hip fractures. The outcome, AOM use, was assessed at baseline (≤ 22 days of hospitalization) and at 2, 6, and 12 months post-hip fracture. Generalized estimating equations (GEE) modeled sex differences and predictors of AOM use during the year post-fracture in 255 participants with complete baseline data and ≥ 1 follow-up observation.

RESULTS

Of the 312 participants, only 53 used AOM at baseline, and 35 initiated use during follow-up. In the unadjusted GEE model, AOM use was significantly less likely in men (OR = 0.42; 95% CI, 0.22-0.78) compared to women. For both men and women, baseline use of AOM was a significant predictor (OR = 28.3; 95% CI, 5.4-148.0 vs. 41.6; 95% CI, 14.0-123.0). The other significant predictors by sex were osteoporosis diagnosis (OR = 3.19; 95% CI, 1.16-8.77) and minimal alcohol use (OR = 3.26; 95% CI, 1.34-7.94) for women versus age (OR = 1.09; 95% CI, 1.01-1.18) for men.

CONCLUSION

In older adults with hip fractures, AOM use is low over the year post-fracture and men are less likely to report AOM use compared to women which has implications for important sex differences in predictors of use. Further research is needed to address overall disparities and sex differences in AOM use.

Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis

PURPOSE

This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location.

METHODS

We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions.

RESULTS

This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes.

CONCLUSION

Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.

Disparities in Osteoporosis Prevention and Care: Understanding Gender, Racial, and Ethnic Dynamics

PURPOSE

Osteoporosis, the most prevalent metabolic bone disease, significantly impacts global public health by increasing fracture risks, particularly among post-menopausal women and the elderly. Osteoporosis is characterized by decreased bone mineral density (BMD) and deterioration of bone tissue, which leads to enhanced fragility. The disease is predominantly diagnosed using dual X-ray absorptiometry (DXA) and is significantly influenced by demographic factors such as age and hormonal changes. This chapter delves into the condition's complex nature, emphasizing the pervasive gender and racial disparities in its screening, diagnosis, and treatment.

RECENT FINDINGS

Recent findings highlight a substantial gap in the management of osteoporosis, with many individuals remaining under-screened and under-treated. Factors contributing to this include the asymptomatic early stages of the disease, lack of awareness, economic barriers, and inconsistent screening practices, especially in under-resourced areas. These challenges are compounded by disparities that affect different genders and races unevenly, influencing both the prevalence of the disease and the likelihood of receiving adequate healthcare services. The summary of this chapter underscores the urgent need for targeted strategies to overcome these barriers and improve health equity in osteoporosis care. Proposed strategies include enhancing public and healthcare provider awareness of osteoporosis, broadening access to diagnostic screenings, and integrating personalized treatment approaches. These efforts aim to align with global health objectives to mitigate the impacts of osteoporosis and ensure equitable health outcomes across all demographic groups.

The digital health divide: Understanding telehealth adoption across racial lines in rural Illinois

Due to long-standing barriers to healthcare access in rural areas, telehealth has been promoted as an effective means of delivering healthcare services. However, there is a general absence of quantitative data showing how geographic residence and race affect telehealth adoption. This study examines variations in telehealth adoption based on race and geographic residence in Southern Illinois using a mail survey. It finds that residents of urban Carbondale, compared to those in rural Cairo, have better access to broadband and are more likely to use telehealth. Respondents significantly differ from each other based on their geographic location of residence and race when it came to using telehealth to save money on travel and to save money on childcare. A significant barrier to telehealth adoption identified across all groups is privacy protection concern. The findings highlight the crucial role of broadband infrastructure in healthcare access and the need for trust in telehealth systems to ensure data privacy.

Bone health assessment in adults with fragility fracture risk factors between 2002-2014: a retrospective cohort study

BACKGROUND

Lifetime risk of fragility fractures is 50% in post-menopausal women and 20% in men aged >50 years. Identifying people at high risk facilitates early intervention and reduction of biopsychosocial morbidity associated with these fractures.

AIM

To explore if bone health assessment (BHA) rates differ between women and men aged ≥50 years with fragility fracture risk factors.

DESIGN & SETTING

A primary care-based cohort study in North Staffordshire, UK.

METHOD

Patients were identified from the Consultations in Primary Care Archive (CiPCA) database between 2002 and 2014 with one or more fragility fracture risk factors (previous fractures, falls, and prolonged steroid use). Evaluation of BHA within 12 months of presentation of the first risk factor was carried out by searching for codes for fracture risk assessment tools (FRAX and QFracture), bone density measurement, specialist service referral, or if bone-protection medication was started.

RESULTS

A total of 15 581 patients with risk factors were identified; men represented 40.4% of the cohort. The study found 1172 (7.5%) had BHA performed within 1 year of presentation, and 8.9% of women and 5.5% of men had BHAs, which was found with strong statistical evidence (χ2 = 59.88, P = 1 × 10-14). This relationship prevailed after adjusting for other covariates, such as comorbidity and number of consultations, with an odds ratio of 1.25 (95% confidence interval [CI] = 1.08 to 1.43).

CONCLUSION

This study has shown that rates of BHA were generally low and even lower in men compared with women. Primary care clinicians should be alert to fragility fracture risk factors in both men and women to enable early assessment and intervention.

Challenges of fracture risk assessment in Asian and Black women

OBJECTIVES

Bone mineral density (BMD) and fracture risk calculators (eg, the Fracture Risk Assessment Tool [FRAX]) guide primary prevention care in postmenopausal women. BMD scores use non-Hispanic White (NHW) reference data for T-score classification, whereas FRAX incorporates BMD, clinical risk factors, and population differences when calculating risk. This study compares findings among Asian, Black, and NHW women who underwent osteoporosis screening in a US health care system.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

Asian, Black, and NHW women aged 65 to 75 years who underwent BMD testing (with no recent fracture, osteoporosis therapy, metastatic cancer, multiple myeloma, metabolic bone disorders, or kidney replacement therapy) were compared across the following measures: femoral neck BMD (FN-BMD) T-score (normal ≥ -1, osteoporosis ≤ -2.5), high FRAX 10-year hip fracture risk (FRAX-Hip ≥ 3%), FRAX risk factors, and diabetes status.

RESULTS

Among 3640 Asian women, 23.8% had osteoporosis and 8.7% had FRAX-Hip scores of at least 3% (34.5% among those with osteoporosis). Among 11,711 NHW women, 12.3% had osteoporosis and 17.2% had FRAX-Hip scores of at least 3% (84.8% among those with osteoporosis). Among 1711 Black women, 68.1% had normal FN-BMD, 4.1% had BMD-defined osteoporosis, and 1.8% had FRAX-Hip scores of at least 3% (32.4% among those with osteoporosis). Fracture risk factors differed by group. Diabetes was 2-fold more prevalent in Black and Asian (35% and 36%, respectively) vs NHW (16%) women.

CONCLUSIONS

A large subset of Asian women have discordant BMD and FRAX scores, presenting challenges in osteoporosis management. Furthermore, FN-BMD and especially FRAX scores identified few Black women at high fracture risk warranting treatment. Studies should examine whether fracture risk assessment can be optimized in understudied racial minority populations, particularly when findings are discordant.

Electronic Health Records (EHRs) Can Identify Patients at High Risk of Fracture but Require Substantial Race Adjustments to Currently Available Fracture Risk Calculators

BACKGROUND

Osteoporotic fracture prediction calculators are poorly utilized in primary care, leading to underdiagnosis and undertreatment of those at risk for fracture. The use of these calculators could be improved if predictions were automated using the electronic health record (EHR). However, this approach is not well validated in multi-ethnic populations, and it is not clear if the adjustments for race or ethnicity made by calculators are appropriate.

OBJECTIVE

To investigate EHR-generated fracture predictions in a multi-ethnic population.

DESIGN

Retrospective cohort study using data from the EHR.

SETTING

An urban, academic medical center in Philadelphia, PA.

PARTICIPANTS

12,758 White, 7,844 Black, and 3,587 Hispanic patients seeking routine care from 2010 to 2018 with mean 3.8 years follow-up.

INTERVENTIONS

None.

MEASUREMENTS

FRAX and QFracture, two of the most used fracture prediction tools, were studied. Risk for major osteoporotic fracture (MOF) and hip fracture were calculated using data from the EHR at baseline and compared to the number of fractures that occurred during follow-up.

RESULTS

MOF rates varied from 3.2 per 1000 patient-years in Black men to 7.6 in White women. FRAX and QFracture had similar discrimination for MOF prediction (area under the curve, AUC, 0.69 vs. 0.70, p=0.08) and for hip fracture prediction (AUC 0.77 vs 0.79, p=0.21) and were similar by race or ethnicity. FRAX had superior calibration than QFracture (calibration-in-the-large for FRAX 0.97 versus QFracture 2.02). The adjustment factors used in MOF prediction were generally accurate in Black women, but underestimated risk in Black men, Hispanic women, and Hispanic men.

LIMITATIONS

Single center design.

CONCLUSIONS

Fracture predictions using only EHR inputs can discriminate between high and low risk patients, even in Black and Hispanic patients, and could help primary care physicians identify patients who need screening or treatment. However, further refinements to the calculators may better adjust for race-ethnicity.

Effect of Race/Ethnicity on United States FRAX Calculations and Treatment Qualification: A Registry-Based Study

Since 2008. the United States has had four race/ethnic fracture risk assessment tool (FRAX) calculators: White ("Caucasian"), Black, Asian, and Hispanic. The American Society for Bone and Mineral Research Task Force on Clinical Algorithms for Fracture Risk has been examining the implications of retaining race/ethnicity in the US FRAX calculators. To inform the Task Force, we computed FRAX scores according to each US calculator in 114,942 White, 485 Black, and 2816 Asian women (self-reported race/ethnicity) aged 50 years and older. We estimated treatment qualification based upon FRAX thresholds (3% for hip fracture, 20% for major osteoporotic fracture [MOF]). Finally, we examined measures for a hypothetical population-based FRAX calculator derived as the weighted mean for the US population based upon US Census Bureau statistics. With identical inputs, the highest FRAX measurements were found with the White FRAX calculator, lowest measurements with the Black calculator, and intermediate measurements for the Asian and Hispanic calculators. The percentage of women with FRAX scores exceeding the hip fracture treatment threshold was 32.0% for White, 1.9% for Black, and 19.7% for Asian women; the MOF treatment threshold was exceeded for 14.9% of White, 0.0% of Black, and 3.5% of Asian women. Disparities in treatment qualification were reduced after considering additional criteria (fracture history and dual-energy X-ray absorptiometry [DXA] T-score -2.5 or lower). When fracture risk was recalculated for non-White women using the White FRAX calculator, mean values for Asian women slightly exceeded those for White women but for Black women remained substantially below those for White women. When using a single population-based FRAX calculator, the mean probability of fracture and treatment qualification increased for non-White women across the age range. In summary, use of a single population-based FRAX calculator, rather than existing US race/ethnic FRAX calculators, will reduce differences in treatment qualification and may ultimately enhance equity and access to osteoporosis treatment. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Racial/Ethnic Differences in Bone Mineral Density for Osteoporosis

PURPOSE OF REVIEW

We primarily aim to review differences in bone mineral density (BMD) for osteoporosis among different racial/ethnic groups and to highlight the magnitude of racial/ethnic differences in obesity and diabetes. We also explore the factors contributing to the BMD differences among various subgroups. In addition, we investigate the existing disparities in research, educational initiatives, screening practices, and treatment options for osteoporosis and discuss these findings' clinical and public health implications.

RECENT FINDINGS

Racial/ethnic differences in BMD for osteoporosis exist in the USA and other countries. There are disparities regarding osteoporosis screening and treatment. Understanding the factors contributing to these differences can help develop targeted interventions and policies to reduce their impact. Clinicians should consider the racial/ethnic differences in BMD when making treatment decisions and providing preventive care. Future research could contribute to developing effective strategies for preventing osteoporosis among different racial/ethnic groups. This review offered a comprehensive examination of differences in BMD across various racial and ethnic groups, elucidating the influence of genetic, lifestyle, and cultural factors on these differences. This review also highlighted the disparities in osteoporosis screening, treatment options, research on medical effectiveness, and educational outreach tailored to each subgroup. Recognizing the importance of addressing these inequalities, we present this review to advocate for targeted interventions to reduce disparities in osteoporosis and improve bone health for all populations.

Real-World Effectiveness of Osteoporosis Medications in France: A Nationwide Cohort Study

Although drugs for osteoporosis have been demonstrated to be effective in reducing fracture risk in placebo-controlled clinical trials, data on effectiveness in real-world practice is limited. Data from the French national health insurance claims database (SNDS) were used to follow five cohorts of women aged ≥55 years after initiating treatment for ≥6 months with either denosumab, zoledronic acid, oral bisphosphonates, raloxifene, or teriparatide in 2014-2016. Fracture incidence was compared within each cohort between the 3 months following initiation (baseline fracture risk) and the 12month, 18month, and 24 month postinitiation periods. Data are presented as incidence rate ratios (IRRs) with their 95% confidence intervals (CIs)s. Overall, 67,046 women were included in the denosumab cohort, 52,914 in the oral bisphosphonate cohort, 41,700 in the zoledronic acid cohort, 11,600 in the raloxifene cohort, and 7510 in the teriparatide cohort. The baseline vertebral fracture rate ranged from 1.74 per 1000 person years (‰PY) in the raloxifene cohort to 34.75‰PY in the teriparatide cohort, and the baseline hip fracture rate from 0.70‰PY in the raloxifene cohort to 10.52‰PY in the zoledronic acid cohort. Compared with the baseline fracture rate, vertebral fractures involving hospitalization were significantly reduced in the 3-24-month postinitiation period with denosumab (IRR 0.6; 95% CI, 0.5-0.7), zoledronic acid (IRR 0.4; 95% CI, 0.3-0.4), teriparatide (IRR 0.3; 95% CI, 0.2-0.5), and oral bisphosphonates (IRR 0.6; 95% CI, 0.4-0.8). Hip fracture incidence was reduced with denosumab (IRR 0.8; 95% CI, 0.6-0.9), but higher for oral bisphosphonates (IRR 1.7; 95% CI, 1.2-2.3); no significant change in hip fracture rate was observed for zoledronic acid, teriparatide, or raloxifene. A reduction in nonvertebral, non-hip fracture incidence was observed only in the denosumab cohort (IRR 0.8; 95% CI, 0.7-0.9). These findings indicate that treatment with osteoporosis drugs is effective in the real-world setting. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Ethnic determinants of skeletal health in female patients with fragility fracture in a culturally diverse population

Background

Low bone density leads to fragility fracture, with significant impact on morbidity and mortality. While ethnic differences in bone density have been observed in healthy subjects, this has not yet been explored in fragility fracture patients.

Aims

To assess if ethnicity is associated with bone mineral density and serum markers of bone health in female patients who experience fragility fractures.

Methods

219 female patients presenting with at least one fragility fracture at a major tertiary hospital in Western Sydney Australia were studied. Western Sydney is a region with great cultural diversity, comprising people from over 170 ethnicities. Within this cohort, the three largest broad ethnic groups were Caucasians (62.1 %), Asians (22.8 %), and Middle Eastern patients (15.1 %). Location and nature of the presenting fracture and other relevant past medical history were obtained. Bone mineral density, measured by dual-energy X-ray absorptiometry, and bone-related serum markers were compared between ethnicities. Covariates (age, height, weight, diabetes, smoking, and at-risk drinking) were adjusted in multiple linear regression model.

Results

Although Asian ethnicity was associated with lower bone mineral density at the lumbar spine in fragility fracture patients, this association was no longer significant after adjustment for weight. Ethnicity (Asian or Middle Eastern) was not a determinant of bone mineral density at any other skeletal site. Caucasians had lower estimated glomerular filtration rate compared to Asian and Middle Eastern subjects. Serum parathyroid hormone concentrations were significantly lower in Asians compared to other ethnicities.

Conclusion

Asian ethnicity and Middle Eastern ethnicity were not major determinants of bone mineral density at the lumbar spine, femoral neck, or total hip.

Algorithmic fairness in artificial intelligence for medicine and healthcare

In healthcare, the development and deployment of insufficiently fair systems of artificial intelligence (AI) can undermine the delivery of equitable care. Assessments of AI models stratified across subpopulations have revealed inequalities in how patients are diagnosed, treated and billed. In this Perspective, we outline fairness in machine learning through the lens of healthcare, and discuss how algorithmic biases (in data acquisition, genetic variation and intra-observer labelling variability, in particular) arise in clinical workflows and the resulting healthcare disparities. We also review emerging technology for mitigating biases via disentanglement, federated learning and model explainability, and their role in the development of AI-based software as a medical device.

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.

Bone health in ageing men

Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.

Calcium status assessment at the population level: Candidate approaches and challenges

Inadequate dietary calcium intake is a global public health problem that disproportionately affects low- and middle-income countries. However, the calcium status of a population is challenging to measure, and there are no standard methods to identify high-risk communities even in settings with an elevated prevalence of a disease caused or exacerbated by low calcium intake (e.g., rickets). The calcium status of a population depends on numerous factors, including intake of calcium-rich foods; the bioavailability of the types of calcium consumed in foods and supplements; and population characteristics, including age, sex, vitamin D status, and genetic attributes that influence calcium retention and absorption. The aim of this narrative review was to assess candidate indicators of population-level calcium status based on a range of biomarkers and measurement methods, including dietary assessment, calcium balance studies, hormonal factors related to calcium, and health outcomes associated with low calcium status. Several promising approaches were identified, but there was insufficient evidence of the suitability of any single indicator to assess population calcium status. Further research is required to develop and validate specific indicators of calcium status that could be derived from the analysis of data or samples that are feasibly collected in population-based surveys.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications.

INTRODUCTION

The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression.

RESULTS

A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40).

CONCLUSION

Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.

Osteoporosis identification among previously undiagnosed individuals with vertebral fractures

Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes.

INTRODUCTION

Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports.

METHODS

We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females.

CONCLUSION

Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.

Management of Postmenopausal Osteoporosis: ACOG Clinical Practice Guideline No. 2

PURPOSE

To provide updated evidence-based recommendations for the treatment of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients with primary osteoporosis.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on who should receive osteoporosis pharmacotherapy, the benefits and risks of available pharmacotherapy options, treatment monitoring and follow-up, and the role of calcium and vitamin D in the management of postmenopausal osteoporosis. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Racial Disparities and Inequalities in the Management of Patients With Osteoporosis

Osteoporosis is a skeletal disease characterized by low bone density and poor bone quality that weakens bones and increases the risk of fractures. Serious consequences of fractures include disability, loss of independence, and death. Despite the availability of clinical tools to evaluate fracture risk and medications to reduce fracture risk, many or most patients at risk, even those with a recent fracture, are not being treated. This represents a large osteoporosis treatment gap that has reached a crisis level. Importantly, the treatment gap is not evenly distributed among populations of different race/ethnicity. Black women are less likely to have bone density testing when indicated, are less likely to be treated, and have worse outcomes after a fracture than White women. This is a review and update of race-based disparities and inequalities, with suggestions for interventions to optimize patient care.

Osteoporosis referral and treatment among people with severe mental illness: A ten-year data linkage study

INTRODUCTION

People with severe mental illness (SMI) are at increased risk of osteoporosis but minimal information is available on their treatment and referral. We investigated differences in these outcomes between patients with/without SMI in linked primary and specialist care data.

METHODS

People with SMI aged 18+ at diagnosis with both primary and mental healthcare records between 1st May 2009 and 31st May 2019 from a south London catchment were matched 1:4 to randomly selected controls on gender, age and duration of primary care follow-up. Outcomes included prescription of osteoporosis medications and referrals for osteoporosis, analysed using multivariable logistic regression analyses.

RESULTS

The study included 2269 people with SMI and 9069 matched non-SMI controls. People with SMI were more likely to have a recorded prescription of osteoporosis medications (odds ratio [OR] = 3.54, 95% confidence interval [CI] 2.87, 4.35) and be referred for osteoporosis (OR = 1.51, 95% CI 1.09, 2.08) within 2 years after the date of first SMI diagnosis after adjusting for ethnicity, deprivation and Charlson Comorbidity Index. Factors including older age (osteoporosis medications: OR = 1.04, 95% CI 1.03, 1.05; osteoporosis referral: OR = 1.05, 95% CI 1.04, 1.07) and being prescribed with Class A analgesics (osteoporosis medications: OR = 1.91, 95% CI 1.31, 2.77; osteoporosis referral: OR = 1.77, 95% CI 1.02, 3.07) are significant predictors for osteoporosis management pathways within SMI patients.

CONCLUSION

People with SMI are more frequently prescribed medications for osteoporosis and referred to osteoporosis screening than the general population. Given the many risk factors for osteoporosis in this group, this increased rate of referrals may well be warranted, and there is need to pay more attention to this at-risk group. Screening studies are needed to determine whether the rate of referral is proportional to the need.

Uptake of osteoporosis treatment recommended by an orthogeriatrics service after hip fracture: Retrospective cohort study of prevalence and potential barriers and enablers at a tertiary referral hospital in Sydney

OBJECTIVES

The primary aim was to determine the 12-month period prevalence of and time to osteoporosis treatment following minimal trauma hip fractures in patients who were recommended treatment by an orthogeriatrics service. The secondary aim was to determine the factors associated with receiving treatment including the impact of osteoporosis clinic follow-up.

METHODS

A retrospective cohort study of patients with minimal trauma hip fractures admitted at a tertiary hospital in Sydney between 1 April 2017 and 31 March 2019 was performed. Baseline characteristics were collected from medical records. Osteoporosis treatment data were collected from patients and general practitioners. Univariate and multivariate logistic regression analyses were used to determine the factors associated with receiving osteoporosis treatment.

RESULTS

There were 189 participants who consented to participate with a mean age of 84.6 years. Most (76.7%) were females, 18.5% were nursing home residents, 70.9% had normal cognition, 20.6% were taking osteoporosis treatment prior to admission, 61.9% had osteoporosis treatment recommendations documented on the discharge summary, and 10.1% were followed up in the osteoporosis clinic. Ninety-eight patients (51.9%) received treatment within the first 12 months after fracture with a median time to treatment of 90 days. Factors associated with receiving osteoporosis treatment within 12 months on multivariate analysis included normal cognition (p = 0.03), taking osteoporosis treatment prior to admission (p < 0.001), including treatment recommendations in the discharge summary (p = 0.006) and osteoporosis clinic follow-up (p < 0.001).

CONCLUSIONS

Osteoporosis treatment after hip fracture remains suboptimal at this hospital. Patient and health service factors associated with treatment uptake could inform future quality improvement work.

Disparities in osteoporosis care among postmenopausal women in the United States

Osteoporosis and fragility fractures result in significant morbidity and mortality and contribute to substantial healthcare costs. Despite being a treatable disease, osteoporosis remains both underdiagnosed and undertreated in the US general population, with significant disparities in care between non-White and White women. These disparities are evident from screening to post-fracture treatment. Non-White women are less likely to be screened for osteoporosis, to be prescribed pharmacotherapy, or to receive treatment post-fracture; furthermore, the mortality rate after fracture is higher in non-White women. Given existing diagnostic and treatment disparities, additional studies and interventions are needed to optimize the bone health of Asian, Black, Hispanic, and Native American women, and to reduce morbidity and mortality from osteoporosis and fragility fractures.

Challenges and Opportunities for Osteoporosis Care During the COVID-19 Pandemic

PURPOSE

The coronavirus disease 2019 (COVID-19) has both directly and indirectly affected osteoporosis diagnosis and treatment throughout the world.

METHODS

This mini-review summarizes the available evidence regarding the effects of COVID-19, its treatment, and the consequences of the pandemic itself on bone health. Additionally, we review evidence and expert recommendations regarding putative effects of osteoporosis medications on COVID-19 outcomes and vaccine efficacy and summarize recommendations for continuation of osteoporosis treatment during the pandemic.

RESULTS

The use of standard screening procedures to assess for osteoporosis and fracture risk declined dramatically early in the pandemic, while rates of fragility fractures were largely unchanged. COVID-19, its treatments, and public health measures to prevent viral spread are each likely to negatively affect bone health. Osteoporosis treatments are not known to increase risk of adverse events from COVID-19, and preclinical data suggest possible beneficial effects of some therapies. Vitamin D deficiency is clearly associated with adverse outcomes from COVID-19, but it remains unclear whether vitamin D supplementation may improve outcomes. Osteoporosis treatment should be continued whenever possible, and recommendations for substituting therapies, if required, are available.

CONCLUSION

The COVID-19 pandemic has decreased screening and disrupted treatment for osteoporosis. Osteoporosis medications are safe and effective during the pandemic and should be continued whenever possible. Further studies are needed to fully understand the impact of the COVID-19 pandemic on long-term bone health.

Racial and Ethnic Disparities in Bone Health and Outcomes in the United States

Osteoporosis is a bone disease classified by deterioration of bone microarchitecture and decreased bone strength, thereby increasing subsequent risk of fracture. In the United States, approximately 54 million adults aged 50 years and older have osteoporosis or are at risk due to low bone mass. Osteoporosis has long been viewed as a chronic health condition affecting primarily non-Hispanic white (NHW) women; however, emerging evidence indicates racial and ethnic disparities in bone outcomes and osteoporosis management. The primary objective of this review is to describe disparities in bone mineral density (BMD), prevalence of osteoporosis and fracture, as well as in screening and treatment of osteoporosis among non-Hispanic black (NHB), Hispanic, and Asian adults compared with NHW adults living on the US mainland. The following areas were reviewed: BMD, osteoporosis prevalence, fracture prevalence and incidence, postfracture outcomes, DXA screening, and osteoporosis treatments. Although there are limited studies on bone and fracture outcomes within Asian and Hispanic populations, findings suggest that there are differences in bone outcomes across NHW, NHB, Asian, and Hispanic populations. Further, NHB, Asian, and Hispanic populations may experience suboptimal osteoporosis management and postfracture care, although additional population-based studies are needed. There is also evidence that variation in BMD and osteoporosis exists within major racial and ethnic groups, highlighting the need for research in individual groups by origin or background. Although there is a clear need to prioritize future quantitative and qualitative research in these populations, initial strategies for addressing bone health disparities are discussed. © 2021 American Society for Bone and Mineral Research (ASBMR).

Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1

PURPOSE

To provide updated evidence-based recommendations for the prevention, screening, and diagnosis of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients without identified risk factors for fracture, low bone mineral density, or secondary osteoporosis related to medication or a medical condition.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within the Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team on the basis of standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations, Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on the role of exercise, calcium, and vitamin D in osteoporosis prevention; osteoporosis screening and diagnosis; rescreening intervals; and interventions to prevent falls. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Management of osteoporosis in older men

As many as one out of three fragility fractures occur in older men and the outcome of major osteoporotic fractures, in particular hip fractures, is worse in men than in women. Osteoporosis in older men is thus an important threat to the quality of life of individual patients and a considerable burden for society. However, only a small minority of older men with high or very high fracture risk are receiving therapy. This does not need to be so as tools for fracture risk assessment are available and several drugs have been approved for treatment. Nevertheless, the evidence base for the management of osteoporosis in older men remains limited. This narrative review summarises the evidence for older men on the burden of osteoporosis, the pathophysiology of fragility fractures, the clinical presentation, diagnosis and risk assessment, the patient evaluation, and the non-pharmacological and pharmacological management.

The accuracy of different FRAX tools in predicting fracture risk in Japan: A comparison study

INTRODUCTION

The web version of Fracture Risk Assessment (FRAX) tool is widely used in many countries to predict the 10-year probability of major osteoporotic fracture (MF) and hip fracture (HF) rate. However, other FRAX tools, calculator older version (first generation), calculator new version (second generation), and application of mobile software had also been used in Japan.

PURPOSE

The aim of this study is to investigate the consistency of results obtained from the four predicting tools for MF and HF rate in both male and female groups.

METHODS

The data were extracted from 2016 medical examination report of Japanese Ministry of Health of Labor and Welfare. The MF and HF rates were calculated from 40 to 90 years old under different risk factors using four FRAX tools while the consistency of predicting value was evaluated.

RESULTS

The predicted MF or HF rates were extremely similar among calculator new version, mobile software, and website version in each risk factors. On other hand, for calculator older version, the predicted MF or HF rates are a little higher than other versions. The significant difference is only present in patients aged 75 and above, and this exceeds the FRAX threshold older than 75 years old by Japanese Society for Bone and Mineral Research.

CONCLUSIONS

The application of four FRAX tools generated consistent results in predicting the 10-year probability of major osteoporotic fracture and HF for clinical practice, which provides an effective evidence for clinical application.

Circulating microRNAs in serum as novel biomarkers for osteoporosis: a case-control study

AIMS

Osteoporosis is underdiagnosed because of the lack of a convenient diagnostic method. Circulating microRNAs (miRNAs) emerge as novel biomarkers for disease diagnosis. Here, we conducted a case-control study that included a total of 448 serum samples collected from 182 healthy participants, 132 osteopenia participants, and 134 osteoporosis patients.

METHODS

Circulating miRNAs dysregulated during osteoporosis were screened and analyzed in three randomly determined sub-cohorts: the discovery cohort identified 22 candidate miRNAs; the training cohort tested the candidate miRNAs and constructed Index 1, comprising five miRNAs by logistic regression, and Index 2, comprising four miRNAs, was developed by linear combination.

RESULTS

Both indices were tested in the validation cohort and showed statistically significant results in distinguishing osteoporosis patients from healthy and osteopenic patients. Moreover, Index 1 also showed improved performance over traditional bone turnover biomarkers type I pro-collagen (tPINP) and type I collagen (β-CTx).

CONCLUSION

In conclusion, circulating miRNAs are potential biomarkers for osteoporosis. The diagnostic panel of circulating miRNAs could be a complementary method for dual-energy X-ray absorptiometry (DXA) in mass screening and routine examination to enhance the osteoporosis detection rate.

Hip fractures and characteristics of living area: a fine-scale spatial analysis in France

We investigated the association between hip fracture incidence and living area characteristics in France. The spatial distribution of hip fracture incidence was heterogeneous and there was a significant relationship between social deprivation, urbanization, health access, and hip fracture risk.

INTRODUCTION

Several studies have shown great disparities in spatial repartition of hip fractures (HF). The aim of the study was to analyze the association between HF incidence and characteristics of the living area.

METHODS

All patients aged 50 or older, living in France, who were hospitalized for HF between 2012 and 2014 were included, using the French national hospital discharge database. Standardized incidence ratio (SIR) was calculated for each spatial unit and adjusted on age and sex. An ecological regression was performed to analyze the association between HF standardized incidence and ecological variables. We adjusted the model for neighborhood spatial structure. We used three variables to characterize the living areas: a deprivation index (French-EDI); healthcare access (French standardized index); land use (percentage of artificialized surfaces).

RESULTS

A total of 236,328 HF were recorded in the French hospital national database, leading to an annual HF incidence of 333/100,000. The spatial analysis revealed geographical variations of HF incidence with SIR varying from 0.67 (0.52; 0.85) to 1.45 (1.23; 1.70). There was a significant association between HF incidence rates and (1) French-EDI (trend p = 0.0023); (2) general practitioner and nurse accessibility (trend p = 0.0232 and p = 0.0129, respectively); (3) percentage of artificialized surfaces (p < 0.0001).

CONCLUSION

The characteristics of the living area are associated with significant differences in the risk of hip fracture of older people.

Diabetes-Related Fracture Risk Is Different in African Americans Compared With Hispanics and Caucasians

CONTEXT

Diabetes mellitus (DM) has been associated with a 60% to 90% increased risk of fracture but few studies have been performed in African American and Hispanic subjects.

OBJECTIVE

The aim of the present study was to quantify the risk of incident major osteoporotic fractures (MOFs) of the hip, wrist, and humerus in African Americans, Hispanics, and Caucasians with DM compared with those with hypertension (HTN).

METHODS

We performed a retrospective cohort study of 19,153 subjects with DM (7618 Caucasians, 7456 African Americans, and 4079 Hispanics) and 26,217 with HTN (15,138 Caucasians, 8301 African Americans, and 2778 Hispanics) aged ≥40 years, treated at a large health care system in Philadelphia, Pennsylvania. All information about the subjects was obtained from electronic health records.

RESULTS

The unadjusted MOF rates for each race/ethnicity were similar among those with DM and those with HTN (Caucasians, 1.85% vs 1.84%; African Americans, 1.07% vs 1.29%; and Hispanics, 1.69% vs 1.33%; P = NS for all). However, the MOF rates were higher for Caucasians and Hispanics with DM than for African Americans with DM (P < 0.01). In a multivariable model controlled for age, body mass index, sex, and previous MOF, DM was a statistically significant predictor of MOFs only for Caucasians and Hispanics [hazard ratio (HR), 1.23; 95% CI, 1.02 to 1.48; P = 0.026] but not for African Americans (HR, 0.92; 95% CI, 0.68 to 1.23; P = 0.56).

CONCLUSIONS

Hispanics had a DM-related fracture risk similar to that of Caucasians, but AAs did not have an additional fracture risk conferred by DM.

Balance performance and related soft tissue components across three age groups

With the aging process, falls and related injuries are common and unwanted events among older women. Lost balance is the last step before the frequent experience of falls. After menopause, women's bone conditions regarding health and balance performance steeply decline often resulting in serious injury. Our purpose in the study is to identify balance performance and its associations with soft tissue components among Korean-American (KA) women with three menopausal conditions. Researchers conducted a cross-sectional study with 63 KA women divided into three age groups: 25-35 years (young), 45-55 years old (middle), and 65+ years (old). Lean and fat mass on the entire body, appendicular and gynoid areas were measured by using the dual X-ray absorptiometry. Static and dynamic balance and physical performance (floor sit to stand) were tested. We found that with increased aging, lean mass, fat and body mass index were changed; balance and physical performance decreased significantly. In regression models, age and fat ratio of android/gynoid changes explain static balance and physical performance; appendicular lean mass predicted dynamic balance. With advancing age, maintaining lean mass and proportion of fat accumulation is critical for stable balance.

Time since menopause, but not age, is associated with increased risk of osteoporosis

Objectives: This study aimed to determine whether estrogen deficiency is a sole risk factor for osteoporosis or is also associated with age, through indicators such as gender, age, and time since menopause. Methods: A cross-sectional study was conducted evaluating 938 postmenopausal women who underwent bone mineral densitometry. We collected the following data: age, ethnic group, body mass index, smoking, and time since menopause. These data were correlated to the presence of osteoporosis, according to the T-score of the femur and lumbar spine. Results: The prevalence of osteoporosis was 37.8%. Ethnic group (p = 0.47) and smoking habits (p = 0.19) were not associated with osteoporosis. In the group of women with osteoporosis, mean age was significantly higher (p < 0.001), mean body mass index was significantly lower (p < 0.001), and time since menopause was significantly higher (p < 0.001) than in the group of women with no osteoporosis. After multivariate analysis was performed, the only variables that remained independently associated with osteoporosis were body mass index and time since menopause. Higher body mass index was a protective factor (odds ratio = 0.80 [95% confidence interval 0.76; 0.84], p < 0.001). Time since menopause represented a risk factor for osteoporosis (odds ratio = 1.04 [1.02; 1.06], p < 0.001). When divided into categories, the risk increased after 20 years of menopause and gradually every 5 years. Conclusion: Time since menopause and body mass index were the most important factors associated with osteoporosis, confirming that estrogen deficiency, and not age, is the major cause of the disease.

The effect of testosterone itself and in combination with letrozole on bone mineral density in male rats

Testosterone is an essential hormone to maintain bone integrity; however, the effect of aromatase enzyme in androgen-induced bone maintenance remains somewhat unclear. The present study evaluated the effect of testosterone itself and combined with letrozole, an aromatase inhibitor, on bone mineral density of male rats. Total of 48 male rats were divided into 4 equal groups (n = 12/group); sham group, O: orchiectomy, O + T: orchiectomized rats treated with testosterone, O + T + L: orchiectomized rats treated with combination of testosterone and letrozole. Bone density (BMD), bone markers, and vitamin D metabolism parameters were checked in all groups before and after the study. There was no significant difference in baseline values of these parameters, but at the end of the study there was a significant decrease in delta BMD at both lumbar and femor in orchiectomized rats in comparison with the sham group (p < 0.001, p < 0.001, respectively). Both testosterone and its combination with letrozole increased lumbar and femoral BMD of orchiectomized rats, with a higher increase in lumbar BMD in O + T group. CTX were higher in O group rats. The present study showed a major role for testosterone on BMD maintenance in male rats. However, testosterone has a potent effect on lumbar BMD, by the aromatization to estradiol.

Hemiarthroplasty or Total Hip Arthroplasty: Is There a Racial Bias in Treatment Selection for Femoral Neck Fractures?

Introduction

Hip fractures in the elderly individuals are associated with significant morbidity and mortality, and outcomes are directly related to prompt surgical intervention with either total hip arthroplasty (THA) or hemiarthroplasty. Minority hip fracture patients have increased delays to surgical intervention and poorer functional outcomes. This study explored racial biases in the surgical treatment decision between THA and hemiarthroplasty for displaced femoral neck fractures as well as racial disparities in postoperative complications, readmission rates, and 30-day mortality.

Methods

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2014. Patients were identified using diagnosis code for transcervical femoral neck fractures and Current Procedural Terminology codes for THA or hemiarthroplasty. A multivariable regression analysis was conducted including race, demographic information, and medical comorbidities.

Results

Of 11 408 patients, race was recorded in 8538 individuals. Most patients were white (88.3%), followed by Hispanic (4.7%), African American (4.1%), and Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native (2.9%). No differences were observed in the likelihood of receiving a THA versus hemiarthroplasty among racial groups. Only younger age and steroid use were independent risk factors for receiving a THA. Race was significantly associated with postoperative mortality (P = .014) and major postoperative complications for the Asian cohort (P = .013).

Discussion

The NSQIP data do not support a racial bias in the selection of patients for THA versus hemiarthroplasty. However, this study found racial disparities in postoperative mortality and complications. The reasons underlying the differences in postoperative outcomes are uncertain but may be the result of specific challenges to accessing care.

Conclusion

There was no racial bias in the treatment of femoral neck fractures. However, there were racial disparities in postoperative mortality and complication rates. Further research is warranted to elucidate the true causes of these observed disparities.

The Endocannabinoid/Endovanilloid System in Bone: From Osteoporosis to Osteosarcoma

Bone is a dynamic tissue, whose homeostasis is maintained by a fine balance between osteoclast (OC) and osteoblast (OB) activity. The endocannabinoid/endovanilloid (EC/EV) system’s receptors are the cannabinoid receptor type 1 (CB1), the cannabinoid receptor type 2 (CB2), and the transient receptor potential cation channel subfamily V member 1 (TRPV1). Their stimulation modulates bone formation and bone resorption. Bone diseases are very common worldwide. Osteoporosis is the principal cause of bone loss and it can be caused by several factors such as postmenopausal estrogen decrease, glucocorticoid (GC) treatments, iron overload, and chemotherapies. Studies have demonstrated that CB1 and TRPV1 stimulation exerts osteoclastogenic effects, whereas CB2 stimulation has an anti-osteoclastogenic role. Moreover, the EC/EV system has been demonstrated to have a role in cancer, favoring apoptosis and inhibiting cell proliferation. In particular, in bone cancer, the modulation of the EC/EV system not only reduces cell growth and enhances apoptosis but it also reduces cell invasion and bone pain in mouse models. Therefore, EC/EV receptors may be a useful pharmacological target in the prevention and treatment of bone diseases. More studies to better investigate the biochemical mechanisms underlining the EC/EV system effects in bone are needed, but the synthesis of hybrid molecules, targeting these receptors and capable of oppositely regulating bone homeostasis, seems to be a promising and encouraging prospective in bone disease management.

Race Plays a Role in the Knowledge, Attitudes, and Beliefs of Women with Osteoporosis

Using a concurrent mixed methods design, we investigated how knowledge, attitudes, values, and beliefs among women with osteoporosis can explain racial disparities in bone health. We recruited African American and White women ≥ 65 years of age with osteoporosis to participate in focus groups. We quantitatively compared scores of the "Osteoporosis & You" knowledge scale and each domain (internal, powerful others, and chance) of the Multidimensional Health Locus of Control scale by race using t tests. We qualitatively explored potential racial differences in attitudes, values, and beliefs in the domains: (1) osteoporosis and bone health concerns, (2) knowledge about osteoporosis, (3) utilization of medical services for osteoporosis, (4) facilitators of osteoporosis prevention activities, and (5) barriers to osteoporosis prevention activities. A total of 48 women (White: 36; African American: 12) enrolled in the study. White women had a mean (SD) of 7.8 (0.92), whereas African American women score a 6.6 (2.6) (p = 0.044) out of 10 on the Osteoporosis & You Scale. The powerful others domain was significantly higher among African American for both general and bone health [General Health - African American: 26.7 (5.9) vs. White: 22.3 (3.8); p = 0.01]. Qualitative thematic analysis revealed differences by race in knowledge, types of physical activity, coping with comorbidities, physician trust, religion, and patient activation. Using both quantitative and qualitative methods, our study identified racial differences in knowledge, attitudes, and beliefs in women with osteoporosis that could result in racial disparities in bone health, indicating the need to improve education and awareness about osteoporosis in African American women.

Exploring Racial, Gender, and Insurance Disparities in Patients with Osteoporotic Fractures

The objective of this study is to examine racial, gender, and insurance disparities in hospital outcomes among patients diagnosed with osteoporotic fractures aged 55 years and older. A total of 36,153 patients were included in this study. The sample was constructed from de-identified patient-level data for 2011 through 2014 from the Virginia Health Information (VHI) inpatient discharge database. Differences in mortality and 30-day readmission across race, gender, and insurance status were examined using logistic regression and generalized linear models for hospital charges and length of stay. Whites and Asians had a shorter stay than Blacks [5.2 days (95% confidence interval (CI) 5.1-5.3) and 5.0 days (95% CI 4.7-5.2) vs. 5.6 days (95% CI 5.4-5.7)], while Hispanics had a significantly longer stay [6.0 days (95% CI 5.6-6.5)]. On average, total charges were the highest among Blacks [$37,916 (95% CI 36,784-39,083)]. All outcomes were poorer for men than women. Privately and publicly insured patients were more likely to be readmitted [odds ratio (OR) 1.6 (95% CI 1.0-2.6) and OR 2.0 (95% CI 1.3-3.2)] and had a shorter stay than the uninsured [4.9 days (95% CI 4.8-5.0) and 5.2 days (95% CI 5.1-5.3) vs. 5.7 days (95% CI 5.4-6.0)], while privately insured patients had considerably lower total charges than those who were uninsured [$34,163 (95% CI 33,214-35,139) vs. $36,335 (95% CI 34,334-38,452)]. As evidenced from this study, there are racial, gender, and insurance disparities in health outcomes. These results and further exploration of these disparities could provide information necessary for strategies to improve these outcomes in at-risk patients diagnosed with osteoporotic fractures.

Social inequality and fractures-secular trends in the Danish population: a case-control study

We examined links between markers of social inequality and fracture risk in the Danish population, demonstrating that high income and being married are associated with a significantly lower risk.

INTRODUCTION

We explored whether the risk of hip, humerus, and wrist fracture was associated with markers of inequality using data from Danish health registries.

METHODS

All patients 50 years or older with a primary hip (ICD10 S720, S721, S722, and S729) humerus (ICD10 S422, S423, S424, S425, S426, and S427), or wrist (ICD10: S52) fracture were identified from 1/1/1995 to 31/12/2011. Fracture patients were matched 1:1 by age, sex, and year of fracture, to a non-fracture control. Markers of inequality were as follows: income (fifths); marital status (married, divorced, widowed, or unmarried); area of residence (remote, rural, intermediate, or urban). Conditional logistic regression was used to investigate associations between these exposures, and risk of fracture, adjusting for covariates (smoking, alcohol, and Charlson co-morbidity). Interactions were fitted between exposure and covariates where appropriate.

RESULTS

A total of 189,838 fracture patients (37,500 hip, 45,602 humerus, and 106,736 wrist) and 189,838 controls were included. Mean age was 73.9 years (hip), 67.5 years (humerus), and 65.3 years (wrist). High income (5th quintile) was significantly associated with a lower odds ratio of all three fractures, compared to average income (3rd quintile). Married subjects had a significantly decreased odds ratio across all three fractures. However, no overall secular difference was observed regarding the influence of the markers of inequality.

CONCLUSION

In conclusion, we have demonstrated important, stable associations between social inequality, assessed using income, marital status, and area of residence, and fracture at the population level. These findings can inform approaches to healthcare, and suggest that much thought should be given to novel interventions aimed especially at those living alone, and ideally societal measures to reduce social inequality.

Trends and Determinants of Osteoporosis Treatment and Screening in Patients With Rheumatoid Arthritis Compared to Osteoarthritis

OBJECTIVE

To profile osteoporosis (OP) care in patients with rheumatoid arthritis (RA) over the past decade.

METHODS

Patients with RA or osteoarthritis (OA) were followed from 2003 through 2014. OP care was defined as receipt of OP treatment (with the exception of calcium/vitamin D) or screening (OPTS). Adjusted trends over followup, and the factors associated with OP care, were examined using multivariable Cox proportional hazards.

RESULTS

OPTS was reported in 67.4% of 11,669 RA patients and in 64.6% of 2,829 OA patients during a median (interquartile range) 5.5 (2-9) years of followup. In patients for whom treatment was recommended by the 2010 American College of Rheumatology (ACR) glucocorticoid-induced OP (GIOP) guidelines (48.4% of RA patients and 17.6% of OA patients), approximately 55% overall reported OP medication use. RA patients were not more likely to undergo OPTS compared to OA patients (hazard ratio 1.04 [95% confidence interval 0.94-1.15]). Adjusted models showed a stable trend for OPTS between 2004 and 2008 compared to 2003, with a significant downward trend after 2008 in both RA and OA patients. Factors associated with receipt of OP care in RA patients were older age, postmenopausal state, prior fragility fracture or diagnosis of OP, any duration of glucocorticoid treatment, and use of biologic agents.

CONCLUSION

Approximately half of RA patients for whom treatment was indicated never received an OP medication. OP care in RA patients was not better than in OA patients, and the relative risk of the application of this care has been decreasing in RA and OA patients since 2008 without improvement after the release of the 2010 ACR GIOP guideline.

Diagnosis and Treatment of Osteoporosis Before and After Fracture: A Side-by-Side Analysis of Commercially Insured and Medicare Advantage Osteoporosis Patients

BACKGROUND

Although treatment for osteoporosis is recommended by U.S. clinical guidelines, a lack of diagnosis and treatment is common among patients with osteoporotic fractures.

OBJECTIVE

To determine the rates of osteoporosis diagnosis and treatment before and after various types of fractures.

METHODS

This was a retrospective claims analysis using data from the Humana Medicare Advantage claims (Medicare group) and Optum Insight Clinformatics Data Mart commercial claims (Commercial group). Patients included in the study had a claim for a qualifying fracture occurring between January 2008 and December 2013 (the index fracture), were continuously enrolled in the health plan for ≥ 1 year before and after the index fracture, and were aged ≥ 65 years in the Medicare group or ≥ 50 years in the Commercial group at the time of the index fracture. Fragility fractures and osteoporosis diagnoses were identified from ICD-9-CM codes. Treatment for osteoporosis included oral and injectable therapies identified by National Drug Code numbers and Healthcare Common Procedure Coding System codes. Diagnosis and treatment rates were assessed during the 1-year periods before and after the index fracture. All analyses were conducted by fracture type (vertebral, hip, nonhip/nonvertebral [NHNV], and multiple), with stratification by age and sex. No comparisons were made between the Medicare and Commercial groups; rather, McNemar tests were used to compare prefracture versus postfracture diagnosis and treatment rates within each group.

RESULTS

For inclusion in the Medicare group, 45,603 patients were identified, and 54,145 patients were identified for the Commercial group. In the prefracture period, the osteoporosis diagnosis rates ranged from 12.0% (NHNV) to 21.5% (vertebral) in the Medicare group and from 5.3% (NHNV) to 12.1% (vertebral) in the Commercial group. In the postfracture period, diagnosis rates significantly increased (P < 0.001)-and nearly doubled-for all fracture types but did not exceed 42.1% (vertebral) in the Medicare group and 27.7% (vertebral) in the Commercial group. Pre-index treatment rates were similarly low, ranging from 9.4% (hip) to 16.6% (vertebral) among Medicare patients, and 7.5% (NHNV) to 14.4% (vertebral) in Commercial patients. Osteoporosis treatment rates improved significantly in the postfracture year, ranging from 12.5% (NHNV) to 26.5% (vertebral) among Medicare patients, and 8.3% (NHNV) to 21.4% (vertebral) in Commercial patients. Larger increases in diagnosis rates and smaller increases in treatment rates were observed in stratified analyses of men and women and of different age groups, with women and older patients having higher overall rates of diagnosis and treatment before and after fracture.

CONCLUSIONS

In men and women, osteoporosis diagnosis rates were low before the index fracture and improved substantially after the fracture, yet still remained low overall (under 50%). Osteoporosis treatment rates among patients experiencing a fracture were low before the index fracture and improved only minimally afterwards.

DISCLOSURES

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

Fracture-related mortality in southern Sweden: A multiple cause of death analysis, 1998-2014

PURPOSE

To assess fracture-related mortality among adults (aged ≥20years) in southern Sweden using multiple causes of death approach.

METHODS

All death certificates (n=201 488) in adults recorded in the region of Skåne from 1998 to 2014 were examined. We identified fracture-related deaths and computed mortality rates by sex, age group, and fracture site. Temporal trends were evaluated using joinpoint regression and associated causes were identified by age- and sex-adjusted observed/expected ratios.

RESULTS

Fractures were mentioned on 6 226 (3.1%) death certificates, with majority of these occurred among women (60%) and those aged≥80years (77%). While hip was the most common site overall (61% of all fracture-related deaths), skull was the most common site in people <60years (60% of all fracture-related deaths). Proportion of death certificates mentioning fracture was stable in women but increased by 0.4% (95% CI: 0.1 to 0.6) in men between 1998-2002 and 2010-2014. The mean age at death was higher in death certificates mentioning fracture than those without and this gap widened over time. The mean age-standardized fracture-related mortality rate was 18.8 (14.0) per 100 000 person-year in men (women) and declined by 1.5% (1.3%) per year during 1998-2014. Injuries (84.6%) and cardiovascular disorders (64.6%) were the most common comorbidities on death certificates mentioning fracture.

CONCLUSIONS

Fracture is a contributing cause of death in more than 3% of all deaths in southern Sweden with hip in lead among older and skull fracture among younger people. There was a slight increase in proportion of deaths associated with fracture in men but not women during the study period.

Cost-effectiveness of Virtual Bone Strength Testing in Osteoporosis Screening Programs for Postmenopausal Women in the United States

Purpose To investigate whether assessment of bone strength with quantitative computed tomography (CT) in combination with dual-energy x-ray absorptiometry (DXA) is cost-effective as a screening tool for osteoporosis in postmenopausal women. Materials and Methods A state-transition microsimulation model of osteoporosis for postmenopausal women aged 55 years or older was developed with a lifetime horizon and U.S. societal perspective. All model inputs were derived from published literature. Three strategies were compared: no screening, DXA with T score-dependent rescreening intervals, and a combination of DXA and quantitative CT with different intervals (3, 5, and 10 years) at different screening initiation ages (55-65 years). Oral bisphosphonate therapy was started if DXA hip T scores were less than or equal to -2.5, 10-year risk for hip fracture was greater than 3% (World Health Organization Fracture Risk Assessment Tool score, or FRAX), 10-year risk for major osteoporotic fracture was greater than 20% (FRAX), quantitative CT femur bone strength was less than 3000 N, or occurrence of first fracture (eg, hip, vertebral body, wrist). Outcome measures were incremental cost-effectiveness ratios (ICERs) in 2015 U.S. dollars per quality-adjusted life year (QALY) gained and number of fragility fractures. Probabilistic sensitivity analysis was also performed. Results The most cost-effective strategy was combined DXA and quantitative CT screening starting at age 55 with quantitative CT screening every 5 years (ICER, $2000 per QALY). With this strategy, 12.8% of postmenopausal women sustained hip fractures in their remaining life (no screening, 18.7%; DXA screening, 15.8%). The corresponding percentages of vertebral fractures for DXA and quantitative CT with a 5-year interval, was 7.5%; no screening, 11.1%; DXA screening, 9%; for wrist fractures, 14%, 17.8%, and 16.4%, respectively; for other fractures, 22.6%, 30.8%, and 27.3%, respectively. In probabilistic sensitivity analysis, DXA and quantitative CT at age 55 years with quantitative CT screening every 5 years was the best strategy in more than 90% of all 1000 simulations (for thresholds of $50 000 per QALY and $100 000 per QALY). Conclusion Combined assessment of bone strength and bone mineral density is a cost-effective strategy for osteoporosis screening in postmenopausal women and has the potential to prevent a substantial number of fragility fractures. © RSNA, 2017 Online supplemental material is available for this article.

Clinical and Community Strategies to Prevent Falls and Fall-Related Injuries Among Community-Dwelling Older Adults

Falls in older adults are the result of several risk factors across biological and behavioral aspects of the person, along with environmental factors. Falls can trigger a downward spiral in activities of daily living, independence, and overall health outcomes. Clinicians who care for older adults should screen them annually for falls. A multifactorial comprehensive clinical fall assessment coupled with tailored interventions can result in a dramatic public health impact, while improving older adult quality of life. For community-dwelling older adults, effective fall prevention has the potential to reduce serious fall-related injuries, emergency room visits, hospitalizations, institutionalization, and functional decline.

Examining the treatment gap and risk of subsequent fractures among females with a fragility fracture in the US Medicare population

Our aim was to evaluate the gap in osteoporosis treatment and the impact of osteoporosis treatment on subsequent fragility fractures. We found osteoporosis medication use lowered risk of subsequent fractures by 21% and that black race, higher CCI scores, dementia, and kidney diseases reduced the likelihood of osteoporosis medication use.

INTRODUCTION

The goal of this study was to evaluate the predictors of osteoporosis medication use and compare the risk of fragility fractures within 1 year of a fragility fracture between osteoporosis treated and untreated women.

METHODS

We conducted a retrospective, observational cohort study using the national Medicare database. Elderly women (≥65 years) who were hospitalized or had an outpatient/ER service for fragility fracture between January 1, 2011 and December 31, 2011 were included. The outcomes of interest were the correlates of and time-to-osteoporosis medication use and risk of a subsequent fracture within 12 months for treated and untreated women. Cox regression was used to evaluate the predictors of treatment use and the risk of fracture based on treatment status.

RESULTS

Women (28,722) (27.7%) were treated with osteoporosis medication within 12 months of index fracture, and 74,979 (72.2%) were untreated. A number of patient characteristics were associated with a reduced likelihood of osteoporosis medication use, including black race, higher Charlson comorbidity index scores, presence of dementia, and kidney diseases in the baseline. The predictor most strongly and positively associated with osteoporosis medication use after fracture was osteoporosis medication use before fragility fracture (HR = 7.87; 95% CI 7.67-8.07). After adjusting for baseline characteristics, osteoporosis medication use lowered the risk of subsequent fractures by 21% (HR = 0.79, 95% CI 0.75-0.83) over 12 months compared to women without treatment.

CONCLUSIONS

Demographics and clinical characteristics were strong predictors of osteoporosis medication use. In the US Medicare population, osteoporosis treatment significantly reduced the risk of fragility fractures.

Ethnic Differences in Trabecular Bone Score

Trabecular bone score (TBS), a noninvasive textural analysis of the lumbar spine dual-energy X-ray absorptiometry (DXA) image, has been shown to predict fractures in Caucasian (CA) populations but has not been thoroughly studied in African-American (AA) populations. The aim of this study was to compare the TBS in AAs and CAs and to assess whether TBS can be used to refine fracture risk stratification in AA patients. Eight hundred twenty-five women (390 AAs, 435 CAs) referred for bone mineral density (BMD) as part of their clinical care had measurements of the TBS, the BMD of the lumbar spine, total hip, and femoral neck, and vertebral fracture assessment for detection of vertebral fractures. Unadjusted TBS was higher in CA than AA (1.275 vs 1.238, p < 0.001), but this was no longer true after adjusting for age and tissue thickness. Interestingly, differences in TBS were still highly significant in those under 60 yr of age even with adjustment for tissue thickness, but not in older subjects. There were 74 CAs and 56 AAs with vertebral fractures on vertebral fracture assessment (17% vs 14%, p = 0.30). In CA, the odds ratio (OR) for prevalent vertebral fracture per SD decrease in TBS was 2.33 (p < 0.001), whereas in AA, the OR was 1.43 (p = 0.02). In a multivariate logistic regression model that also included age, BMD T-score, and glucocorticoid use, the association between TBS and prevalent vertebral fractures was still highly significant in CAs (OR 1.54, p = 0.008) but not in AAs (OR 1.23, p = 0.21). Our results suggest that TBS may be less discriminatory in regard to fracture risk in AAs than in CAs and that TBS may need to be used differently in these 2 ethnic groups.

The Effects of Annatto Tocotrienol on Bone Biomechanical Strength and Bone Calcium Content in an Animal Model of Osteoporosis Due to Testosterone Deficiency

Osteoporosis reduces the skeletal strength and increases the risk for fracture. It is an underdiagnosed disease in men. Annatto tocotrienol has been shown to improve bone structural indices and increase expression of bone formation genes in orchidectomized rats. This study aimed to evaluate the effects of annatto tocotrienol on biomechanical strength and calcium content of the bone in orchidectomized rats. Thirty three-month-old male Sprague-Dawley rats were randomly assigned to five groups. The baseline control (BC) group was sacrificed at the onset of the study. The sham-operated group (SHAM) received olive oil (the vehicle of tocotrienol) orally daily and peanut oil (the vehicle of testosterone) intramuscularly weekly. The remaining rats were orchidectomized and treated with three different regimens, i.e., (1) daily oral olive oil plus weekly intramuscular peanut oil injection; (2) daily oral annatto tocotrienol at 60 mg/kg plus weekly intramuscular peanut oil injection; (3) daily oral olive oil plus weekly intramuscular testosterone enanthate injection at 7 mg/kg. Blood, femur and tibia of the rats were harvested at the end of the two-month treatment period for the evaluation of serum total calcium and inorganic phosphate levels, bone biomechanical strength test and bone calcium content. Annatto-tocotrienol treatment improved serum calcium level and tibial calcium content (p < 0.05) but it did not affect femoral biomechanical strength (p > 0.05). In conclusion, annatto-tocotrienol at 60 mg/kg augments bone calcium level by preventing calcium mobilization into the circulation. A longer treatment period is needed for annatto tocotrienol to exert its effects on bone strength.

Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders

Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture.

INTRODUCTION

Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care.

METHODS

The Veteran's Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures.

RESULTS

There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9-11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4-6.1) and 6.7 years (median 6.7, IQR 3.1-11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14-0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period.

CONCLUSIONS

There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.