Use of administrative data for national surveillance of osteoporosis and related fractures in Canada: results from a feasibility study

Treatment reclassification in Canada from the Osteoporosis Canada 2023 clinical practice guidelines: the Manitoba BMD Registry

Osteoporosis Canada 2023 clinical practice guidelines increase the number of individuals recommended or suggested for anti-osteoporosis pharmacotherapy by refining treatment guidance for those who fell within the 2010 guidelines' moderate-risk category.

PURPOSE

In 2023, Osteoporosis Canada updated its 2010 clinical practice guidelines based upon consideration of fracture history, 10-year major osteoporotic fracture (MOF) risk, and BMD T-score in conjunction with age. The 2023 guidelines eliminated risk categories, including the moderate-risk group that did not provide clear treatment guidance. The current study was performed to appreciate the implications of the shift from 2010 risk categories to 2023 treatment guidance.

METHODS

The study population consisted of 79,654 individuals age ≥ 50 years undergoing baseline DXA testing from January 1996 to March 2018. Each individual was assigned to mutually exclusive categories based on 2010 and 2023 guideline recommendations. Treatment qualification, 10-year predicted and 10-year observed MOF risk were compared.

RESULTS

Treatment reclassification under the 2023 guidelines only affected 33.8% of individuals in the 2010 moderate-risk group, with 13.0% assigned to no treatment, 14.4% to suggest treatment, and 6.4% to recommend treatment. During the mean follow-up of 7.2 years, 6364 (8.0%) individuals experienced one or more incidents of MOF. The observed 10-year cumulative incidence of MOF in the study population was 10.5% versus the predicted 10.7% (observed to predicted mean calibration ratio 0.98, 95% CI 0.96-1.00). Individuals reclassified from 2010 moderate risk to 2023 recommend treatment were at greater MOF risk than those in the 2010 moderate-risk group assigned to 2023 suggest treatment or no treatment, but at lower risk than those in the 2010 high-risk group.

CONCLUSIONS

Osteoporosis Canada 2023 clinical practice guidelines affect individuals within the 2010 moderate-risk category, increasing the number for whom anti-osteoporosis pharmacotherapy is recommended or suggested. Increased treatment could reduce the population burden of osteoporotic fractures, though moderate-risk individuals now qualifying for treatment have a lower predicted and observed fracture risk than high-risk individuals recommended for treatment under the 2010 guidelines.

Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study

This population-based study analyzes hip fracture and osteoporosis treatment rates among older adults, stratified by place of residence prior to fracture. Hip fracture rates were higher among older adults living in the community and discharged to long-term care (LTC) after fracture, compared to LTC residents and older adults living in the community. Only 23% of LTC residents at high fracture risk received osteoporosis treatment.

PURPOSE

This population-based study examines hip fracture rate and osteoporosis management among long-term care (LTC) residents > 65 years of age compared to community-dwelling older adults at the time of fracture and admitted to LTC after fracture, in Ontario, Canada.

METHODS

Healthcare utilization and administrative databases were linked using unique, encoded identifiers from the ICES Data Repository to estimate hip fractures (identified using the Public Health Agency of Canada algorithm and International Classification of Diseases (ICD)-10 codes) and osteoporosis management (pharmacotherapy) among adults > 66 years from April 1, 2014 to March 31, 2018. Sex-specific and age-standardized rates were compared by pre-fracture residency and discharge location (i.e., LTC to LTC, community to LTC, or community to community). Fracture risk was determined using the Fracture Risk Scale (FRS).

RESULTS

At baseline (2014/15), the overall age-standardized hip fracture rate among LTC residents was 223 per 10,000 person-years (173 per 10,000 females and 157 per 10,000 males), 509 per 10,000 person-years (468 per 10,000 females and 320 per 10,000 males) among the community to LTC cohort, and 31.5 per 10,000 person-years (43.1 per 10,000 females and 25.6 per 10,000 males). During the 5-year observation period, the overall annual average percent change (APC) for hip fracture increased significantly in LTC (AAPC =  + 8.6 (95% CI 5.0 to 12.3; p = 0.004) compared to the community to LTC group (AAPC =  + 2.5 (95% CI - 3.0 to 8.2; p = 0.248)) and the community-to-community cohort (AAPC - 3.8 (95% CI - 6.7 to - 0.7; p = 030)). However, hip fracture rate remained higher in the community to LTC group over the study period. There were 33,594 LTC residents identified as high risk of fracture (FRS score 4 +), of which 7777 were on treatment (23.3%).

CONCLUSION

Overall, hip fracture rates have increased in LTC and among community-dwelling adults admitted to LTC after fracture. However, hip fracture rates among community-dwelling adults have decreased over time. A non-significant increase in osteoporosis treatment rates was observed among LTC residents at high risk of fracture (FRS4 +). Residents in LTC are at very high risk for fracture and require individualized based on goals of care and life expectancy.

Validity of an ultrasound device to measure bone mineral density

This study aims to examine the validity and reliability of the UltraScan650™, a portable ultrasound device, used to measure BMD at the 1/3rd radius position. Fifty-two female first responders and healthcare providers were assessed using DXA (forearm, femur, lumbar, and total body) and the UltraScan650™. Fat and lean mass were also assessed using the DXA. Pearson correlations, Bland-Altman plots, t-tests, and linear regressions were used to assess validity. Intra-class correlation (ICC) coefficients were used to assess reliability. Inter-rater reliability and repeatability were good (ICC = 0.896 [0.818; 0.942], p < 0.001) and excellent (ICC = 0.917 [0.785; 0.989], p < 0.001), respectively. BMD as measured by the UltraScan650™ was weakly correlated to the DXA (r = 0.382 [0.121; 0.593], p = 0.0052). Bland-Altman plots revealed that the UltraScan650™ underestimated BMD (-0.0569 g/cm2), this was confirmed with a significant paired t-test (p < 0.001). A linear regression was performed (0.4744 × UltraScan650™ + 0.4170) to provide more information as to the issue of agreement. Bland-Altman plots revealed a negligible bias, supported by a paired t-test (p = 0.9978). Pearson's correlation revealed a significant relationship (r = -0.771 [-0.862; -0.631], p < 0.0001) between adjusted UltraScan650™-DXA and the average of the two scans (i.e., adjusted UltraScan650™ and DXA), suggesting a proportional constant error and proportional constant variability in measurements of BMD from the UltraScan650™. The UltraScan650™ is not a valid alternative to DXA for diagnostic purposes; however, the UltraScan650™ could be used as a screening tool in the clinical and research setting given the linear transformation is employed.

Long-term clinical outcomes of bariatric surgery in adults with severe obesity: A population-based retrospective cohort study

BACKGROUND

Bariatric surgery leads to sustained weight loss in a majority of recipients, and also reduces fasting insulin levels and markers of inflammation. We described the long-term associations between bariatric surgery and clinical outcomes including 30 morbidities.

METHODS

We did a retrospective population-based cohort study of 304,157 adults with severe obesity, living in Alberta, Canada; 6,212 of whom had bariatric surgery. We modelled adjusted time to mortality, hospitalization, surgery and the adjusted incidence/prevalence of 30 new or ongoing morbidities after 5 years of follow-up.

RESULTS

Over a median follow-up of 4.4 years (range 1 day-22.0 years), bariatric surgery was associated with increased risk of hospitalization (HR 1.46, 95% CI 1.41,1.51) and additional surgery (HR 1.42, 95% CI 1.32,1.52) but with a decreased risk of mortality (HR 0.76, 95% CI 0.64,0.91). After 5 years (median of 9.9 years), bariatric surgery was associated with a lower risk of severe chronic kidney disease (HR 0.45, 95% CI 0.27,0.75), coronary disease (HR 0.49, 95% CI 0.33,0.72), diabetes (HR 0.51, 95% CI 0.47,0.56), inflammatory bowel disease (HR 0.55, 95% CI 0.37,0.83), hypertension (HR 0.70, 95% CI 0.66,0.75), chronic pulmonary disease (HR 0.75, 95% CI 0.66,0.86), asthma (HR 0.79, 95% 0.65,0.96), cancer (HR 0.79, 95% CI 0.65,0.96), and chronic heart failure (HR 0.79, 95% CI 0.64,0.96). In contrast, after 5 years, bariatric surgery was associated with an increased risk of peptic ulcer (HR 1.99, 95% CI 1.32,3.01), alcohol misuse (HR 1.55, 95% CI 1.25,1.94), frailty (HR 1.28, 95% 1.11,1.46), severe constipation (HR 1.26, 95% CI 1.07,1.49), sleep disturbance (HR 1.21, 95% CI 1.08,1.35), depression (HR 1.18, 95% CI 1.10,1.27), and chronic pain (HR 1.12, 95% CI 1.04,1.20).

INTERPRETATION

Bariatric surgery was associated with lower risks of death and certain morbidities. However, bariatric surgery was also associated with increased risk of hospitalization and additional surgery, as well as certain other morbidities. Since values and preferences for these various benefits and harms may differ between individuals, this suggests that comprehensive counselling should be offered to patients considering bariatric surgery.

Degree of Albuminuria is Associated With Increased Risk of Fragility Fractures Independent of Estimated GFR

Introduction

Fragility fractures are common in persons with chronic kidney disease (CKD); however, the association between fragility fractures and albuminuria is not well-studied. The primary objective of this study is to determine the association of albuminuria with incident risk of fragility fractures. The secondary objective is to examine the risk of fragility fracture by estimated glomerular filtration rate (eGFR) and Kidney Disease Improving Global Outcomes (KDIGO) risk categories.

Methods

Community dwelling adults residing in Alberta, Canada who had at least 1 creatinine and albuminuria measurement between April 1, 2008 and March 31, 2019 participated in the study (N = 2.72 million). Incident fragility fractures were identified using Canadian Chronic Disease Surveillance Systems Osteoporosis Working Group algorithms. Albuminuria was categorized as none/mild (albumin-to-creatinine ratio [ACR] <30 mg/g, protein-to-creatinine ratio [PCR] <150 mg/g, trace/negative dipstick); moderate (ACR 30-300 mg/g, PCR 150-500 mg/g, 1+ dipstick) or severe (ACR >300 mg/g, PCR >500 mg/g, ≥2+ dipstick). Multivariable analysis controlled for 42 variables.

Results

Patients with severe albuminuria had an increased risk of hip fracture (odds ratio [OR] = 1.37; 95% confidence interval [CI] 1.28, 1.47]), vertebral fracture (OR = 1.31; 95% CI 1.21, 1.41) and any-type fracture (OR = 1.22; 95% CI 1.17, 1.28) compared with patients with none/mild albuminuria. Patients in the most severe KDIGO risk category had an increased risk of hip fracture (OR = 1.22; 95% CI 1.16, 1.29), vertebral fracture (OR = 1.18; 95% CI 1.09, 1.26) and any type of fracture (OR = 1.25; 95% CI 1.21, 1.30).

Conclusion

This study demonstrates the important role of albuminuria as a risk factor for fragility fractures in CKD and may help inform risk stratification and prevention strategies in this high-risk population category.

Association of Different Prescribing Patterns for Oral Corticosteroids With Fracture Preventive Care Among Older Adults in the UK and Ontario

Importance

Identifying and mitigating modifiable gaps in fracture preventive care for people with relapsing-remitting conditions such as eczema, asthma, and chronic obstructive pulmonary disease who are prescribed high cumulative oral corticosteroid doses may decrease fracture-associated morbidity and mortality.

Objective

To estimate the association between different oral corticosteroid prescribing patterns and appropriate fracture preventive care, including treatment with fracture preventive care medications, among older adults with high cumulative oral corticosteroid exposure.

Design, Setting, and Participants

This cohort study included 65 195 participants with UK electronic medical record data from the Clinical Practice Research Datalink (January 2, 1998, to January 31, 2020) and 28 674 participants with Ontario, Canada, health administrative data from ICES (April 1, 2002, to September 30, 2020). Participants were adults 66 years or older with eczema, asthma, or chronic obstructive pulmonary disease receiving prescriptions for oral corticosteroids with cumulative prednisolone equivalent doses of 450 mg or higher within 6 months. Data were analyzed October 22, 2020, to September 6, 2022.

Exposures

Participants with prescriptions crossing the 450-mg cumulative oral corticosteroid threshold in less than 90 days were classified as having high-intensity prescriptions, and participants crossing the threshold in 90 days or more as having low-intensity prescriptions. Multiple alternative exposure definitions were used in sensitivity analyses.

Main Outcomes and Measures

The primary outcome was prescribed fracture preventive care. A secondary outcome was major osteoporotic fracture. Individuals were followed up from the date they crossed the cumulative oral corticosteroid threshold until their outcome or the end of follow-up (up to 1 year after index date). Rates were calculated for fracture preventive care and fractures, and hazard ratios (HRs) were estimated from Cox proportional hazards regression models comparing high- vs low-intensity oral corticosteroid prescriptions.

Results

In both the UK cohort of 65 195 participants (mean [IQR] age, 75 [71-81] years; 32 981 [50.6%] male) and the Ontario cohort of 28 674 participants (mean [IQR] age, 73 [69-79] years; 17 071 [59.5%] male), individuals with high-intensity oral corticosteroid prescriptions had substantially higher rates of fracture preventive care than individuals with low-intensity prescriptions (UK: 134 vs 57 per 1000 person-years; crude HR, 2.34; 95% CI, 2.19-2.51, and Ontario: 73 vs 48 per 1000 person-years; crude HR, 1.49; 95% CI, 1.29-1.72). People with high- and low-intensity oral corticosteroid prescriptions had similar rates of major osteoporotic fractures (UK: crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15 and Ontario: crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96). Results from sensitivity analyses suggested that reaching a high cumulative oral corticosteroid dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing.

Conclusions

The results of this cohort study suggest that older adults prescribed high cumulative oral corticosteroids across multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care.

Associations between hearing loss and clinical outcomes: population-based cohort study

Background

Hearing loss (HL) is a leading cause of disability worldwide, but its clinical consequences and population burden have been incompletely studied.

Methods

We did a retrospective population-based cohort study of 4,724,646 adults residing in Alberta between April 1, 2004 and March 31, 2019, of whom 152,766 (3.2%) had HL identified using administrative health data. We used administrative data to identify comorbidity and clinical outcomes, including death, myocardial infarction, stroke/transient ischemic attack, depression, dementia, placement in long-term care (LTC), hospitalization, emergency visits, pressure ulcers, adverse drug events and falls. We used Weibull survival models (binary outcomes) and negative binomial models (rate outcomes) to compare the likelihood of outcomes in those with vs without HL. We calculated population-attributable fractions to estimate the number of binary outcomes associated with HL.

Findings

The age-sex-standardized prevalence of all 31 comorbidities at baseline was higher among participants with HL than those without. Over median follow-up of 14.4 y and after adjustment for potential confounders at baseline, participants with HL had higher rates of days in hospital (rate ratio 1.65, 95% CI 1.39, 1.97), falls (RR 1.72, 95% CI 1.59, 1.86), adverse drug events (RR 1.40, 95% CI 1.35, 1.45), and emergency visits (RR 1.21, 95% CI 1.14, 1.28) compared to those without, and higher adjusted hazards of death, myocardial infarction, stroke/transient ischemic attack, depression, heart failure, dementia, pressure ulcers and LTC placement. The estimated number of people with HL who required new LTC placement annually in Canada was 15,631, of which 1023 were attributable to HL. Corresponding estimates for new dementia among people with HL were 14,959 and 4350, and for stroke/TIA the estimates were 11,582 and 2242.

Interpretation

HL is common, is often accompanied by substantial comorbidity, and is associated with significant increases in risk for a broad range of adverse clinical outcomes, some of which are potentially preventable. This high population health burden suggests that increased and coordinated investment is needed to improve the care of people with HL.

Funding

Canadian Institutes of Health Research; David Freeze chair in health services research.

Adverse events with quetiapine and clarithromycin coprescription: A population-based retrospective cohort study

Background and Aims

Quetiapine is an atypical antipsychotic predominantly metabolized by the cytochrome P450 3A4 (CYP3A4) enzyme. We studied the risk of adverse events following coprescription of clarithromycin (a strong CYP3A4 inhibitor) versus azithromycin (not a CYP3A4 inhibitor) in quetiapine users.

Materials and Methods

This was a population-based retrospective cohort study from 2004 to 2020 in Ontario, Canada in adult quetiapine users newly co-prescribed clarithromycin (n = 16,909) or azithromycin (n = 25,267). The primary outcome was the composite of hospital encounters with encephalopathy (defined as a diagnosis of delirium, disorientation, transient alteration of awareness, transient ischemic attack, or unspecified dementia), a fall, or a fracture within 30 days of new coprescription. Secondary outcomes were individual components of the composite outcome, hospital encounter with computed tomography (CT) head scan, and all-cause mortality.

Results

Coprescription of clarithromycin versus azithromycin with quetiapine was associated with a higher risk of the primary composite outcome (365 of 16,909 clarithromycin users [2.2%] vs. 309 of 16,929 azithromycin users [1.8%]; absolute risk increase, 0.34% [95% confidence interval, CI, 0.04-0.63]; relative risk [RR], 1.19 [95% CI, 1.02-1.38]). This was primarily driven by an increase in fragility fractures (78 of 16,909 clarithromycin users [0.5%] vs. 45 of 16,923 azithromycin users [0.3%]; absolute risk increase, 0.20% [95% CI, 0.07-0.32]; RR, 1.74 [95% CI, 1.21-2.52]). Hospital encounters with a CT head scan were higher in clarithromycin users (220 of 16,909 [1.3%] vs. 175 of 16,923 azithromycin users [1.0%]; absolute risk increase, 0.27% [95% CI, 0.04-0.50]; RR, 1.26 [95% CI, 1.04-1.54]), but there was no difference in hospital encounters with encephalopathy, falls, or all-cause mortality between macrolide groups.

Conclusion

Among adults taking quetiapine, concurrent use of clarithromycin compared with azithromycin was associated with a small but statistically greater 30-day risk of a hospital encounter for encephalopathy, falls, or fracture, which was predominantly related to a higher rate of fragility fractures.

Characterization of Hip Fractures Among Adults With Schizophrenia in Ontario, Canada

Importance

Evidence suggests that individuals with schizophrenia are at an increased risk of hip fractures; however, the sex-specific burden of hip fractures among adults with schizophrenia has not been quantified and compared with the general population.

Objective

To describe sociodemographic and clinical characteristics of patients with hip fracture and schizophrenia and to quantify their sex-specific annual hip fracture rates relative to those without schizophrenia.

Design, Setting, and Participants

This repeated population-based, cross-sectional study leveraged multiple individually linked health administrative databases for patients in Ontario, Canada. We included patients aged 40 to 105 years with hip fracture-related hospitalization between April 1, 2009, and March 31, 2019. Statistical analysis was performed between November 2021 and February 2023.

Exposure

Schizophrenia diagnosis, ascertained using a validated algorithm.

Main Outcomes and Measures

The main outcome was sex-specific age-standardized annual hip fracture rate per 10 000 individuals and annual percent change in age-standardized rates. Rates were direct adjusted to the 2011 Ontario population, and joinpoint regression analysis was performed to evaluate annual percent change.

Results

We identified 117 431 hip fracture records; of these, there were 109 908 index events. Among the 109 908 patients with hip fracture, 4251 had schizophrenia and 105 657 did not. Their median age was 83 years (IQR, 75-89 years), and 34 500 (31.4%) were men. Patients with hip fracture and schizophrenia were younger at the index event compared with those without schizophrenia. Men had a median age of 73 vs 81 years (IQR, 62-83 vs 71-87 years; standardized difference, 0.46), and women had a median age of 80 vs 84 years (IQR, 71-87 vs 77-89 years; standardized difference, 0.32). A higher proportion of patients with vs without schizophrenia had frailty (53.7% vs 34.2%; standardized difference, 0.40) and previous fragility fractures (23.5% vs 19.1%; standardized difference, 0.11). The overall age-standardized rate per 10 000 individuals with vs without schizophrenia was 37.5 (95% CI, 36.4 to 38.6) vs 16.0 (95% CI, 15.9 to 16.1). Age-standardized rates were 3-fold higher in men with vs without schizophrenia (31.0 [95% CI, 29.5 to 32.6] vs 10.1 [95% CI, 10.0 to 10.2]) and more than 2-fold higher in women with vs without schizophrenia (43.4 [95% CI, 41.9 to 44.9] vs 21.4 [95% CI, 21.3 to 21.6]). Overall, joinpoint regression analysis identified a steady annual decrease of 0.7% (95% CI, -1.1% to -0.3%) in age-standardized rates for both study groups.

Conclusions and Relevance

The findings of this cross-sectional study suggest that individuals with schizophrenia experience an earlier age of onset and considerably higher rate of hip fractures compared with the general population, with implications for targeted fracture prevention and optimization of clinical bone health management over the course of their psychiatric illness.

Fracture rate increases after immune checkpoint inhibitor treatment: a potential new immune related adverse event

INTRODUCTION

T cell activation can lead to osteoporosis and while there are several case reports of fractures occurring after immune checkpoint inhibitor (ICI) use, to date, there are no population level studies looking at fracture risk related to ICI use.

METHODS

Using Alberta Cancer Registry data, we identified all individuals treated with ICI for cancer between September 29, 2010, and March 31, 2019. Linked records from Alberta's healthcare administrative databases were assessed for the presence of fracture diagnostic codes in the year prior to and up to two years after ICI initiation. Fracture rate was stratified based on the time-period before and after ICI initiation. Fracture rates after ICI were compared to baseline.

RESULTS

The study cohort consisted of 1600 ICI users (mean age 65.7 years, 60% male). Most patients were treated with an anti-PD-1 agent (73.9%). ICIs were initiated on average 707.8 days after cancer diagnosis. 76 (4.8%) individuals had a remote history of a major fracture, and 141 (8.8%) had been treated with an osteoporosis medication prior to ICI treatment. The fracture rate in the year prior to ICI initiation was 11.3 per 1000 patient-years. The fracture rate in the year after ICI initiation was significantly higher at 27.3 per 1000 patient-years. The fracture rate dropped to 17.6 per 1000 patient-years in the second year after ICI initiation. The incidence rate ratio of sustaining a major fracture in the year after compared to the year prior to ICI initiation was 2.43 (95% CI 1.34-4.27).

CONCLUSIONS

Fracture risk may be increased in cancer patients early after initiation of ICI, and this may represent a novel immune-related adverse event.

External validation of FRISBEE 5-year fracture prediction models: a registry-based cohort study

Five-year fracture risk prediction from the Fracture Risk Brussels Epidemiological Enquiry (FRISBEE) models was externally tested in 9716 Canadian women and demonstrated good discrimination but consistently overestimated risk.

INTRODUCTION

Five-year risk prediction models for all fractures, major osteoporotic fractures (MOFs) and central fractures (proximal to forearm and ankle) from the FRISBEE cohort demonstrated good performance in the original derivation cohort. Our aim was to externally validate the FRISBEE-based 5-year prediction models in routine practice.

METHODS

Using the population-based Manitoba Bone Mineral Density (BMD) registry, we identified women aged 60-85 years undergoing baseline BMD assessment from September 1, 2012 to March 31, 2018. Five-year probabilities of all fractures, MOFs and central fractures were calculated using the FRISBEE prediction models. We identified incident non-traumatic fractures up to 5 years from population-based healthcare data sources. Performance characteristics included area under the receiver operating characteristic curve (AUROC), gradient of risk (hazard ratio [HR] per SD increase and across risk tertiles) from Cox regression analysis, and calibration (ratio 5-year observed cumulative incidence to predicted fracture probability).

RESULTS

We included 9716 women (mean age 70.7 + / - SD 5.3 years). During a mean observation time of 2.5 years, all fractures, MOFs and central fractures were identified in 377 (3.9%), 264 (2.7%) and 259 (2.7%) of the women. AUROC showed significant fracture risk stratification with the FRISBEE models (all fractures 0.69 [95%CI 0.67-0.72], MOFs 0.71 [95%CI 0.68-0.74], central fractures 0.72 [95%CI 0.69-0.75]). There was a strong gradient of risk for predicting fracture outcomes per SD increase (HRs from 1.98 to 2.26) and across risk tertiles (HRs for middle vs lowest from 2.25 to 2.41, HRs for highest vs lowest from 4.70 to 6.50). However, risk was overestimated for all fractures (calibration-in-the-large 0.63, calibration slope 0.63), MOF (calibration-in-the-large 0.51, calibration slope 0.57) and central fractures (calibration-in-the-large 0.55, calibration slope 0.60).

CONCLUSIONS

FRISBEE 5-year prediction models were externally validated to stratify fracture risk similar to the derivation cohort, but would need recalibration for Canada as risk was overestimated.

Fractures and long-term mortality in cancer patients: a population-based cohort study

We assessed post-fracture mortality in a population-based cohort of 122,045 individuals with cancers. Major fractures (hip, vertebrae, humerus, and forearm) were associated with early and long-term increased all-cause mortality.

INTRODUCTION

Currently, there are no population-based data among cancer patients on post-fracture mortality risk across a broad range of cancer diagnoses. Our objective was to estimate the association of fracture with mortality in cancer survivors.

METHODS

Using Manitoba Cancer Registry data from the province of Manitoba, Canada, we identified all women and men with cancer diagnosed between January 1, 1987, and March 31, 2014. We then linked cancer data to provincial healthcare administrative data and ascertained fractures after cancer diagnosis and mortality to March 31, 2015. Hazard ratios for all-cause mortality in those with versus without fracture were estimated from time-dependent Cox proportional hazards models adjusted for multiple covariates.

RESULTS

The study cohort consisted of 122,045 cancer patients (median age 68 years, IQR 58-77, 49.2% female). During the median follow-up of 5.8 years from cancer diagnosis, we ascertained 7120 (5.8%) major fractures. All fracture sites, except for the forearm, were associated with increased mortality risk, even after multivariable adjustment. Excess mortality risk associated with a major fracture was greatest in the first year after fracture (HR 2.42, 95% CI 2.30-2.54) and remained significant > 5 years after fracture (HR 1.60, 95% CI 1.50-1.70) and for fractures occurring > 10 years after cancer diagnosis (HR 1.93, 95% CI 1.79-2.07).

CONCLUSION

Fractures among cancer patients are associated with increased all-cause mortality. This excess risk is greatest in the first year and persists more than 5 years post-fracture; increased risk is also noted for fractures occurring up to and beyond 10 years after cancer diagnosis.

Accuracy of administrative database algorithms for autism spectrum disorder, attention-deficit/hyperactivity disorder and fetal alcohol spectrum disorder case ascertainment: a systematic review

INTRODUCTION

The purpose of this study was to perform a systematic review to assess the validity of administrative database algorithms used to identify cases of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD) and fetal alcohol spectrum disorder (FASD).

METHODS

MEDLINE, Embase, Global Health and PsycInfo were searched for studies that validated algorithms for the identification of ASD, ADHD and FASD in administrative databases published between 1995 and 2021 in English or French. The grey literature and reference lists of included studies were also searched. Two reviewers independently screened the literature, extracted relevant information, conducted reporting quality, risk of bias and applicability assessments, and synthesized the evidence qualitatively. PROSPERO CRD42019146941.

RESULTS

Out of 48 articles assessed at full-text level, 14 were included in the review. No studies were found for FASD. Despite potential sources of bias and significant between-study heterogeneity, results suggested that increasing the number of ASD diagnostic codes required from a single data source increased specificity and positive predictive value at the expense of sensitivity. The best-performing algorithms for the identification of ASD were based on a combination of data sources, with physician claims database being the single best source. One study found that education data might improve the identification of ASD (i.e. higher sensitivity) in school-aged children when combined with physician claims data; however, additional studies including cases without ASD are required to fully evaluate the diagnostic accuracy of such algorithms. For ADHD, there was not enough information to assess the impact of number of diagnostic codes or additional data sources on algorithm accuracy.

CONCLUSION

There is some evidence to suggest that cases of ASD and ADHD can be identified using administrative data; however, studies that assessed the ability of algorithms to discriminate reliably between cases with and without the condition of interest were lacking. No evidence exists for FASD. Methodologically higher-quality studies are needed to understand the full potential of using administrative data for the identification of these conditions.

Performance of the Garvan Fracture Risk Calculator in Individuals with Diabetes: A Registry-Based Cohort Study

Diabetes increases fracture and falls risks. We evaluated the performance of the Garvan fracture risk calculator (FRC) in individuals with versus without diabetes. Using the population-based Manitoba bone mineral density (BMD) registry, we identified individuals aged 50-95 years undergoing baseline BMD assessment from 1 September 2012, onwards with diabetes and self-reported falls in the prior 12 months. Five-year Garvan FRC predictions were generated from clinical risk factors, with and without femoral neck BMD. We identified non-traumatic osteoporotic fractures (OF) and hip fractures (HF) from population-based data to 31 March 2018. Fracture risk stratification was assessed from area under the receiver operating characteristic curves (AUROC). Cox regression analysis was performed to examine the effect of diabetes on fractures, adjusted for Garvan FRC predictions. The study population consisted of 2618 women with and 14,064 without diabetes, and 636 and 2201 men with and without the same, respectively. The Garvan FRC provided significant OF and HF risk stratification in women with diabetes, similar to those without diabetes. Analyses of OF in men were limited by smaller numbers; no significant difference was evident by diabetes status. Cox regression showed that OF risk was 23% greater in women with diabetes adjusted for Garvan FRC including BMD (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.49), suggesting it slightly underestimated risk; a non-significant increase in diabetes-related HF risk was noted (HR 1.37, 95% CI 0.88-2.15). Garvan FRC shows similar fracture risk stratification in individuals with versus without diabetes, but may underestimate this risk.

Fracture Risk of Sodium-Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been associated with a higher risk of skeletal fractures in some randomized, placebo-controlled trials. Secondary hyperparathyroidism and increased bone turnover (also common in CKD) may contribute to the observed fracture risk. We aimed to determine if SGLT2 inhibitor use associates with a higher risk of fractures compared with dipeptidyl peptidase-4 (DPP-4) inhibitors, which have no known association with fracture risk. We hypothesized that this risk, if present, would be greatest in patients with lower eGFR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a population-based cohort study in Ontario, Canada between 2015 and 2019 using linked provincial administrative data to compare the incidence of fracture between new users of SGLT2 inhibitors and DPP-4 inhibitors. We used inverse probability of treatment weighting on the basis of propensity scores to balance the two groups of older adults (≥66 years of age) on indicators of baseline health. We compared the 180- and 365-day cumulative incidence rates of fracture between groups. Prespecified subgroup analyses were conducted by eGFR category (≥90, 60 to <90, 45 to <60, and 30 to <45 ml/min per 1.73 m²). Weighted hazard ratios were obtained using Cox proportional hazard regression.

RESULTS

After weighting, we identified a total of 38,994 new users of a SGLT2 inhibitor and 37,449 new users of a DPP-4 inhibitor and observed a total of 342 fractures at 180 days and 689 fractures at 365 days. The weighted 180- and 365-day risks of a fragility fracture did not significantly differ between new users of a SGLT2 inhibitor versus a DPP-4 inhibitor: weighted hazard ratio, 0.95 (95% confidence interval, 0.79 to 1.13) and weighted hazard ratio, 0.88 (95% confidence interval, 0.88 to 1.00), respectively. There was no observed interaction between fracture risk and eGFR category (P=0.53).

CONCLUSIONS

In this cohort study of older adults, starting a SGLT2 inhibitor versus DPP-4 inhibitor was not associated with a higher risk of skeletal fracture, regardless of eGFR.

Comparative Fracture Risk During Osteoporosis Drug Holidays After Long-Term Risedronate Versus Alendronate Therapy : A Propensity Score-Matched Cohort Study

BACKGROUND

An osteoporosis drug holiday is recommended for most patients after 3 to 5 years of therapy. Risedronate has a shorter half-life than alendronate, and thus the residual length of fracture protection may be shorter.

OBJECTIVE

To examine the comparative risks of drug holidays after long-term (≥3 years) risedronate versus alendronate therapy.

DESIGN

Population-based, matched, cohort study.

SETTING

Province-wide health care administrative databases providing comprehensive coverage to Ontario residents aged 65 years or older between November 2000 and March 2020.

PATIENTS

Persons aged 66 years or older who had long-term risedronate therapy and a drug holiday were matched 1:1 on propensity score to those who had long-term alendronate therapy and a drug holiday.

MEASUREMENTS

The primary outcome was hip fracture within 3 years after a 120-day ascertainment period. Secondary analyses included shorter follow-up and sex-specific estimates. Cox proportional hazards models were used to estimate hazard ratios (HRs) for fracture risk between groups.

RESULTS

A total of 25 077 propensity score-matched pairs were eligible (mean age, 81 years; 81% women). Hip fracture rates were higher among risedronate than alendronate drug holidays (12.4 and 10.6 events, respectively, per 1000 patient-years; HR, 1.18 [95% CI, 1.04 to 1.34]; 915 total hip fractures). The association was attenuated when any fracture was included as the outcome (HR, 1.07 [CI, 1.00 to 1.16]) and with shorter drug holidays (1 year: HR, 1.03 [CI, 0.85 to 1.24]; 2 years: HR, 1.14 [CI, 0.96 to 1.32]).

LIMITATION

Analyses were limited to health care administrative data (potential unmeasured confounding), and some secondary analyses contained few events.

CONCLUSION

Drug holidays after long-term therapy with risedronate were associated with a small increase in risk for hip fracture compared with alendronate drug holidays. Future research should examine how best to mitigate this risk.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research.

Predictive performance of the Garvan Fracture Risk Calculator: a registry-based cohort study

The G arvan Fracture Risk Calculator predicts risk of osteoporotic fractures. We evaluated its predictive performance in 16,682 women and 2839 men from Manitoba, Canada, and found significant risk stratification, with a strong gradient across scores. The tool outperformed clinical risk factors and bone mineral density for fracture risk stratification.

INTRODUCTION

The optimal model for fracture risk estimation to guide treatment decision-making remains controversial. Our objective was to evaluate the predictive performance of the Garvan Fracture Risk Calculator (FRC) in a large clinical registry from Manitoba, Canada.

METHODS

Using the population-based Manitoba Bone Mineral Density (BMD) registry, we identified women and men aged 50-95 years undergoing baseline BMD assessment from September 1, 2012, onwards. Five-year Garvan FRC predictions were generated from clinical risk factors (CRFs) with and without femoral neck BMD. We identified incident non-traumatic osteoporotic fractures (OFs) and hip fractures (HFs) from population-based healthcare data sources to March 31, 2018. Fracture risk was assessed from area under the receiver operating characteristic curve (AUROC). Cox regression analysis and calibration ratios (5-year observed/predicted) were assessed for risk quintiles. All analyses were sex stratified.

RESULTS

We included 16,682 women (mean age 66.6 + / - SD 8.7 years) and 2839 men (mean age 68.7 + / - SD 10.2 years). During a mean observation time of 2.6 years, incident OFs were identified in 681 women and 140 men and HFs in 199 women and 22 men. AUROC showed significant fracture risk stratification with the Garvan FRC. Tool predictions without BMD were better than from age or decreasing weight, and the tool with BMD performed better than BMD alone. Garvan FRC with BMD performed better than without BMD, especially for HF prediction (AUROC 0.86 in women, 0.82 in men). There was a strong gradient of increasing risk across Garvan FRC quintiles (highest versus lowest, hazard ratios women 5.75 and men 3.43 for any OF; women 101.6 for HF). Calibration differences were noted, with both over- and underestimation in risk.

CONCLUSIONS

Garvan FRC outperformed CRFs and BMD alone for fracture risk stratification, particularly for HF, but may require recalibration for accurate predictions in this population.

An update of the prevalence of osteoporosis, fracture risk factors, and medication use among community-dwelling older adults: results from the Canadian Longitudinal Study on Aging (CLSA)

The prevalence of self-reported and DXA-confirmed osteoporosis was 7.8% (males 2.2%; females 12.7%), and 3.6% (males 1.2%; females 5.9%), respectively. We found that most community-dwelling older adults at high fracture risk are not taking osteoporosis medication, particularly males. There is a major opportunity for improved primary fracture prevention in the community.

PURPOSE

To provide an up-to-date prevalence estimate of osteoporosis, fracture risk factors, fracture risk, and the proportion of older Canadians at high fracture risk who are not taking an osteoporosis medication.

METHODS

We included Canadian Longitudinal Study on Aging (CLSA) participants: a community-dwelling cohort aged 45 to 85 years who completed the baseline (2015) comprehensive interview and had dual-energy X-ray absorptiometry (DXA) scans (N = 30,097). We describe the age- and sex-stratified prevalence of (1) self-reported osteoporosis; (2) DXA-confirmed osteoporosis; (3) fracture risk factors and people who are at high risk (FRAX® major osteoporotic fracture probability ≥ 20%); and (4) people who are at high fracture risk not taking osteoporosis medications. Sampling weights, as defined by the CLSA, were applied.

RESULTS

The mean age of participants was 70.0 (SD 10.3). Overall, 7.8% had self-reported osteoporosis (males 2.2%; females 12.7%) while 3.6% had DXA-confirmed osteoporosis (males 1.2%; females 5.9%), and 2.8% were at high fracture risk (males 0.3%; females 5.1%). Of people who had osteoporosis and were at high risk, 77.3% were not taking an osteoporosis medication (males 92.3%; females 76.8%).

CONCLUSIONS

Our study provides an up-to-date prevalence estimate of osteoporosis for community-dwelling older Canadians. We found that most community-dwelling older adults at high fracture risk are not taking an osteoporosis medication, particularly males. There is a major opportunity for improved primary fracture prevention in the community.

Time dependency in early major osteoporotic and hip re-fractures in women and men aged 50 years and older: a population-based observational study

We analyzed patterns in recurrent major osteoporotic fracture (MOF) following a first major osteoporotic fracture in a large population-based cohort. Re-fracture risk remained elevated over 10 years, with only modest and inconsistent attenuation in risk over time.

INTRODUCTION

Recurrent fracture risk remains elevated for up to 25 years, and is reportedly highest in the initial 2 years (imminent risk). Our aim was to characterize early time dependency in re-fracture rates up to 10 years after a first fracture in a population-based cohort.

METHODS

Using Province of Manitoba (Canada) healthcare databases, we performed a matched cohort study in 22,105 women (mean age 74.1 ± 10.6 years) and 7589 men (mean age 71.8 ± 11.2 years) after a first MOF (age ≥ 50 years) during 1989-2006 and matched fracture-free controls (3 for each case). Incident fractures were ascertained over the next 10 years. Fracture rate ratios (RRs, cases versus controls) stratified by sex and age were computed, and tested for linear trend using linear regression. Joinpoint regression was performed to determine non-linear change in fracture rates over time, with particular attention to the first 2-year post-fracture.

RESULTS

RRs for incident MOF and hip fracture exceeded unity for the primary analyses in all subgroups and follow-up intervals. There was a tendency of RRs to decline over time, but this was inconsistent. Absolute rates per 100,000 person-years for fracture cases were consistently greater than for controls in all subgroups and observation times. Among fracture cases, there was a tendency for rates to decline gradually in all subgroups except younger women, but these temporal trends appeared monotonic without an inflection at 2 years. Joinpoint regression analyses did not detect an inflection in risk between the first 2 years and subsequent years. No significant time dependency was seen for incident hip fracture.

CONCLUSIONS

MOF and hip re-fracture risk was elevated in all age and sex subgroups over 10 years. There was inconsistent and only modest time dependency in early MOF risk, most evident in women after age 65 years. No strong transition in risk was seen between the first 2-year post-fracture and subsequent years.

Long-term risk of subsequent major osteoporotic fracture and hip fracture in men and women: a population-based observational study with a 25-year follow-up

The risk of subsequent major osteoporotic and hip fracture following an initial fracture was increased in both sexes over 25 years, with modest time-dependent attenuation. This risk was highest in men, underscoring the importance of targeted treatment strategies particularly in this under-treated population.

INTRODUCTION

The risk of subsequent fractures is increased following an index fracture, and declines over time. We aimed to determine whether this risk was sustained over 25 years and evolved similarly in men and women.

METHODS

Using population-based databases, we performed a matched cohort study in 16,876 men and 39,230 women ≥ 50 years who sustained an index fracture during 1989-2006. Rates of subsequent major osteoporotic fractures (MOF) and hip fractures until 2016 were compared to rates for matched controls (n = 160,983). Age- and sex-stratified cumulative incidences to 25 years were estimated in the presence of competing mortality. Hazard ratios (HRs) with 95% confidence intervals (CI) for subsequent fractures were estimated for each on the first 15 years of follow-up with a final category ≥ 15 years, adjusted for comorbidities.

RESULTS

Risk for MOF and hip fractures remained elevated up to 25 years in both sexes. The cumulative incidence of fractures was higher in cases vs controls in both sexes and across all age categories except in those > 90 years. Crude rate ratios for subsequent MOF were 2.5 (95% CI 2.3-2.7) in men and 1.6 (95% CI 1.6-1.7) in women and were higher in the younger age groups. Adjusted HRs (aHRs) for subsequent MOF were higher in men than in women in the first year (men aHR 2.6, 95% CI 2.1-3.3; women aHR 1.6, 95% CI 1.4-1.7).

CONCLUSIONS

The risk of subsequent fractures following an initial fracture was increased over 25 years and the magnitude of risk was initially greater in men than in women.

The association between endocrine therapy use and osteoporotic fracture among post-menopausal women treated for early-stage breast cancer in Ontario, Canada

Background

The use of endocrine therapy for early-stage breast cancer, particularly aromatase inhibitor therapy has been associated with an increased risk of osteoporosis and fracture in clinical trials. We sought to validate this observation in real-world practice.

Methods

We used health administrative data collected from post-menopausal women (aged ≥66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2012. Patients were classified by use of either an aromatase inhibitor or tamoxifen and followed until 2017 for a new diagnosis of an osteoporotic fracture. A multivariable analysis using a Cox proportional hazards model was adjusting for age, medical co-morbidities, medication use and duration of endocrine therapy.

Results

We identified 12,077 patients of whom 73% were treated with an aromatase inhibitor as compared to 27% with tamoxifen. Our multivariable analysis did not demonstrate any significant difference in the rate of osteoporotic fracture between patients treated with an aromatase inhibitor when compared with tamoxifen [Hazard ratio (HR) = 1.09; 95% confidence interval (CI) = 0.96–1.23, p-value = 0.18]. The 5-year rate of osteoporotic fracture for patients treated with either an aromatase inhibitor or tamoxifen was 7.5% and 6.9%, respectively. A completed sensitivity analysis did observe a decreased risk of fracture associated with tamoxifen usage over time.

Conclusion

We could not detect a significant difference in the rate of osteoporotic fracture among patients treated with an aromatase inhibitor versus tamoxifen. Nonetheless, the risk with tamoxifen was numerically lower and significantly decreased when accounting for total duration of endocrine therapy.

•

Our real-world study investigated the osteoporotic fracture risk among early-stage post-menopausal breast cancer patients.

•

No significant difference in fracture rates was observed among patients treated with aromatase inhibitors versus tamoxifen.

•

The risk of osteoporotic fracture decreased with tamoxifen usage over time.

•

Bone health should be carefully monitored and optimized among breast cancer patients recieving endocrine therapy.

MyTEMP: Statistical Analysis Plan of a Registry-Based, Cluster-Randomized Clinical Trial

Background:

Major Outcomes with Personalized Dialysate TEMPerature (MyTEMP) is a 4-year cluster-randomized clinical trial comparing the effect of using a personalized, temperature-reduced dialysate protocol versus a dialysate temperature of 36.5°C on cardiovascular-related death and hospitalization. Randomization was performed at the level of the dialysis center (“the cluster”).

Objective:

The objective is to outline the statistical analysis plan for the MyTEMP trial.

Design:

MyTEMP is a pragmatic, 2-arm, parallel-group, registry-based, open-label, cluster-randomized trial.

Setting:

A total of 84 dialysis centers in Ontario, Canada.

Patients:

Approximately 13 500 patients will have received in-center hemodialysis at the 84 participating dialysis centers during the trial period (April 3, 2017, to March 1, 2021, with a maximum follow-up to March 31, 2021).

Methods:

Patient identification, baseline characteristics, and study outcomes will be obtained primarily through Ontario administrative health care databases held at ICES. Covariate-constrained randomization was used to allocate the 84 dialysis centers (1:1) to the intervention group or the control group. Centers in the intervention group used a personalized, temperature-reduced dialysate protocol, and centers in the control group used a fixed dialysate temperature of 36.5°C.

Outcomes:

The primary outcome is a composite of cardiovascular-related death or major cardiovascular-related hospitalization (defined as a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) recorded in administrative health care databases. The key secondary outcome is the mean drop in intradialytic systolic blood pressure, defined as the patients’ predialysis systolic blood pressure minus their nadir systolic blood pressure during the dialysis treatment. Anonymized data on patients’ predialysis and intradialytic systolic blood pressure were collected at monthly intervals from each dialysis center.

Analysis plan:

The primary analysis will follow an intent-to-treat approach. The primary outcome will be analyzed at the patient level as the hazard ratio of time-to-first event, estimated from a subdistribution hazards model. Within-center correlation will be accounted for using a robust sandwich estimator. In the primary analysis, patients’ observation time will end if they experience the primary outcome, emigrate from Ontario, or die of a noncardiovascular cause (which will be treated as a competing risk event). The between-group difference in the mean drop in intradialytic systolic blood pressure obtained during the dialysis sessions throughout the trial period will be analyzed at the center level using an unadjusted random-effects linear mixed model.

Trial status:

The MyTEMP trial period is April 3, 2017, to March 31, 2021. We expect to analyze and report results by 2023 once the updated data are available at ICES.

Trial registration:

MyTEMP is registered with the US National Institutes of Health at clincaltrials.gov (NCT02628366).

Statistical analytic plan:

Version 1.1 June 15, 2021.

Assessment of site-specific X-ray procedure codes for fracture ascertainment: a registry-based cohort study

Site-specific X-ray procedure codes are a useful ancillary source of information for identifying fractures in healthcare administrative and claims data.

INTRODUCTION

Real-world evaluation of fracture epidemiology at the population level from electronic healthcare information, such as administrative data, requires comprehensive data sources and validated case definitions. Only hip fractures are routinely hospitalized, and the identification of most osteoporosis-related fractures which are non-hospitalized fractures remains challenging. Plain X-rays (radiographs) are first-line tests for fracture diagnosis and are frequently repeated to monitor fracture healing, and claims data related to radiologic procedures are available in many healthcare systems. We hypothesized that temporal clustering in plain X-ray procedure codes might be an ancillary source of fracture data.

METHODS

We identified individuals age 40 years and older in Manitoba Bone Mineral Density (BMD) Registry with a fracture diagnosis (hip, forearm, humerus, clinical vertebral) before or following a BMD test. A subset underwent detailed review of X-rays to verify an acute fracture. We examined the association between fracture diagnosis and numbers of site-specific X-ray procedures.

RESULTS

The registry cohort included 7793 individuals with a fracture in the previous 5 years and 8417 incident fractures. The X-ray review cohort included 167 radiologically-verified fractures. The number of site-specific X-ray codes was greater in those with vs without fracture (all P < 0.001). The number of days with site-specific X-rays was strongly associated with a fracture diagnosis (area under the curve 0.90 to 0.99 for all non-vertebral fractures, 0.66 to 0.75 for clinical vertebral fractures). There was good agreement between the date of fracture diagnosis and the first X-ray at all non-vertebral fracture sites (Spearman correlation range 0.65 to 0.99), but this was lower for clinical vertebral fractures (range 0.29 to 0.59).

CONCLUSIONS

Temporal clustering in site-specific X-ray procedures was associated with a corresponding fracture diagnosis in administrative medical records. Non-vertebral fracture sites were more strongly associated with X-ray procedures than clinical vertebral fractures.

Multimorbidity in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results From a Longitudinal, Multicenter Data Linkage Study

OBJECTIVE

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is considered a chronic, relapsing condition. To date, no studies have investigated multimorbidity in AAV nationally. This study was undertaken to characterize temporal trends in multimorbidity and report excess health care expenditures associated with multimorbidities in a national AAV cohort from Scotland.

METHODS

Eligible patients with AAV were diagnosed between 1997 and 2017. Each patient was matched with up to 5 general population controls. Linked morbidity and health care expenditure data were retrieved from a Scottish national hospitalization repository and from published national cost data. Multimorbidity was defined as the development of ≥2 disorders. Prespecified morbidities, individually and together, were analyzed for risks and associations over time using modified Poisson regression, discrete interval analysis, and chi-square test for trend. The relationship between multimorbidities and health care expenditure was investigated using multivariate linear regression.

RESULTS

In total, 543 patients with AAV (median age 58.7 years [range 48.9-68.0 years]; 53.6% male) and 2,672 general population controls (median age 58.7 years [range 48.9-68.0 years]; 53.7% male) were matched and followed up for a median of 5.1 years. AAV patients were more likely to develop individual morbidities at all time points, but especially <2 years after diagnosis. The highest proportional risk observed was for osteoporosis (adjusted incidence rate ratio 8.0, 95% confidence interval [95% CI] 4.5-14.2). After 1 year, 23.0% of AAV patients and 9.3% of controls had developed multimorbidity (P < 0.0001). After 10 years, 37.0% of AAV patients and 17.3% of controls were reported to have multimorbidity (P < 0.0001). Multimorbidity was associated with disproportionate increases in health care expenditures in AAV patients. Health care expenditure was highest for AAV patients with ≥3 morbidities (3.89-fold increase in costs, 95% CI 2.83-5.31; P < 0.001 versus no morbidities).

CONCLUSION

These findings emphasize the importance of holistic care in patients with AAV, and may identify a potentially critical opportunity to consider early screening.

Cancer patients with fractures are rarely assessed or treated for osteoporosis: a population-based study

Among 4238 cancer and 16,418 cancer-free individuals with incident major non-traumatic fractures (hip, clinical vertebral, forearm, humerus), post-fracture osteoporosis care was equally poor for both groups, whether assessed from bone mineral density (BMD) testing, initiation of osteoporosis therapy or either intervention (BMD testing and/or osteoporosis therapy).

INTRODUCTION

Most individuals sustaining a fracture do not undergo evaluation and/or treatment for osteoporosis. Cancer survivors are at increased risk for osteoporosis and fracture. Whether cancer survivors experience a similar post-fracture "care gap" is unclear. Using population-based databases, we assessed whether cancer patients are evaluated and/or treated for osteoporosis after a major fracture.

METHODS

From the Manitoba Cancer Registry, we identified cancer cases (first cancer diagnosis between 1987 and 2013) and cancer-free controls with incident major non-traumatic fractures (from provincial physician billing claims and hospitalization databases). The outcomes were performance of BMD testing (from the BMD Registry), initiation of osteoporosis therapy (from drug dispensation database) or either intervention (BMD testing and/or osteoporosis therapy) in the 12 months post-fracture.

RESULTS

There were 4238 cancer and 16,418 cancer-free individuals who sustained a fracture after the index date (cancer diagnosis) and were followed for at least 1 year post-fracture. Subsequent BMD testing was performed in 11.0% of cancer cases versus 11.5% non-cancer controls (P = 0.43), osteoporosis treatment in 22.9% cancer cases versus 21.8% non-cancer controls (P = 0.15), and either testing or treatment in 28.9% cancer cases versus 28.4% non-cancer controls (P = 0.53). Predictors of BMD testing and/or initiation of therapy were similar for non-cancer and cancer patients. Post-fracture interventions were consistently used more frequently among women, older patients (age 50 years or older), those who sustained fractures in a later calendar period, and (for treatment) after vertebral fracture. Cancer-specific variables (cancer type, years from cancer diagnosis to fracture, specialty of care provider) showed only weak and inconsistent effects.

CONCLUSIONS

A large care gap exists among cancer patients who sustain a fracture, similar to the general population, whereby the evaluation or treatment for osteoporosis is seldom conducted. Care maps may need to be developed for cancer populations to improve post-fracture care.

Use of an electronic medical record dashboard to identify gaps in osteoporosis care

Using an electronic medical record (EMR)-based dashboard, this study explored osteoporosis care gaps in primary care. Eighty-four physicians shared their practice activities related to bone mineral density testing, 10-year fracture risk calculation and treatment for those at high risk. Significant gaps in fracture risk calculation and osteoporosis management were identified.

PURPOSE

To identify care gaps in osteoporosis management focusing on Canadian clinical practice guidelines (CPG) related to bone mineral density (BMD) testing, 10-year fracture risk calculation and treatment for those at high risk.

METHODS

The ADVANTAGE OP EMR tool consists of an interactive algorithm to facilitate assessment and management of fracture risk using CPG. The FRAX® and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools were embedded to facilitate 10-year fracture risk calculation. Physicians managed patients as clinically indicated but with EMR reminders of guideline recommendations; participants shared practice level data on management activities after 18-month use of the tool.

RESULTS

Eighty-four physicians (54%) of 154 who agreed to participate in this study shared their aggregate practice activities. Across all practices, there were 171,310 adult patients, 40 years of age and older, of whom 17,214 (10%) were at elevated risk for fracture. Sixty-two percent of patients potentially at elevated risk for fractures did not have BMD testing completed; most common reasons for this were intention to order BMD later (48%), physician belief that BMD was not required (15%) and patient refusal (20%). For patients with BMD completed, fracture risk was calculated in 29%; 19% were at high risk, of whom 37% were not treated with osteoporosis medications as recommended by CPG.

CONCLUSION

Despite access to CPG and fracture risk calculators through the ADVANTAGE OP EMR tool, significant gaps remain in fracture risk calculation and osteoporosis management. Additional strategies are needed to address this clinical inertia among family physicians.

Trabecular bone score in patients with chronic kidney disease

Patients with chronic kidney disease have high risk of osteoporotic fractures. Lower trabecular bone score (TBS) was associated with poorer kidney function and higher fracture risk when kidney function was normal. Addition of TBS to The Fracture Risk Assessment Tool with bone mineral density did not improve fracture risk prediction.

INTRODUCTION

We sought to determine whether trabecular bone score (TBS) either independently or adjusted for The Fracture Risk Assessment Tool (FRAX) could predict risk of major osteoporotic fractures (MOFs) in a large population-based sample of patients with all stages of chronic kidney disease (CKD).

METHODS

We used population-based administrative databases to identify patients above age 20 years who had dual-energy X-ray absorptiometry (DXA) scan and serum creatinine measured within 1 year, during the years 2005 to 2010. Patients were excluded if they were on dialysis or had a functioning renal transplant. We stratified patients by estimated glomerular filtration rate (eGFR). We collected femoral neck bone mineral density (BMD), lumbar spine TBS, incident major osteoporotic fractures (MOF) and hip fractures, and other clinical characteristics.

RESULTS

Among 8289 patients, there were 6224 (75.1%) with eGFR ≥ 60 mL/min/1.73 m², 1624 (19.6%) with eGFR 30-60 mL/min/1.73 m², and 441 (5.3%) with eGFR < 30 mL/min/1.73 m². There were 593 patients (7.2%) with MOFs and 163 (2.0%) with hip fractures. Lower TBS score was associated with increased risk of MOF and hip fractures across all eGFR strata in unadjusted Cox proportional hazards models but after adjusting for FRAX with BMD, lower TBS was only statistically significant for MOF prediction for eGFR ≥ 60 mL/min/1.73 m².

CONCLUSION

Lower TBS scores were associated with lower eGFR and increased fracture risk in patients with eGFR ≥ 60 mL/min/1.73 m². However, the addition of TBS to the FRAX score with BMD did not significantly improve fracture risk prediction in patients with CKD.

Parental cardiorespiratory conditions and offspring fracture: A population-based familial linkage study

BACKGROUND

The role of parental cardiorespiratory conditions on fracture risk is unclear. We examined the associations between parental cardiorespiratory conditions and offspring fracture risk.

METHODS

In this population-based retrospective cohort study, we identified 279,085 offspring aged≥40 years between April 1, 1997 and December 31, 2015 with successful linkage to 273,852 mothers and 254,622 fathers. Parental cardiorespiratory conditions, including cerebral vascular disease, congestive heart failure, hypertension, ischemic heart disease, myocardial infarction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease, were ascertained using physician and hospital records dating back to 1979. The outcome was offspring incident major osteoporotic fracture (MOF).

RESULTS

During an average of 11.8 years of offspring follow-up, we identified 8762 (3.1%) incident MOF. Either parent congestive heart failure (adjusted hazard ratio [HR]: 1.13; 95% confidence interval [CI] 1.07-1.19) and COPD (adjusted HR: 1.12; 95% CI 1.07-1.17) were independently associated with increased offspring MOF risk; all their false discovery rates were <0.001. Similar risk estimates were observed when analyses were performed for fathers only, mothers only or both parents, in multivariable models with and without adjustment for offspring cardiorespiratory conditions, and stratified by offspring sex and offspring incident fracture site. Parental cerebrovascular disease, hypertension, ischemic heart disease and myocardial infarction were not associated with offspring MOF.

CONCLUSIONS

Parental congestive heart failure and parental COPD are independent risk factors for offspring MOF.

Factors That Predict 1-Year Incident Hip and Non-Hip Fractures for Home Care Recipients: A Linked-Data Retrospective Cohort Study

OBJECTIVES

The purpose of our study was to identify factors that predict 1-year incident hip and major osteoporotic non-hip fractures (ie, wrist, spine, pelvis, humerus) for home care recipients while accounting for the competing risk of death.

DESIGN

We conducted a retrospective cohort study with linked population data.

SETTING AND PARTICIPANTS

All home care recipients in Ontario, Canada, receiving services for more than 6 months with an admission assessment between April 1, 2011, and March 31, 2015, were included.

METHODS

Clinical data from the Resident Assessment Instrument Home Care were linked to fracture data from the Discharge Abstract Database and the National Acute Care Reporting System. Competing risk proportional hazard regressions using the Fine and Grey method were performed to model the association between potential risk factors and fracture.

RESULTS

Previous fall, previous fracture, cognitive impairment, unsteady gait, alcohol use, tobacco use, and Parkinson disease were consistently associated with all fracture types. Cognitive impairment (hazard ratio 2.09; 95% confidence interval 1.86-2.36) and wandering [1.66 (1.06-1.27)] were most predictive of hip fractures and being female [1.86 (1.76-1.98)] and experiencing a previous fracture [1.86 (1.76-1.98)] were most predictive of non-hip fractures. Risk factors unique to non-hip fractures as compared with hip fractures were locomotion ability outdoors and psychotropic medication use.

CONCLUSIONS AND IMPLICATIONS

Our results indicate that, in addition to typical fracture risk factors, home care recipients have unique characteristics that increase their risk. Fracture risk assessment tools and subsequent prevention strategies should be modified to accurately identify home care recipients at risk for imminent 1-year fracture.

Development and validation of the fracture risk scale home care (FRS-HC) that predicts one-year incident fracture: an electronic record-linked longitudinal cohort study

BACKGROUND

Fractures have dire consequences including pain, immobility, and death. People receiving home care are at higher risk for fractures than the general population. Yet, current fracture risk assessment tools require additional testing and assume a 10-year survival rate, when many die within one year. Our objectives were to develop and validate a scale that predicts one-year incident hip fracture using the home care resident assessment instrument (RAI-HC).

METHODS

This is a retrospective cohort study of linked population data. People receiving home care in Ontario, Canada between April 1st, 2011 and March 31st, 2015 were included. Clinical data were obtained from the RAI-HC which was linked to the Discharge Abstract Database and National Ambulatory Care Reporting System to capture one-year incident hip fractures. Seventy-five percent (n = 238,011) of the sample were randomly assigned to a derivation and 25% (n = 79,610) to a validation sample. A decision tree was created with the derivation sample using known fracture risk factors. The final nodes of the decision tree were collapsed into 8 risk levels and logistic regression was performed to determine odds of having a fracture for each level. c-Statistics were calculated to compare the discriminative properties of the full, derivation, and validation samples.

RESULTS

Approximately 60% of the sample were women and 53% were 80 years and older. A total of 11,526 (3.6%) fractures were captured over the 1-year time period. Of these, 5057 (43.9%) were hip fractures. The proportion who experienced a hip fracture in the next year ranged from 0.3% in the lowest risk level to 5.2% in the highest risk level. People in the highest risk level had 18.8 times higher odds (95% confidence interval, 14.6 to 24.3) of experiencing a hip fracture within one year than those in the lowest. c-Statistics were similar for the full (0.658), derivation (0.662), and validation (0.645) samples.

CONCLUSIONS

The FRS-HC predicts hip fracture over one year and should be used to guide clinical care planning for home care recipients at high risk for fracture. Our next steps are to develop a fracture risk clinical assessment protocol to link treatment recommendations with identified fracture risk.

Loss in DXA-estimated total body lean mass but not fat mass predicts incident major osteoporotic fracture and hip fracture independently from FRAX: a registry-based cohort study

During median follow-up 6.0 years in 9622 individuals, prior loss in estimated total body lean mass (TBLM), but not total body fat mass loss (TBFM), was associated with increased fracture risk, particularly for hip fracture.

INTRODUCTION

Weight loss, and especially muscle loss, adversely affects skeletal health. The FRAX® tool considers baseline body mass index, but not body composition nor changes in its components over time. Our aim was to compare the independent associations between prior loss in DXA-estimated TBLM and TBFM and subsequent fracture risk.

METHODS

We identified women and men age 40 years or older with two DXA assessments at least 1 year apart (median interval 3.3 years). TBLM and TBFM were estimated from weight, sex, and DXA of the spine and hip. Incident fractures and deaths were ascertained from linked population-based health service data after the date of the second DXA. Hazard ratios (HRs) from Cox regression models were used to study time to fracture from prior loss in TBLM and TBFM adjusted for FRAX-related covariates.

RESULTS

The study population consisted of 9622 individuals (mean age 67 [SD 10] years, 95% female). We identified 692 subjects with incident major osteoporotic fracture [MOF] and 194 with hip fracture. Mean TBLM loss was significantly greater in those with incident MOF and hip fracture (P < 0.001) while TBFM loss was only significantly greater in those with incident hip fracture (P < 0.001). Each SD greater TBLM loss was associated with 10-13% increased MOF risk and 29-38% increased hip fracture risk, adjusted for TBFM loss and other covariates. Prior TBFM loss was not associated with fractures when adjusted for TBLM loss.

CONCLUSIONS

Prior loss in total body lean mass, but not in fat mass, is associated with increased fracture risk, particularly hip fracture, independent of other risk factors. This is consistent with the hypothesis that muscle loss (sarcopenia) adversely impacts skeletal health and fracture risk.

Measured height loss predicts incident clinical fractures independently from FRAX: a registry-based cohort study

During median follow-up 6.0 years in 11,495 individuals, prior absolute and annualized measured height loss was significantly greater in those with subsequent incident fracture compared with those without incident fracture.

PURPOSE

FRAX® accepts baseline height and weight as input variables, but does not consider change in these parameters over time.

AIM

To evaluate the association between measured height or weight loss on subsequent fracture risk adjusted for FRAX scores, risk factors, and competing mortality.

METHODS

Using a dual-energy x-ray absorptiometry (DXA) registry for the Province of Manitoba, Canada, we identified women and men age 40 years or older with height and weight measured at the time of two DXA scans. Cox regression analyses were performed to test for a covariate-adjusted association between prior height and weight loss with incident fractures occurring after the second scan using linked population-based healthcare data.

RESULTS

The study population consisted of 11,495 individuals (average age 68.0 ± 9.9 years, 94.6% women). During median follow-up 6.0 years, records demonstrated incident major osteoporotic fracture (MOF) in 869 individuals, hip fractures in 265, clinical vertebral fractures in 207, and any fracture in 1203. Prior height loss was significantly greater in individuals with fracture compared with those without fracture, regardless of fracture site. Mortality was greater in those with prior height loss (HR per SD 1.11, 95% CI 1.06-1.17) or weight loss (HR per SD 1.26, 95% CI 1.19-1.32). Each SD in height loss was associated with increased fracture risk (MOF 12-17%, hip 8-19%, clinical vertebral 28-37%, any fracture 14-19%). Prior weight loss was associated with 21-30% increased risk for hip fracture, but did not increase risk for other fractures. Height loss of 3.0 cm or greater more than doubled the risk for subsequent fracture.

CONCLUSIONS

Prior height loss is associated with a small but significant increase in risk of incident fracture at all skeletal sites independent of other clinical risk factors and competing mortality as considered by FRAX. Prior weight loss only increases risk for subsequent hip fracture.

A Safety Comparison of Metformin vs Sulfonylurea Initiation in Patients With Type 2 Diabetes and Chronic Kidney Disease: A Retrospective Cohort Study

OBJECTIVE

To compare the safety of metformin vs sulfonylureas in patients with type 2 diabetes by chronic kidney disease (CKD) stage.

PATIENTS AND METHODS

This retrospective cohort study included adults in Manitoba, Canada, with type 2 diabetes, an incident monotherapy prescription for metformin or a sulfonylurea, and a serum creatinine measurement from April 1, 2006, to March 31, 2017. Patients were stratified by estimated glomerular filtration rate (eGFR) into the following groups: eGFR of 90 or greater, 60 to 89, 45 to 59, 30 to 44, or less than 30 mL/min/1.73 m². Outcomes included all-cause mortality, cardiovascular events, and major hypoglycemic episodes. Baseline characteristics were used to calculate propensity scores and perform inverse probability of treatment weights analysis, and eGFR group was examined as an effect modifier for each outcome.

RESULTS

The cohort consisted of 21,996 individuals (19,990 metformin users and 2006 sulfonylurea users). Metformin use was associated with lower risk for all-cause mortality (hazard ratio [HR], 0.48; 95% CI, 0.40-0.58; P<.001), cardiovascular events (HR, 0.67; 95% CI, 0.52-0.86; P=.002), and major hypoglycemic episodes (HR, 0.14; 95% CI, 0.09-0.20; P<.001) when compared with sulfonylureas. CKD was a significant effect modifier for all-cause mortality (P=.002), but not for cardiovascular events or major hypoglycemic episodes.

CONCLUSION

Sulfonylurea monotherapy is associated with higher risk for all-cause mortality, major hypoglycemic episodes, and cardiovascular events compared with metformin. Although the presence of CKD attenuated the mortality benefit, metformin may be a safer alternative to sulfonylureas in patients with CKD.

Fracture Risk in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry-Based Cohort Study

BACKGROUND

Aromatase inhibitors (AIs) used in breast cancer induce loss in bone mineral density (BMD) and are reported to increase fracture risk.

MATERIALS AND METHODS

Using a population-based BMD registry, we identified women aged at least 40 years initiating AIs for breast cancer with at least 12 months of AI exposure (n = 1,775), women with breast cancer not receiving AIs (n = 1,016), and women from the general population (n = 34,205). Fracture outcomes were assessed to March 31, 2017 (mean, 6.2 years for AI users).

RESULTS

At baseline, AI users had higher body mass index (BMI), higher BMD, lower osteoporosis prevalence, and fewer prior fractures than women from the general population or women with breast cancer without AI use (all p < .001). After adjusting for all covariates, AI users were not at significantly greater risk for major osteoporotic fractures (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.93-1.42), hip fracture (HR, 0.90; 95% CI, 0.56-1.43), or any fracture (HR, 1.06; 95% CI, 0.88-1.28) compared with the general population.

CONCLUSION

Higher baseline BMI, BMD, and lower prevalence of prior fracture at baseline may offset the adverse effects of AI exposure. Although confirmatory data from large cohort studies are required, our findings challenge the view that all women with breast cancer initiating AI therapy should be considered at high risk for fractures.

IMPLICATIONS FOR PRACTICE

In a population-based observational registry that included 1,775 patients initiating long-term aromatase inhibitor therapy, risk for major osteoporotic fracture, hip fracture, or any fracture was similar to the general population. Higher baseline body mass index, bone mineral density, and lower prevalence of prior fracture at baseline may offset the adverse effects of aromatase inhibitor exposure.

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.

Association of Bone Density Monitoring in Routine Clinical Practice With Anti-Osteoporosis Medication Use and Incident Fractures: A Matched Cohort Study

Routine bone mineral density (BMD) monitoring of individuals during the initial 5 years of anti-osteoporosis treatment is controversial. Using a registry-based cohort from the Province of Manitoba, Canada, we compared anti-osteoporosis medication use and fracture outcomes in women with versus without BMD monitoring receiving anti-osteoporosis medication. We identified 4559 women aged 40 years and older receiving anti-osteoporosis therapy with serial BMD testing (monitoring) within 5 years (mean interval 3.2 years) and 4559 propensity score-matched women without BMD monitoring. We assessed anti-osteoporosis medication use over 5 years from a population-based retail pharmacy database. Incident fractures to 10 years from health services data. During median 10 years observation, 1225 (13.4%) women developed major osteoporotic fracture, including 382 (4.2%) with hip fractures. Monitored women had significantly better fracture-free survival for major osteoporotic fracture (p = 0.040; 10-year cumulative risk 1.9% lower, 95% confidence interval [CI] 0.3-3.6%) and hip fracture ( p = 0.001; 10-year cumulative risk 1.8% lower, 95% CI 0.7-2.8%) compared with women who were not monitored. Hazard ratios (HRs) were significantly lower in monitored versus not monitored women for major osteoporotic fracture (HR = 0.89, 95% CI 0.80-0.98) and hip fracture (HR = 0.74, 95% CI 0.63-0.87). Days of medication use, medication persistence ratio, and treatment switching over 5 years were greater in monitored versus not monitored women. At the end of 5 years, more women in the monitored group persisted on treatment and more switched treatment, with switching behavior associated with an observed interval reduction in BMD. In conclusion, our findings suggest a possible role for BMD monitoring after initiating anti-osteoporosis therapy in the routine clinical practice setting. © 2019 American Society for Bone and Mineral Research.

Factors associated with endocrine therapy adherence among post-menopausal women treated for early-stage breast cancer in Ontario, Canada

PURPOSE

Adherence to adjuvant endocrine therapy among post-menopausal breast cancer patients is an important survivorship care issue. We explored factors associated with endocrine therapy adherence and survival in a large real-world population-based study.

METHODS

We used health administrative databases to follow women (aged ≥ 66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2010. Adherence was measured by medical possession ratio (MPR) and characterized as low (< 39% MPR), intermediate (40-79% MPR), or high (≥ 80% MPR) over a 5-year period. We investigated factors associated with adherence using a multinomial logistic regression model. Factors associated with all-cause mortality (5 years after starting endocrine therapy) were investigated using a multivariable Cox proportional hazards model.

RESULTS

We identified 5692 eligible patients starting adjuvant endocrine therapy who had low, intermediate, and high adherence rates of 13% (n = 749), 13% (n = 733), and 74% (n = 4210), respectively. Lower rates of adherence were associated with increased age [low vs. high adherence: odds ratio (OR) 1.03, 95% CI 1.02-1.05 (per year); intermediate vs. high adherence: OR 1.02, 95% CI 1.01-1.04 (per year)]. High adherence was associated with previous use of adjuvant chemotherapy (low versus high adherence OR 0.42, 95% CI 0.30-0.59) and short-term follow-up with a medical oncologist within 4 months of starting endocrine therapy (low versus high adherence OR 0.83, 95% CI 0.69-0.99). Unadjusted analysis showed increased survival among patients with high endocrine therapy adherence. However, an independent association was no longer clearly detected after controlling for confounders.

CONCLUSION

Interventions to improve adjuvant endocrine therapy adherence are warranted. Non-adherence may be a more significant issue among elderly patients. Short-term follow-up visit by a patient's medical oncologist after starting endocrine therapy may help to improve compliance.

Five-year refracture rates of a province-wide fracture liaison service

We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk.

INTRODUCTION

To examine refractures among patients screened in a province-wide fracture liaison service (FLS).

METHODS

We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates.

RESULTS

The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70 years: HR = 1.3, CI 95%, 1.0-1.7; 71-80 years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5).

CONCLUSIONS

One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.

Performance of FRAX in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry-Based Cohort Study

FRAX was developed to predict 10-year probability of major osteoporotic fracture (MOF) and hip fracture in the general population. Aromatase inhibitors (AI) used in breast cancer induce loss in bone mineral density (BMD) and are reported to increase fracture risk. AI exposure is not a direct input to FRAX but is captured under "secondary osteoporosis". To inform use of FRAX in women treated with AI, we used a population-based registry for the Province of Manitoba, Canada, to identify women aged ≥40 years initiating AI for breast cancer with at least 12 months' AI exposure (n = 1775), women with breast cancer not receiving AI (n = 1016), and women from the general population (n = 34,205). Among AI users, fracture probability estimated without BMD (AI use coded as secondary osteoporosis) significantly overestimated risk (10-year observed/predicted ratio 0.56, 95% confidence interval [CI] 0.45-0.68; 10-year hip fracture observed/predicted ratio 0.33, 95% CI 0.18-0.49). However, when BMD was included in the fracture probability, there was no significant difference between observed and predicted fracture risk. In Cox proportional hazards models, FRAX stratified risk of MOF, hip, and any fracture equally well in all subgroups (p-interaction >0.1). When adjusted for FRAX score without BMD, with AI use coded as secondary osteoporosis, AI users were at significantly lower risk for MOF (hazard ratio [HR] = 0.78, 95% CI 0.64-0.95), hip fracture (HR = 0.46, 95% CI 0.29-0.73) and any fracture (HR = 0.75, 95% CI 0.63-0.89). AI use was no longer significantly associated with fractures when AI use was not entered as secondary osteoporosis in FRAX without BMD or when BMD was included in the FRAX calculation. In conclusion, FRAX scores stratify fracture risk equally well in women receiving AI therapy as in non-users, but including secondary osteoporosis as a risk factor for AI users overestimates fracture risk. Our results call this practice into question. © 2019 American Society for Bone and Mineral Research.

Performance of FRAX and FRAX-Based Treatment Thresholds in Women Aged 40 Years and Older: The Manitoba BMD Registry

We examined among women aged ≥40 years the performance of the Fracture Risk Assessment Tool (FRAX) and FRAX-based osteoporosis treatment thresholds under the US National Osteoporosis Foundation (NOF) and UK National Osteoporosis Guideline Group (NOGG) guidelines. We used registry data for all women aged ≥40 years in Manitoba, Canada, with baseline bone mineral density (BMD) testing (n = 54,459). Incident major osteoporotic fracture (MOF), hip fracture, and clinical fracture were assessed from population-based health services data (mean follow-up 10.5 years). Age-stratified hazard ratios (HR) were estimated from Cox regression models. We assessed the sensitivity, specificity, positive predictive value (PPV), number needed to screen (NNS), and number needed to treat (NNT) to prevent a fracture (assuming 20% relative risk reduction on treatment) for osteoporosis treatment thresholds under the NOF and NOGG guidelines. Femoral neck T-score and FRAX (with and without BMD) predicted all fracture outcomes at all ages. There was good calibration in FRAX-predicted versus observed 10-year MOF and hip fracture probability. Overall sensitivity (PPV) for incident MOF was 25.7% (24.0%) for femoral neck T-score ≤ -2.5; 20.3% (26.3%) for FRAX (with BMD)-predicted 10-year MOF risk ≥20% (NOF threshold); 27.3% (22.0%) for FRAX-predicted 10-year MOF risk ≥ age-dependent cut-off (NOGG threshold), 59.4% (19.0%) for the NOF treatment algorithm; and 28.5% (18.4%) for the NOGG treatment algorithm. Sensitivity for identifying incident MOF varied by age, ranging from 0.0% to 26.3% in women 40 to 49 years old and from 49.0% to 93.3% in women aged 80+ years. The gradient of risk for fracture prediction from femoral neck T-score and FRAX (with and without BMD) as continuous measures was strong across the age spectrum. The sensitivity and PPV of the strategies based on dichotomous cut-offs are low, especially among women aged 40 to 49 years (who have lowest incidence rates). Threshold-based approaches should be reassessed, particularly in younger women. © 2019 American Society for Bone and Mineral Research.

Administrative healthcare data applied to fracture risk assessment

Fracture risk scores generated from population-based administrative healthcare data showed comparable or better discrimination than the Fracture Risk Assessment Tool (FRAX) scores computed without bone mineral density for predicting incident major osteoporotic fracture. Administrative data may be useful to identify individuals at high fracture risk at the population level.

PURPOSE

To evaluate the discrimination of fracture risk scores defined using inputs available from administrative data for predicting incident major osteoporotic fracture (MOF) and hip fracture (HF) alone.

METHODS

Using the Manitoba Bone Mineral Density (BMD) Database (1997-2013), we identified 61,041 individuals aged 50 years or older with healthcare coverage following their first BMD test. We calculated two-modified FRAX)scores based on administrative data: FRAX-A and FRAX-A⁺. The FRAX-A modification used all FRAX inputs, except for BMD, body mass index, and parental HF, while the FRAX-A⁺ modification using all FRAX-A inputs plus a comorbidity score, number of hospitalizations in the 3 years prior to the BMD test, depression diagnosis, and dementia diagnosis. FRAX scores computed with BMD (i.e., FRAX [BMD]) and without BMD (i.e., FRAX [no-BMD]) were the comparators.

RESULTS

During a mean of 7 years of follow-up, we identified 5306 (8.7%) incident MOF and 1532 (2.5%) incident HF. The c-statistic for MOF associated with FRAX-A was lower than FRAX (BMD) (0.655 vs 0.675; P < 0.05) and comparable to FRAX (no-BMD) (0.654; P = 0.07). The c-statistic for MOF using FRAX-A⁺ (0.663) was lower than FRAX (BMD) but higher than FRAX (no-BMD) (both P < 0.05). For predicting incident HF, c-statistics associated with FRAX-A (0.762) and FRAX-A⁺ (0.767) were lower than FRAX (BMD) (0.789) and FRAX (no-BMD) (0.773; both P < 0.05).

CONCLUSIONS

FRAX-A and FRAX-A⁺ showed comparable or better discrimination than FRAX without BMD for predicting incident MOF, but slightly lower discrimination for HF alone.

Validation of a one year fracture prediction tool for absolute hip fracture risk in long term care residents

BACKGROUND

Frail older adults living in long term care (LTC) homes have a high fracture risk, which can result in reduced quality of life, pain and death. The Fracture Risk Scale (FRS) was designed for fracture risk assessment in LTC, to optimize targeting of services in those at highest risk. This study aims to examine the construct validity and discriminative properties of the FRS in three Canadian provinces at 1-year follow up.

METHODS

LTC residents were included if they were: 1) Adults admitted to LTC homes in Ontario (ON), British Columbia (BC) and Manitoba (MB) Canada; and 2) Received a Resident Assessment Instrument Minimum Data Set Version 2.0. After admission to LTC, one-year hip fracture risk was evaluated for all the included residents using the FRS (an eight-level risk scale, level 8 represents the highest fracture risk). Multiple logistic regressions were used to determine the differences in incident hip or all clinical fractures across the provinces and FRS risk levels. We examined the differences in incident hip or all clinical fracture for each FRS level across the three provinces (adjusted for age, BMI, gender, fallers and previous fractures). We used the C-statistic to assess the discriminative properties of the FRS for each province.

RESULTS

Descriptive statistics on the LTC populations in ON (n = 29,848), BC (n = 3129), and MB (n = 2293) are: mean (SD) age 82 (10), 83 (10), and 84 (9), gender (female %) 66, 64, and 70% respectively. The incident hip fractures and all clinical fractures for FRS risk level were similar among the three provinces and ranged from 0.5 to 19.2% and 1 to 19.2% respectively. The overall discriminative properties of the FRS were similar between ON (C-statistic = 0.673), BC (C-statistic = 0.644) and MB (C-statistic = 0.649) samples.

CONCLUSION

FRS is a valid tool for identifying LTC residents at different risk levels for hip or all clinical fractures in three provinces. Having a fracture risk assessment tool that is tailored to the LTC context and embedded within the routine clinical assessment may have significant implications for policy, service delivery and care planning, and may improve care for LTC residents across Canada.

Comparison of Methods for Improving Fracture Risk Assessment in Diabetes: The Manitoba BMD Registry

Type 2 diabetes is a risk factor for fracture independent of FRAX (fracture risk assessment) probability. We directly compared four proposed methods to improve the performance of FRAX for type 2 diabetes by: (1) including the rheumatoid arthritis (RA) input to FRAX; (2) making a trabecular bone score (TBS) adjustment to FRAX; (3) reducing the femoral neck T-score input to FRAX by 0.5 SD; and (4) increasing the age input to FRAX by 10 years. We examined major osteoporotic fractures (MOFs) and hip fractures (HFs) over a mean of 8.3 years observation among 44,543 women and men 40 years of age or older (4136 with diabetes) with baseline lumbar spine and hip DXA from 1999 through 2016. Controlled for unadjusted FRAX probability, diabetes was associated with an increased risk for MOFs and HFs. All four FRAX adjustments attenuated the effect of diabetes, but a residual effect of diabetes was seen on MOF risk after TBS adjustment, and on HF risk after the RA and TBS adjustments. Among those with diabetes, unadjusted FRAX risk underestimated MOF (observed/predicted ratio 1.15; 95% CI, 1.03 to 1.28), but this was no longer significant after applying the diabetes adjustments. HF risk was more severely underestimated (observed/predicted ratio 1.85; 95% CI, 1.51 to 2.20) and was only partially corrected with the diabetes adjustments (still significant for the RA and TBS adjustments). Among those with diabetes, there was moderate reclassification based upon a fixed MOF cut-off of 20% (4.1% to 7.1%) or fixed HF cut-off of 3% (5.7% to 16.5%). Net reclassification improvement increased for MOF with each of the diabetes adjustments (range 3.9% to 5.6% in the diabetes subgroup). In conclusion, each of the proposed methods for addressing limitations in the ability of FRAX to assess fracture risk in individuals with diabetes was found to improve performance, though no single method was optimal in all settings. © 2018 American Society for Bone and Mineral Research.

Long-term effects of inhaled corticosteroids on bone mineral density in older women with asthma or COPD: a registry-based cohort study

We assessed the association between long-term inhaled corticosteroid (ICS) use and bone mineral density (BMD) in older women with chronic respiratory disease. Women with > 50% adherence to ICS use had very slightly accelerated BMD loss at the total hip compared with those with lower or ICS use.

INTRODUCTION

This study evaluated the impact of long-term ICS therapy on bone loss in older women with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

We used a population-based bone densitometry registry linked with administrative health data covering the province of Manitoba, Canada (1999-2013), to identify women aged > 40 years who had diagnosed asthma or COPD. ICS exposure was defined as cumulative dispensed days and medication possession ratio (MPR). Associations were examined both cross-sectionally and longitudinally, and results were covariate adjusted.

RESULTS

Among 6561 women with asthma and/or COPD (mean age 65 years [SD = 11]), compared to no ICS treatment, those in the highest tertile of prior ICS use (≥ 720 days) had lower BMD at the femoral neck (- 0.09 T-score, 95% CI - 0.16, - 0.02) and total hip (- 0.14 T-score, 95% CI - 0.22, - 0.05), but not at the lumbar spine. Over a mean of 5 years of follow-up, the highest tertile of ICS exposure (MPR > 0.5) was associated with a - 0.02 SD/year (95% CI - 0.04, - 0.01) greater decline in total hip BMD relative to non-users, with no significant effect at the femoral neck or lumbar spine. Middle and lower tertiles of ICS use were not associated with baseline or longitudinal change in BMD.

CONCLUSIONS

The highest tertile of ICS use was associated with a slightly lower hip BMD at baseline and slightly greater reduction in total hip BMD over time in older women with asthma or COPD. No adverse effects on BMD were seen from low to moderate ICS exposure.

The Canadian Chronic Disease Surveillance System: A model for collaborative surveillance

Chronic diseases have a major impact on populations and healthcare systems worldwide. Administrative health data are an ideal resource for chronic disease surveillance because they are population-based and routinely collected. For multi-jurisdictional surveillance, a distributed model is advantageous because it does not require individual-level data to be shared across jurisdictional boundaries. Our objective is to describe the process, structure, benefits, and challenges of a distributed model for chronic disease surveillance across all Canadian provinces and territories (P/Ts) using linked administrative data. The Public Health Agency of Canada (PHAC) established the Canadian Chronic Disease Surveillance System (CCDSS) in 2009 to facilitate standardized, national estimates of chronic disease prevalence, incidence, and outcomes. The CCDSS primarily relies on linked health insurance registration files, physician billing claims, and hospital discharge abstracts. Standardized case definitions and common analytic protocols are applied to the data for each P/T; aggregate data are shared with PHAC and summarized for reports and open access data initiatives. Advantages of this distributed model include: it uses the rich data resources available in all P/Ts; it supports chronic disease surveillance capacity building in all P/Ts; and changes in surveillance methodology can be easily developed by PHAC and implemented by the P/Ts. However, there are challenges: heterogeneity in administrative databases across jurisdictions and changes in data quality over time threaten the production of standardized disease estimates; a limited set of databases are common to all P/Ts, which hinders potential CCDSS expansion; and there is a need to balance comprehensive reporting with P/T disclosure requirements to protect privacy. The CCDSS distributed model for chronic disease surveillance has been successfully implemented and sustained by PHAC and its P/T partners. Many lessons have been learned about national surveillance involving jurisdictions that are heterogeneous with respect to healthcare databases, expertise and analytical capacity, population characteristics, and priorities.

Multi-province epidemiological research using linked administrative data: a case study from Canada

Background

Canada has a publicly-funded universal healthcare system with information systems managed by 13 different provinces and territories. This context creates inconsistencies in data collection and challenges for research or surveillance conducted at the national or multi-jurisdictional level.

Objective

Using a recent Canadian research project as a case study, we document the strengths and challenges of using administrative health data in a multi-jurisdictional context. We discuss the implications of using different health information systems and the solutions we adopted to deal with variations. Our goal is to contribute to better understanding of these challenges and the development of a more integrated and harmonized approach to conducting multi-jurisdictional research using administrative data.

Context and model

Using data from five separate provincial healthcare data systems, we sought to create and report on a set of provincially-comparable mental health and addiction services performance indicators. In this paper, we document the research process, challenges, and solutions. Finally, we conclude by making recommendations for investment in national infrastructure that could help cut costs, broaden scope, and increase use of administrative health data that exists in Canada.

Conclusions

Canada has an incredible wealth of administrative data that resides in 13 territorial and provincial government systems. Navigating access and improving comparability across these systems has been an ongoing challenge for the past 20 years, but progress is being made. We believe that with some investment, a more harmonized and integrated information network could be developed that supports a broad range of surveillance and research activities with strong policy and program implications.

Comparison of femoral strength and fracture risk index derived from DXA-based finite element analysis for stratifying hip fracture risk: A cross-sectional study

BACKGROUND

Dual-energy X-ray absorptiometry (DXA)-based finite element analysis (FEA) has been studied for assessment of hip fracture risk. Femoral strength (FS) is the maximum force that the femur can sustain before its weakest region reaches the yielding limit. Fracture risk index (FRI), which also considers subject-specific impact force, is defined as the ratio of von Mises stress induced by a sideways fall to the bone yield stress over the proximal femur. We compared risk stratification for prior hip fracture using FS and FRI derived from DXA-based FEA.

METHODS

The study cohort included women aged ≥65years undergoing baseline hip DXA, with femoral neck T-scores <-1 and no osteoporosis treatment; 324 cases had prior hip fracture and 655 controls had no prior fracture. Using anonymized DXA hip scans, we measured FS and FRI. Separate multivariable logistic regression models were used to estimate odds ratios (ORs), c-statistics and their 95% confidence intervals (95% CIs) for the association of hip fracture with FS and FRI.

RESULTS

Increased hip fracture risk was associated with lower FS (OR per SD 1.36, 95% CI: 1.15, 1.62) and higher FRI (OR per SD 1.99, 95% CI: 1.63, 2.43) after adjusting for Fracture Risk Assessment Tool (FRAX) hip fracture probability computed with bone mineral density (BMD). The c-statistic for the model containing FS (0.69; 95% CI: 0.65, 0.72) was lower than the c-statistic for the model with FRI (0.77; 95% CI: 0.74, 0.80) or femoral neck BMD (0.74; 95% CI: 0.71, 0.77; all P<0.05).

CONCLUSIONS

FS and FRI were independently associated with hip fracture, but there were differences in performance characteristics.