Variabilidad en las recomendaciones para el abordaje clínico de la osteoporosis

Incidence of Subsequent Hip Fracture and Mortality in Elderly Patients: A Multistate Population-Based Cohort Study in Eastern Spain

Osteoporotic hip fractures in older people may confer an increased risk of subsequent hip fractures and death. The aim of this study was to estimate the cumulative incidence of both recurrent hip fracture and death in the Valencia region. We followed a cohort of 34,491 patients aged ≥65 years who were discharged alive from Valencia Health System hospitals after an osteoporotic hip fracture between 2008 and 2015, until death or end of study (December 31, 2016). Two Bayesian illness-death models were applied to estimate the cumulative incidences of recurrent hip fracture and death by sex, age, and year of discharge. We estimated 1-year cumulative incidences of recurrent hip fracture at 2.5% in women and 2.3% in men, and 8.3% and 6.6%, respectively, at 5 years. Cumulative incidences of total death were 18.3% in women and 28.6% in men at 1 year, and 51.2% and 69.8% at 5 years. One-year probabilities of death after recurrent hip fracture were estimated at 26.8% and 43.8%, respectively, and at 57.3% and 79.2% at 5 years. Our analysis showed an increasing trend in the 1-year cumulative incidence of recurrent hip fracture from 2008 to 2015, but a decreasing trend in 1-year mortality. Male sex and age at discharge were associated with increased risk of death. Women showed higher incidence of subsequent hip fracture than men although they were at the same risk of recurrent hip fracture. Probabilities of death after recurrent hip fracture were higher than those observed in the general population. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Predictive Performance of the FRAX Tool Calibrated for Spain vs. an Age and Sex Model: Prospective Cohort Study with 9082 Women and Men Followed for up to 8 Years

In Spain, the Fracture Risk Assessment Tool (FRAX) was adapted using studies with a small number of patients, and there are only a few external validation studies that present limitations. In this prospective cohort study, we compared the performance of FRAX and a simple age and sex model. We used data from the ESOSVAL cohort, a cohort composed of a Mediterranean population of 11,035 women and men aged 50 years and over, followed for up to 8 years, to compare the discrimination, calibration, and reclassification of FRAX calibrated for Spain and a logistic model including only age and sex as variables. We found virtually identical AUC, 83.55% for FRAX (CI 95%: 80.46, 86.63) and 84.10% for the age and sex model (CI 95%: 80.91, 87.29), and there were similar observed-to-predicted ratios. In the reclassification analyses, patients with a hip fracture that were reclassified correctly as high risk by FRAX, compared to the age and sex model, were −2.86%, using either the 3% threshold or the observed incidence, 1.54% (95%CI: −8.44, 2.72 for the 3% threshold; 95%CI: −7.68, 1.97 for the incidence threshold). Remarkably simple and inexpensive tools that are easily transferable into electronic medical record environments may offer a comparable predictive ability to that of FRAX.

Organisational and Clinical Approach to Osteoporosis in Rheumatology: OP-SER-Excellence Survey and Consensus

OBJECTIVE

To determine and analyse the organisational approach adopted by Spanish rheumatologists to osteoporosis (OP) to define strategic priorities.

MATERIAL AND METHOD

A group of experts designed a questionnaire on OP in the rheumatologist practice. The survey was sent to the Spanish Society of Rheumatology (SER) members. Through the Delphi round, strategic priorities were agreed upon in OP.

RESULTS

The priorities are: 1) The SER should promote the inclusion of OP in 100% of the services and expand the training offer; 2) Rheumatology services should promote the role of the nurse in OP, promote quality indicators and referral protocols agreed with primary care in addition to promoting their training in this area; 3) The SER and Rheumatology services should promote electronic consultation, OP monographic clinics and participation in Fracture Liaison Service units.

CONCLUSIONS

Strategic priorities in OP help identify areas of improvement at organisational, structural and quality standards level in this pathology.

Impact of Drug Safety Warnings and Cost-Sharing Policies on Osteoporosis Drug Utilization in Spain: A Major Reduction But With the Persistence of Over and Underuse. Data From the ESOSVAL Cohort From 2009 to 2015

Background: Recent studies in several countries show a significant decrease in the consumption of osteoporosis drugs from a peak around 2009, mainly attributed to bisphosphonate safety warnings issued by regulatory agencies on jaw osteonecrosis, atypical fractures, and esophageal cancer, but no studies have assessed the impact of these warnings by risk of fracture strata. Aim: The aim of this work is to assess changes in the utilization of osteoporosis drugs in the region of Valencia (Spain) after safety warnings from regulatory agencies and cost-sharing changes, according to patient socio-demographic and risk of fracture characteristics. Patients and Methods: We constructed a monthly series of osteoporosis drug consumption for 2009-2015 from the ESOSVAL cohort (n = 11,035; women: 48%; mean age: 65 years old) and used interrupted time series and segmented linear regression models to assess changes in osteoporosis drug utilization while controlling for previous levels and trends after three natural intervention dates: the issue of the Spanish Agency for Drugs and Medical Products (AEMPS) Osteonecrosis Jaw Warning (Sept 2009), the AEMPS Atypical femur Fracture Warning (Apr 2011), and the modification of the cost-sharing scheme (Jul 2012). Results: The AEMPS Osteonecrosis Jaw Warning was not associated with a decline in the consumption of osteoporosis drugs, while the warning on atypical fracture (a downward trend of 0.11% fewer people treated each month) and the increase in the cost-sharing scheme (immediate change level of -1.07% in the proportion of people treated) were associated with a strong decline in the proportion of patients treated, so that by the end of 2015 osteoporosis drug consumption was around half that of 2009. The relative decline was similar in people with both a high and low risk of fracture. Conclusion: The AEMPS Atypical femur Fracture Warning of Apr 2010 was associated with a significant decrease in the number of people treated, reinforced by the increase in the pharmaceutical cost-sharing in 2012. Decreases in treatment affected patients both at a low and higher risk of fracture.

[Osteosarcopenia: A narrative review]

Osteosarcopenia is a phenotype resulting from the combination of sarcopenia and low bone mineral density. Based on the relationship between bone and muscle, this phenotype is associated with a higher risk of falls, fractures, dependence, and health care costs than its individual components. Given its characteristics, it can be considered as a new geriatric syndrome. Therefore, understanding its pathophysiology and diagnosis, as well as its non-pharmacological and pharmacological management is a task of great importance. The problem in addressing this phenotype arises from the tradition of managing sarcopenia and osteoporosis separately. There is also a lack of consensus on what to call it (sarco-osteopenia, sarco-osteoporosis, osteosarcopenia). The aim of this review is to outline the epidemiology, pathophysiology, diagnoses, adverse events, and management of osteosarcopenia.

Osteoporosis: a clinical and pharmacological update

Osteoporosis is characterized by the loss of bone mass, deterioration of the bone microarchitecture, and an increased risk of fractures; these later complications are associated with significant morbidity and mortality. The asymptomatic and progressive nature of osteoporosis underscores the importance of identifying this entity in early stages. Despite the various treatments available, the prevention of the disease represents the most important aspect of management. An adequate intake of calcium and vitamin D as well as a healthy lifestyle is the basis for maintaining bone health. When osteoporosis is diagnosed, the choice of medications must be individualized considering characteristics of the patient and the risk of fractures. In this article, we review the main causes of osteoporosis, when and how to start treatment, and appropriate therapy and monitoring.

Variations in osteoporosis medication utilization. A population-based ecological cross-sectional study in the region of Valencia, Spain

Little is known about the contextual variability in osteoporosis medication utilization. Our aims were 1) to describe variations in utilization and spending on osteoporotic medication between the Primary Care Health Zones (PHZ) of the Valencia region, Spain, 2) to analyze observed variations using Small Area Variation Analysis methods, and 3) to quantify the influence of the specialized care level on variations in utilization. We conducted a population-based cross-sectional ecological study of expenditure and utilization of five therapeutic groups marketed as osteoporosis treatments in Spain in 2009. The unit of analysis was the PHZ (in total 240) nested in the 23 Hospital Healthcare Departments (HHD) of the region of Valencia, covering a population of about 4.9 million inhabitants. Drug utilization was measured by dispensed Defined Daily Dose per 1000 women aged 50 years old and over and day (DID) per PHZ and cost was measured by the annual osteoporosis drug cost per woman aged 50 and older as well as the average price of DDD (Defined Daily Dose) in each PHZ. We calculated Indirect Standardized Drug Utilization Ratios (ISR) and we used Spearman's correlation to analyze associations between the ISRs of the different therapies. The average osteoporosis drug consumption was 119.1 DID, ranging from 77.6 to 171.3 DID (2.2 times higher) between PHZs in the 5th and 95th percentiles. Annual expenditure also showed a two-fold variation among PHZs. Average prices of the DDD by therapeutic group showed very low or no variation, although they differed substantially among therapeutic groups. Regarding the standardized consumption of osteoporotic drugs, HHDs explained a substantial part (39%) of the variance among PHZs. In conclusion, there is considerable variability in the volume and choice of anti-osteoporotic treatments between PHZs. with HHDs explaining an important proportion of the variation in utilization. Interventions aimed at reducing variation to improve appropriate care should take into account both the PHZ and HHD levels of care.

Variation in Antiosteoporotic Drug Prescribing and Spending Across Spain. A Population-Based Ecological Cross-Sectional Study

Introduction: Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Nevertheless, very few studies have addressed the variability in osteoporotic drug consumption. We aimed to describe variations in pharmaceutical utilization and spending on osteoporotic drugs between Health Areas (HA) in Spain.

Methods: Population-based cross-sectional ecological study of expenditure and utilization of the five therapeutic groups marketed for osteoporosis treatment in Spain in 2009. Small area variation analysis (SAVA) methods were used. The units of analysis were the 168 HA of 13 Spanish regions, including 7.2 million women aged 50 years and older. The main outcomes were the defined daily dose (DDD) per 1000 inhabitants and day (DDD/1000/Day) dispensed according to the pharmaceutical claims reimbursed, and the expenditure on antiosteoporotics at retail price per woman ≥50 years old and per year.

Results: The average osteoporosis drug consumption was 116.8 DDD/1000W/Day, ranging from 78.5 to 158.7 DDD/1000W/Day between the HAs in the 5th and 95th percentiles. Seventy-five percent of the antiosteoporotics consumed was bisphosphonates, followed by raloxifene, strontium ranelate, calcitonins, and parathyroid hormones including teriparatide. Regarding variability by therapeutic groups, biphosphonates showed the lowest variation, while calcitonins and parathyroid hormones showed the highest variation. The annual expenditure on antiosteoporotics was €426.5 million, translating into an expenditure of €59.2 for each woman ≥50 years old and varying between €38.1 and €83.3 between HAs in the 5th and 95th percentiles. Biphosphonates, despite accounting for 79% of utilization, only represented 63% of total expenditure, while parathyroid hormones with only 1.6% of utilization accounted for 15% of the pharmaceutical spending.

Conclusion: This study highlights a marked geographical variation in the prescription of antiosteoporotics, being more pronounced in the case of costly drugs such as parathyroid hormones. The differences in rates of prescribing explained almost all of the variance in drug spending, suggesting that the difference in prescription volume between territories, and not the price of the drugs, is the main source of variation in this setting. Data on geographical variation of prescription can help guide policy proposals for targeting areas with inadequate antiosteoporotic drug use.

Secular trends of use of anti-osteoporotic treatments in Spain: A population-based cohort study including over 1.5million people and more than 12years of follow-up

OBJECTIVE

Different regulatory actions for anti-osteoporotic medication (AOM) were taken during the last years, including marketing of new drugs, safety warnings, or restrictions on the indications. We aimed to characterise the secular trends of AOM use in Spain from 2001 to 2013.

METHODS

A cohort study using the Spanish Database for Pharmacoepidemiological Research in Primary Care (BIFAP), was performed. BIFAP includes anonym records for 4million patients. Participants entered the study when aged ≥50years in 2001-2013 and after 1year of data available, and were followed to an AOM prescription (including alendronate, other bisphosphonates, SERM (selective estrogen receptor modulators), strontium ranelate, teriparatide or denosumab), death, lost or the end of December 2013. Prevalence (%) and incidence rate (IR/1000person-years (py)) of AOM users were computed by years and sex.

RESULTS

Out of 1.5million participants, 135,410 received AOM treatment during 2001-2013. Prevalence was 6.1% (women) and 1.1% (men), that increased from 2001 (2.0%) to 2009 (7.6%) to decrease thereafter. Out of them, 95,057 were incident. The IR was 24.90 (women) and 2.77 (men), that increased from 2001 (21.25 and 1.96) to 2007 (35.84 and 3.64), and decreased to 12.48 and 1.81 (2013). IRs were highest for bisphosphonates along the years (ranging 3.70-14.73 and 0.57-1.75 in women and men respectively), followed by SERM up to 2005 (6.51-9.02 and 0.06-0.07), and strontium ranelate from 2006 (4.66 and 0.45) to 2012 (2.05 and 0.26). IR for teriparatide increased from marketing in 2004 (0.10-1.01 and 0.02-0.29), as was denosumab from marketing in 2011 (0.03-2.64 and 0.09-0.15).

CONCLUSIONS

Population-based estimates of AOM use in Spain peaked in 2007-2009 and decreased thereafter, irrespective of age and sex. New treatments were ten times higher in women than men. Bisphosphonates were the most frequently prescribed class, followed by SERM in women before 2006, strontium otherwise till 2012, and denosumab in women or teriparatide in men in 2013. Changes in the osteoporosis criteria, fracture risk assessment strategies, and regulatory actions for AOM around the time, may explain that trend.

Primary and secondary non-adherence to osteoporotic medications after hip fracture in Spain. The PREV2FO population-based retrospective cohort study

Osteoporotic medication after hip fracture is widely recommended by clinical practice guidelines, and medication adherence is essential to meet clinical trial risk reduction figures in the real world. We assessed primary and secondary non-adherence to osteoporosis medications in patients discharged following a hip fracture and identified factors associated with secondary non-adherence. From a population-based retrospective cohort of 19,405 patients aged 65 years and over discharged from a hip fracture in the region of Valencia (Spain) from January 1, 2008 and June 30, 2012, we followed, over a minimum of 365 days, 4,856 patients with at least one osteoporotic medication prescribed within the first six months after discharge. Less than one third of the patients discharged alive after a hip fracture received osteoporotic treatment. Primary non-adherence among naïve patients was low. However, long-term secondary adherence measured by Proportion of Days Covered with medication (PDC) and persistence was largely suboptimal, with naïve users having worse results than experienced patients. Secondary non-adherence was associated with primary non-adherence and age, dementia or sedative treatments for naïve users and with being male, being older than 85 and having dementia for experienced users. Three quarters of naïve users and two thirds of experienced users had interrupted treatment at 48 months.

[Orthogeriatrics: The First multicentre regional register of hip fractures in Castilla y León (Spain)]

OBJECTIVE

The objective of this study is to describe the characteristics of the patients with hip fracture admitted to the Public Hospitals of Castilla y León during three monthly periods (November 2014, and October and November 2015).

MATERIAL AND METHOD

The Castilla y León orthogeriatrics work group created a common register to collect data on hip fractures. The study included patients 75 years-old and over hospitalised with hip fractures in the 13 public hospitals in the community during November 2014, and October and November 2015. A multicentre, prospective, and observational study was conducted, in which clinical, functional, and social variables, as well as in-hospital mortality, were collected.

RESULTS

The analysis included data from a total of 776 patients with a mean age of 86 (±6) years. The surgical delay was 4±2.8 days, and the mean hospital stay was 10±4.7 days. The anaesthesia risk was ASA 3±0.6. Around two-thirds (66.5%) of the patients had medical complications while in hospital, and 55.5% required a transfusion. In-hospital mortality was 4.6%. The mean pre-surgical stay was related to the overall stay: P<.001.

CONCLUSIONS

Hip fracture registers are an essential tool for evaluating the process and for improving the treatment quality of these patients. This is the first multicentre register of hip fracture in the elderly created in a Spanish region, and could be a good precedent reference for a future national register.

[Adequacy of treatment for osteoporosis in primary prevention. Quantitative and qualitative study]

Objetivo

Estudio cuantitativo: conocer la prevalencia de inadecuación del tratamiento para la osteoporosis en prevención primaria (OPP) en mujeres de 60-74 años. Estudio cualitativo: conocer los criterios diagnósticos y de tratamiento de la OPP y su variabilidad en médicos de atención primaria (AP) y especialistas.

Material y método

Estudio cuantitativo: estudio observacional, transversal y retrospectivo. Población: mujeres de 60-74 años con tratamiento activo para la OPP (n = 424) en mayo del 2012. Se consideró inadecuación si presentaban ≤ 2 factores de riesgo con DXA realizada o con DXA T-score ≥ −2,4. Estudio cualitativo: técnica Delphi (15 ítems) y dos rondas de consulta. Periodo: marzo-abril del 2014. Población: médicos AP, reumatólogos y traumatólogos (n = 251). Muestreo aleatorio.

Resultados

Estudio cuantitativo: grado de inadecuación del 63,4%. En el 43,2% no constaba diagnóstico de osteoporosis. En el 82,3% no constaban factores de riesgo. Tratamiento: 40,3% con bisfosfonatos y 47,9% con calcio + vitamina D. Estudio cualitativo: el 23% respondieron a la primera ronda y, de estos, el 67% a la segunda ronda. Los ítems con mayor acuerdo fueron valoración de factores de riesgo para el diagnóstico y bisfosfonatos como tratamiento. Los ítems con menor consenso fueron utilización del FRAX y densitometría y tratamiento solo con calcio + vitamina D.

Conclusiones

El porcentaje de inadecuación es alto. El grado de registro en historia clínica es bajo. La metodología Delphi es útil para detectar discrepancias entre recomendaciones de guías de práctica clínica y resultados.

[Deprescribing long-term treatments with bisphosphonates for osteoporosis in primary care in the Basque Country (Spain)]

OBJECTIVE

To evaluate the impact of a multifactorial intervention to promote bisphosphonate deprescription after over 5 years of use (BF5y) in a health care organisation (HCO) in Gipuzkoa (Spain) and to compare it with the standard intervention in other HCOs in the Basque Health Service-Osakidetza.

METHODS

An 8-month follow-up study (results from before and after) to assess the impact of two interventions. All patients from Osakidetza receiving BF5y treatment (electronic prescription) in July 2013 were included. The standard intervention (9 HCOs) consisted of mailing a consensus statement on BF5y deprescribing and facilitating patient identifiers with BF5y prescription for review by the primary care physician. The multifactorial intervention (Gipuzkoa) also included a local consensus with leading specialists and training sessions in health centres.

RESULTS

18,725 patients were included; 94.7% were women. Standard intervention deprescribing rates ranged from 26.4% (Bilbao) to 49.4% (Araba), being 37.2% overall. The multifactorial intervention deprescribing rate was 44.6%, 7.4% (p <0.0001; 95% confidence interval [95%CI]: 5.4-9.4) higher than standard intervention. Changes to other treatments were less common with the multifactorial intervention, with a difference of 3.7% (p <0.0001; 95%CI: -2.2 to -5.2).

CONCLUSIONS

Standard and multifactorial interventions are very effective in reducing unnecessary treatments with bisphosphonates. The multifactorial intervention is more effective than the standard one, although more complex to implement.

Impact of the NOGG and NOF Guidelines on the Indication of Bone Mineral Density in Routine Clinical Practice

The universal screening for osteoporosis by bone mineral density (BMD) is not feasible because of its unfavorable cost-benefit due to its low sensitivity. The aim of the present study was to estimate the population and economic impact of the diagnostic criteria of the National Osteoporosis Guideline Group (NOGG) and the National Osteoporosis Foundation (NOF) and assess the appropriateness of the BMD tests performed in routine clinical practice. A cross-sectional study was conducted in individuals referred for BMD testing who were not receiving antiresorptive therapy. The absolute risk of major and hip fracture was calculated using the British formula of the Fracture Risk Assessment Tool. NOGG and NOF guidelines diagnostic thresholds interventions were used. A total of 640 individuals were included, of which 95% were women, with a median age of 59.4 years (interquartile range = 14). When applying the NOGG criteria, BMD testing was recommended in 32.3% of the individuals, whereas this percentage increased to 75.6% with the NOF guidelines (p < 0.05). Regarding the appropriateness of the BMD tests performed, 31.9% were deemed appropriate according to both the NOGG and NOF guidelines, whereas 23.9% were considered inappropriate. In conclusion, the application of the NOGG and NOF guidelines led to a decrease in BMD indications, reducing costs and improving efficiency in the diagnostic management of osteoporosis, although variability exists between the guidelines.

Overuse and Underuse of Antiosteoporotic Treatments According to Highly Influential Osteoporosis Guidelines: A Population-Based Cross-Sectional Study in Spain

Inappropriate prescribing of antiosteoporotic medications has been observed; however, the joint study of both overuse and underuse has barely been attempted. Spain, with its high utilization rates, constitutes a good example to assess differences in over and under use according to diverse highly-influential osteoporosis guidelines (HIOG) worldwide. We used data of a population-based cross-sectional study including 824 post-menopausal women ≥50 years old living in the city of Valencia, Spain and aimed to estimate the percentage of women eligible for treatment, and the proportion of overuse and underuse of antiosteoporotic treatment according to HIOG. The prevalence of antiosteoporotic treatment in postmenopausal women ≥ 50 in Valencia was 20.9% (95%CI:17.6–24.4). The type of antiosteoporotic drugs prescribed varied greatly depending on the medical specialty responsible of the initial prescription. When applying the HIOG, the percentage of women 50 and over who should be treated varied from less than 9% to over 44%. In real terms, from the approximately eight million women of 50 years old and over in Spain, the number eligible for treatment would range from 0.7 to 3.8 million, depending on the guideline used. A huge proportion of inappropriate treatments was found when applying these guidelines to the Spanish population, combining a high overuse (42–78% depending on the guideline used) and underuse (7–41%). In conclusion, we found that the pharmacological management of osteoporosis in women of 50 and over in this population combines an important overuse and, to a lesser extent, underuse, although the level of inappropriateness varied strikingly depending on the CPG used. It seems urgent to reduce treatment overuse without neglecting underuse, as is urgent an attempt to reach wider agreement worldwide regarding osteoporosis management, in order to facilitate appropriate treatment and development of policies to reduce effectively treatment inappropriateness.

Use of oral bisphosphonates in primary prevention of fractures in postmenopausal women: a population-based cohort study

OBJECTIVE

To compare incidence of first osteoporotic fracture in two cohorts of postmenopausal women, one treated with bisphosphonates and the other only with calcium and vitamin D.

DESIGN

Retrospective population cohort study with paired matching based on data from electronic health records.

SETTING

Women aged 60 years and older in 2005, from 21 primary care centers in a healthcare region of Spain.

PARTICIPANTS

Two groups of women aged 60 years and older (n = 1208), prescribed either calcium and vitamin D (CalVitD) or bisphosphonates (BIPHOS) with or without calcium and vitamin D, were compared for the end point of first recorded osteoporotic-related fracture, with 5-years follow-up.

MAIN OUTCOME MEASURE

Incidence of first fracture: Vertebral fracture, osteoporosis with pathological fracture, fracture of the upper humeral epiphysis, fracture of the lower radial epiphysis, or femur fracture.

RESULTS

Estimated 10-year risk of fracture was 11.4% (95% confidence interval: 9.6 to 13.2), 11.8% (9.2 to 14.3) in the BIPHOS group and 11.1% (8.6 to 13.6) in the CalVitD group. No significant differences were found between groups in total fractures (Hazard ratio = 0.934 (0.67 to 1.31)) or location (vertebral, femoral, radial or humeral).

CONCLUSIONS

In postmenopausal women, bisphosphonates have not been shown to better decrease risk of first fracture compared with calcium and vitamin D therapy alone.