Recognition of osteoporosis by primary care physicians

Delayed Scaphoid Fracture Union in Patients With Comorbid Psychiatric Diagnoses: A Retrospective Analysis of 20 340 Patients

BACKGROUND

Psychiatric comorbidities have been shown to influence outcomes of various orthopedic pathologies. This study aimed to compare rates of delayed scaphoid union and surgical intervention for fractures in patients with and without comorbid psychiatric diagnoses.

METHODS

A matched retrospective cohort study was performed using the PearlDiver database to determine the association of depression, anxiety, bipolar disorder, and schizophrenia with delayed union rates within 3 and 6 months and rates of nonacute surgical intervention (fixation or grafting) within 6 and 12 months of scaphoid fracture. Analyses were completed using multivariate logistic regression.

RESULTS

Among 20 340 patients, a comorbid psychiatric diagnosis was associated with increased rates of delayed scaphoid union at 3 months (odds ratio [OR] = 1.29; 95% confidence interval [CI], 1.14-1.45) and 6 months (OR = 1.23; 95% CI, 1.10-1.38). At 3 months, women with any psychiatric disorder (OR = 1.58; 1.29-1.66), depression (OR = 1.68; 1.31-2.17), and schizophrenia (OR = 5.32; 95% CI, 1.06-26.79) were more likely to experience delayed union, with similar results at 6 months. Men with bipolar disorder experienced increased delayed union rates at 6 months (OR = 1.40; 1.03-1.91). A comorbid psychiatric diagnosis (OR = 1.10; 1.01-1.20) was associated with increased rates of surgical intervention, whereas schizophrenia was associated with decreased rates (OR = 0.58; 0.34-0.99).

CONCLUSION

Patients with comorbid psychiatric conditions experienced increased rates of delayed scaphoid union. These results underscore the importance of understanding factors that may place patients at risk of impaired recovery.

The Prevalence of Osteoporosis and Osteopenia Among Older Adults in a Community-Based Setting in Riyadh, Saudi Arabia

Background Osteoporosis is a disease of bone density. It makes bones fragile and easy to break. Fragility fractures can cause significant morbidity, mortality, poor quality of life, and financial stress on medical care. Osteoporosis is overlooked and undertreated. Saudi Arabia issued a national plan promoting the early diagnosis and management of osteoporosis. Few and old studies are available in Saudi Arabia estimating the prevalence of osteoporosis in the Saudi older adult population. The aim of this study is to measure the prevalence of osteoporosis and osteopenia among older adult patients. Methodology This retrospective cross-sectional study is based on data gathered from patients ≥60 years of age. Data were collected from January 1, 2016, to December 31, 2021, for patients who were attending family medicine clinics at King Faisal Specialist Hospital & Research Centre in Riyadh, Saudi Arabia, who were screened using dual-energy X-ray absorptiometry (DEXA). Patients who have secondary causes of osteoporosis were excluded. Results A total of 1,302 patients were studied during the course of data collection. The mean age was 68.26. Out of the studied subjects, 75% were female and 25% were males. The prevalence of osteoporosis was 8.2% and 11.8% in femoral and lumbar bone mineral density (BMD) results, respectively. The prevalence of osteopenia based on femoral and lumbar BMD results was 50.2% and 41.2%, respectively. Conclusion Osteoporosis and osteopenia are prevalent in the Saudi older adult population. Multiple clinical characteristics have been associated with low bone density disease. Thus, it is important to reinforce primary care physicians' efforts for early screening and treatment of the Saudi older adult population based on their clinical and demographic risk factors.

Demographic and economic trends in vertebral fracture surgeries throughout the United States

Background

Vertebral fractures, frequently resulting from high-impact trauma to the spine, are an increasingly relevant public health concern. Little is known about the long-term economic and demographic trends affecting patients undergoing surgery for such fractures. This study examines national economic and demographic trends in vertebral fracture surgery in the United States to improve value-based care and health care utilization.

Methods

The National Inpatient Sample (NIS) was queried for patients who underwent surgical treatment of a vertebral fracture (ICD-9-CM-3.53) (excluding kyphoplasty and vertebroplasty) between 1993 and 2015. Demographic data included patient age, sex, income, insurance type, hospital size, and location. Economic data including aggregate charge, aggregate cost, hospital cost, and hospital charge were analyzed.

Results

The number of vertebral fracture surgeries, excluding kyphoplasty and vertebroplasty, increased 461% from 3,331 in 1993 to 18,675 in 2014, while inpatient mortality increased from 1.9% to 2.5%.The mean age of patients undergoing vertebral fracture surgeries increased from 42 in 1993 to 53 in 2015. The aggregate cost of surgery increased from $189,164,625 in 2001 to $1,060,866,580 in 2014, a 461% increase.

Conclusions

The significant increase in vertebral fracture surgeries between 1993 and 2014 may reflect an increased rate of fractures, more surgeons electing to treat fractures surgically, or a combination of both. The increasing rate of vertebral fracture surgery, coupled with increasing hospital costs and mortality, signifies that the treatment of vertebral fractures remains a challenging issue in healthcare. Further research is necessary to determine the underlying cause of both the increase in surgeries and the increasing mortality rate.

Practice of Family Physicians in the Management of Osteoporosis Among Older Female Patients at King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background

Osteoporosis is one of the major worldwide health concerns and carries medical, social, and financial impacts due to its significant morbidity and mortality. The aim of this study was to explore the practice of family physicians in osteoporosis management in older female patients.

Method

This study was performed in a cross-sectional manner. Data, including patient and disease characteristics and management practices, were obtained from the electronic patient chart for female patients aged 60 years and older who were followed in family medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during the period from January 1, 2018, to December 31, 2020. Management was checked and evaluated against osteoporosis management guidelines.

Results

In 42 patients out of 250, an osteoporosis diagnosis was missed. Among the 208 charts that were reviewed, the mean patient age was 72.06 years, and the mean duration of the disease according to the initial dual-energy X-ray absorptiometry (DXA) scan was 3.68 years. Laboratory tests were performed for only about half of the patients. Vitamin D was given only to 54.3% while calcium supplements were given only to 53.4%. Almost one-third of the patients have not been prescribed any antiosteoporosis medications.

Conclusion

The current study documented that older females with osteoporosis were not well-managed in the investigated family medicine settings. Continuous professional development activities and periodic practice reviews are suggested to improve this situation.

The Multi-Modal Risk Analysis and Medical Prevention of Lumbar Degeneration, Fatigue, and Injury Based on FEM/BMD for Elderly Chinese Women Who Act as Stay-Home Grandchildren Sitters

Background: An increasing number of Chinese elderly women stay at home and act as grandchildren sitters. In consequence of the frequent load-bearing, chronic lumbar fatigue probably caused a higher risk of lumbar degeneration, fatigue, and injury which has become one of the most important aging and health problems in China. In this study, a multi-mode lumbar finite element model (FEM) with specific bone mineral density (BMD) were developed and validated for further spine injury prevention and control.

Methods: The material properties of lumbar vertebra were modified according to degenerated bone mineral density, and geometry was adjusted based on intervertebral disc height. The motion of lifting children was simulated by a 76 year-old Chinese women's FEM, and the stress distribution was calculated and predicted.

Results: The pressure of L5-S intervertebral disc in the bending 3-year-old dummy lifting posture was significantly higher than the same posture without lifting, the maximum effective stress of endplate cartilage in the upright child lifting posture was 1.6 times that of the bending without lifting posture. And the fatigue risk limitation frequency of the upright with dummy posture was predicted with the functional equation of fatigue and stress which was deduced by genetic algorithm, which combined with the effective stress of lumbar vertebrae spongy bone calculated from FEM.

Conclusions: The child-lifting motion could increase the risk of lumbar degeneration, fatigue, and injury in elderly women, and they should keep below the frequency limit of the motion of lifting children in their daily life. This study could put forward scientific injury prevention guidance to Chinese elderly women who lift children in daily life frequently.

Evaluation of a dedicated outpatient hip fracture clinic

OBJECTIVES

There is a lack of guidance on how to manage the multiple post-discharge issues of older people following minimal trauma hip fracture. We developed a geriatrician-staffed outpatient service for people aged ≥65 years admitted with a hip fracture who were not discharged to a nursing home. We aimed to evaluate the potential benefits of the addition of a dedicated hip fracture follow-up clinic by measuring the actions performed by such a clinic.

METHODS

We evaluated the potential benefit of the clinic through a retrospective review of the medical records of all those referred to the clinic over a 2-year period.

RESULTS

A total of 80 people were provided a clinic appointment, with 43 (54%) attending. The median age of clinic attendees was 81 years. A total of 40/43 (93%) of attendees received inpatient rehabilitation in a sub-acute facility before discharge. At the dedicated outpatient clinic, multiple issues were identified and managed including further fall reduction strategies (n = 12), commencement of anti-resorptive medications (n = 11) and medication deprescribing (n = 11).

CONCLUSIONS

We found that the introduction of a dedicated hip fracture outpatient clinic identified and managed a broad range of issues. It is unclear if these needs would have been met by previously existing services. Further work is required to clarify whether managing these issues translates into improved patient outcomes and whether a dedicated clinic is a cost-effective practice of achieving this.

Influence of Residence Area and Basic Livelihood Conditions on the Prevalence and Diagnosis Experience of Osteoporosis in Postmenopausal Women Aged over 50 Years: Evaluation Using Korea National Health and Nutrition Examination Survey Data

Patients with osteoporosis are asymptomatic and are at risk for fractures. Therefore, early detection and interventions are important. We found that a population with a low socioeconomic status living in rural areas was reported to have a high osteoporosis prevalence but a relatively low diagnosis rate. Research on the disparity of osteoporosis prevalence and treatment from the socioeconomic perspective was conducted. This study aimed to investigate the influence of residence area and basic livelihood conditions on osteoporosis prevalence and diagnosis in postmenopausal women aged over 50 years. The cross-sectional data of 1477 postmenopausal women aged over 50 years obtained from the Korea National Health and Nutrition Examination Survey V-2 were analyzed. Univariate analyses were performed to calculate the prevalence and diagnosis rate according to risk factor categories. A multivariate logistic regression analysis was performed to identify the influence of residence area and basic livelihood conditions after controlling for other factors. The osteoporosis prevalence in basic livelihood beneficiaries (53.7%) and rural area residents (41.9%) was higher than that in non-beneficiaries (33.1%) and urban area residents (31.8%). There was no significant difference in the diagnosis rates in relation to the basic livelihood conditions or residence areas. The adjusted odds ratio for the prevalence among the beneficiaries living in rural areas was 2.08 (95% confidence interval: 1.06-4.10). However, the odds ratio for diagnosis was not significantly different. Earlier screening examination policies for osteoporosis in postmenopausal women with a low socioeconomic status living in rural areas are needed.

Prevalence and risk factors for osteoporotic fracture among adults with comorbidities in Al-Ahsaa, Saudi Arabia

Background and Aims

Little is known about the prevalence of osteoporotic fracture, its sociodemographic correlates, and its comorbid conditions among the adult population of the Kingdome of Saudi Arabia (KSA). Hence, the present work aimed to assess the prevalence of adults at high risk of osteoporotic fracture in the presence of its known risk factors. As well, to determine the most commonly associated comorbidities of osteoporosis in Saudi Arabia.

Methods

A cross-sectional study was performed among 518 Saudi adults aged over 45 years in Al-Ahsaa city, KSA. The Arabic version of the fracture risk assessment FRAX without bone mineral density (BMD) was presented in an online questionnaire.

Results

The 10-year risk for major osteoporotic fracture was found in 50.81% of the participants; 23.48% of them were at high risk and 25.71% at moderate risk. Also, 26.27% of the respondents were at high risk of hip fracture. Significant correlates of osteoporotic fractures included female gender (P = 0.003), old age (P = 0.000), age at menopause (P = 0.000), low body mass index (BMI; P = 0.000), previous fracture (P = 0.000), alcohol consumption (P = 0.000), positive family history (P = 0.000), corticosteroids (P = 0.000), rheumatoid arthritis (P = 0.000), thyroid hyperactivity (P = 0.000), gonadal insufficiency (P = 0.000), chronic liver disease (P = 0.000), nutritional, or gestational disease (P = 0.000).

Conclusion

More than a third of the surveyed population had osteoporosis, which was associated with many sociodemographic and clinical characteristics. Therefore, early interventions for osteoporosis and the prevention of other comorbidities may improve the outcome of osteoporosis.

The Fracture Liaison Service to close the osteoporosis care gap: a leadership educational model for undergraduate and postgraduate trainees

Osteoporotic fractures have been rising and are a cause of severe morbidity and mortality. Care gaps exist in osteoporosis treatment and diagnosis, which presents an opportunity for education. A number of healthcare systems in the world have developed a fracture liaison service (FLS) to combat osteoporotic fractures. The Rheumatology division at Loma Linda University Health (LLUH) developed an FLS not only to address osteoporosis care gaps but to also develop a new educational model. An interdisciplinary model of osteoporosis care has been implemented along with a revamp of educational focus on osteoporosis and bone health in the rheumatology fellowship and internal medicine residency. Pre-LLUH FLS studies showed that 85% of patients pre-fracture were never screened nor treated for osteoporosis; post-fracture, only 10% of patients were treated, and only 6% had dual x-ray absorptiometry (DXA). Notably, 30% had a prior fracture. We discuss how the FLS has served as a catalyst for education, not only at our academic center but also as an outreach for our community in order to elevate the care of osteoporosis in our community.Key Points• Care gaps exist in osteoporosis treatment and are addressed by the Fracture Liaison Service.• The Loma Linda University Health Fracture Liaison Service is an interdisciplinary program.• The Fracture Liaison Service is an educational model that gives hands on learning through an amalgam of processes, namely quality improvement through the Plan-Do-Study-Act cycle and medical education through Kolb's learning cycle and cognitive apprenticeship.

Vertebral fragility fractures - How to treat them?

Approximately 20% of men and women aged 50 years or older will present with a vertebral fragility fracture - a prevalence that steadily increases with age. The condition may be associated with severe pain and disability, significant reductions in overall quality of life, mobility, social participation, sleep quality and increased fear for the future. There is, however, no current consensus on what constitutes the best management of symptomatic vertebral fractures. Moreover, evidence supporting common treatment approaches is scarce and often of poor quality. The lack of adequate management of VFF and associated osteoporosis and the burden of this condition to patient and society are estimated to increase substantially in coming years as recurrent, disabling episodes are set to occur. This chapter will address these issues, including a discussion on existing care pathways for vertebral fragility fractures, and an overview of the evidence supporting recommendations of the main international clinical practice guidelines.

Osteoporosis and its perspective in Pakistan: A review of evidence and issues for addressing fragility fractures

Despite major advances in osteoporosis diagnosis and treatment, low rates of investigating and treating osteoporosis in patients with fragility fracture are reported in Pakistan. Cost of therapies, time and cost of resources for diagnosis, concerns about medications and lack of clarity regarding the onus of responsibility to undertake this care, are some of the barriers to osteoporosis identification and treatment. Data from our part of the world on osteoporosis as well as on fragility fractures is sparse. This review addresses the current screening and diagnostic strategies for osteoporosis and reviews the existing literature to highlight the issues prevalent in our society on this major public health problem.

Bone Response to Dietary Co-Enrichment with Powdered Whole Grape and Probiotics

Nutrition is a primary modifiable determinant of chronic noncommunicable disease, including osteoporosis. An etiology of osteoporosis is the stimulation of bone-resorbing osteoclasts by reactive oxygen species (ROS). Dietary polyphenols and probiotics demonstrate protective effects on bone that are associated with reduced ROS formation and suppressed osteoclast activity. This study tested the effect of dietary enrichment with powdered whole grape and probiotics (composed of equal parts Bifidobacterium bifidum, B. breve, Lactobacillus casei, L. plantarum, and L. bulgaricus) on bone microarchitecture in a mouse model of age-related osteoporosis. Groups (n = 7 each) of 10-month-old male mice were fed one of six diets for 6 months: 10% grape powder with sugar corrected to 20%; 20% grape powder; 1% probiotic with sugar corrected to 20%; 10% grape powder + 1% probiotic with sugar corrected to 20%; 20% grape powder + 1% probiotic; 20% sugar control. Femur, tibia and 4th lumbar vertebrae from 10-month-old mice served as comparator baseline samples. Bone microarchitecture was measured by micro-computed tomography and compared across diet groups using analysis of variance. Aging exerted a significant effect on tibia metaphysis trabecular bone, with baseline 10-month-old mice having significantly higher bone volume/total volume (BV/TV) and trabecular number measurements and lower trabecular spacing measurements than all 16-month-old groups (p < 0.001). Neither grape nor probiotic enrichment significantly improved bone microarchitecture during aging compared to control diet. The combination of 20% grape + 1% probiotic exerted detrimental effects on tibia metaphysis BV/TV compared to 10% grape + 1% probiotic, and trabecular number and trabecular spacing compared to 10% grape + 1% probiotic, 1% probiotic and control groups (p < 0.05). Femur metaphysis trabecular bone displayed less pronounced aging effects than tibia bone, but also showed detrimental effects of the 20% grape + 1% probiotic vs. most other diets for BV/TV, trabecular number, trabecular spacing and trabecular pattern factor (p < 0.05). Tibia and femur diaphysis cortical bone (cortical wall thickness and medullary area) displayed neither aging nor diet effects (p > 0.05). Vertebrae bone showed age-related deterioration in trabecular thickness and trabecular spacing and a trend toward preservation of trabecular thickness by grape and/or probiotic enrichment (p < 0.05). These findings demonstrate no benefit to bone of combined compared to independent supplementation with probiotics or whole grape powder and even suggest an interference of co-ingestion.

Utilization and cost of anti-osteoporosis therapy among US Medicare beneficiaries

There is a strong impetus to prevent and treat osteoporosis to prevent fractures. $990 million dollars was spent on anti-osteoporosis drugs in 2013. As we shift our focus on primary prevention of fractures, providers are encouraged to find the most cost-effective anti-osteoporosis therapy for patients.

PURPOSE

Osteoporosis is a major global problem with osteoporotic fractures posing a potentially avoidable burden on healthcare resources. We studied the utilization and cost of anti-osteoporotic therapy using the 2013 Medicare Part D data.

METHODS

Descriptive data were produced from Microsoft Excel and SPSS regarding the anti-osteoporotic drugs of interest.

RESULTS

In total, Medicare and its beneficiaries spent approximately $990 million on anti-osteoporotic therapy in 2013. Despite this cost, only one in two adults with osteoporosis aged 65 and older received a prescription for an anti-osteoporosis drug. $756 million (77 %) was attributable to brand name drugs which accounted for 2,459,931 claims (22 %). Generic dispensing rate varied from 57-86 % (mean 77 ± 6) across the different states in the USA. States that mandate substitution with generic equivalents had a higher generic dispensing rate compared to the states that permit generic substitution (92 vs. 90 %; p < 0.05). After adjusting for claim counts, we found that if the states that permit substitution with generic equivalents showed the same generic dispensing rate of 92 % as the states that mandate such substitution, there is a potential for savings of $7.5 million, approximately 9 % of the total expenditure in these states on oral bisphosphonates alone. Thirty-eight percent of the total prescriptions from orthopedic surgeons were for Forteo® or Prolia® compared to 12.5 % from specialists.

CONCLUSIONS

These findings highlight the need for ongoing training for physicians who engage in the care of patients with osteoporosis to manage the disease in a cost-effective manner.

Psychometric properties of the osteoporosis assessment questionnaire (OPAQ) 2.0: results from the multiple outcomes of raloxifene evaluation (MORE) study

Background

We explored psychometric properties of the Osteoporosis Assessment Questionnaire 2.0 in terms of reliability, validity, and responsiveness with generic, clinical, demographic, and preference-based data collected from a population of postmenopausal women with osteoporosis.

Methods

The Multiple Outcomes of Raloxifene Evaluation study was a randomized, placebo-controlled, multinational clinical trial evaluating efficacy and safety of raloxifene. The Osteoporosis Assessment Questionnaire 2.0, a generic quality of life measure (Nottingham Health Profile), and a preference-based measure (Health Utilities Index) were administered at baseline and annually. Psychometric properties of the 14 Osteoporosis Assessment Questionnaire 2.0 domains were evaluated by standard statistical techniques.

Results

This study included a subset of 1477 women from the Multiple Outcomes of Raloxifene Evaluation study population completing the questionnaires. Mean (standard deviation) age was 68.4 (6.8) years. Prevalent vertebral fractures were found in 70% (n =1038) of women. Internal consistency was >0.7 in 9 Osteoporosis Assessment Questionnaire 2.0 domains. Correlations were moderate and significant for similar Osteoporosis Assessment Questionnaire 2.0 domain scores, Nottingham Health Profile domains, and Health Utilities Index scores. All but 2 Osteoporosis Assessment Questionnaire 2.0 domains distinguished between patients with or without prevalent vertebral fractures and detected worsening with increased number of vertebral fractures. Women with ≥1 incident vertebral fracture generally had a greater worsening in Osteoporosis Assessment Questionnaire 2.0 scores (excluding social activity and support of family and friends) from baseline to study endpoint compared with women without incident vertebral fractures.

Conclusions

Most domains in the Osteoporosis Assessment Questionnaire 2.0 demonstrated robust psychometric properties; however, several domains not showing these criteria may need to be reassessed and removed for a potentially shorter and validated version of the Osteoporosis Assessment Questionnaire.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-374) contains supplementary material, which is available to authorized users.

Understanding and communicating the benefits and risks of denosumab, raloxifene, and teriparatide for the treatment of osteoporosis

The number needed to treat is a valuable metric to determine the benefit of therapy, but it must be viewed against the respective number needed to harm. Denosumab and teriparatide (TPTD) have proven antifracture efficacy at vertebral and nonvertebral sites, whereas raloxifene has proven antifracture efficacy at the spine only. Denosumab use has been associated with a small, yet statistically significant, increased incidence of eczema and serious cellulitis. Raloxifene use has been associated with statistically significant increases in the risk of venous thromboembolism and possibly deadly stroke, although not an increase in total strokes. No significant, nontransient adverse events have been reported with TPTD use. When used for the treatment of postmenopausal osteoporosis, denosumab, raloxifene, and TPTD all generally have favorable risk-to-benefit profiles, but therapy-specific contraindications necessitate thoughtful consideration of all available clinical information and individualization of treatment decisions.

Delphinidin, one of the major anthocyanidins, prevents bone loss through the inhibition of excessive osteoclastogenesis in osteoporosis model mice

Anthocyanins, one of the flavonoid subtypes, are a large family of water-soluble phytopigments and have a wide range of health-promoting benefits. Recently, an anthocyanin-rich compound from blueberries was reported to possess protective property against bone loss in ovariectomized (OVX) animal models. However, the active ingredients in the anthocyanin compound have not been identified. Here we show that delphinidin, one of the major anthocyanidins in berries, is a potent active ingredient in anti-osteoporotic bone resorption through the suppression of osteoclast formation. In vitro examinations revealed that delphinidin treatment markedly inhibited the differentiation of RAW264.7 cells into osteoclasts compared with other anthocyanidins, cyanidin and peonidin. Oral administration of delphinidin significantly prevented bone loss in both RANKL-induced osteoporosis model mice and OVX model mice. We further provide evidence that delphinidin suppressed the activity of NF-κB, c-fos, and Nfatc1, master transcriptional factors for osteoclastogenesis. These results strongly suggest that delphinidin is the most potent inhibitor of osteoclast differentiation and will be an effective agent for preventing bone loss in postmenopausal osteoporosis.

Suboptimal vitamin D screening in older patients with compromised skeletal health

RATIONALE, AIMS AND OBJECTIVES

Increasing number of primary care visits for osteoporosis by older patients combined with new vitamin D screening recommendations necessitate primary care providers (PCPs) to identify and screen at-risk patients. We described prevalence and determinants of vitamin D screening among older patients treated for osteopoenia, osteoporosis and related fractures in academic outpatient primary care clinics (family medicine and geriatric medicine) in Houston, TX.

METHODS

Electronic chart review collected data on patients ≥50 years old from January 2008 to December 2010. Orders for serum 25-hydroxy vitamin D indicated vitamin D screening. Differences in patient characteristics were described between the groups with and without vitamin D screening. Age, body mass index, racial/ethnic background, bone-promoting medication (BPM) use and clinic types (family medicine versus geriatric medicine) were determinants for vitamin D screening in the regression analysis.

RESULTS

Patients were mostly women (95%), Caucasian (65%) and had a mean age of 69 ± 12 years. Twenty-two per cent of the family medicine clinic patients (total n = 78) and 51% of the geriatric medicine clinics patients (total n = 70) were screened. Older age (odds ratio, 0.94 confidence interval = 0.90-0.99) and BPM use (2.58, 1.03 to 6.45) were significant positive determinants for vitamin D screening.

CONCLUSIONS

In primary care clinics, vitamin D screening remains low among patients diagnosed with osteopoenia, osteoporosis and fractures. In light of new guidelines, suboptimal screening in the vulnerable older patients is disturbing. We recommend increased PCPs' awareness about vitamin D screening guidelines for improving skeletal health in older patients.

Appropriateness of referrals to a tertiary referral centre for bone mineral density testing

INTRODUCTION

Evidence-based guidelines for who should have a dual-energy X-ray absorptiometry (DXA) scan are well established. Much attention has been appropriately focussed on increasing the proportion of persons at high risk for fracture who are being referred for such investigation. Little literature exists on the extent of inappropriate referrals for DXA. In this cross-sectional study we assessed the prevalence of inappropriate referrals for DXA studies at our centre using modified International Society for Clinical Densitometry (ISCD) guidelines.

METHODS

All DXA referrals were vetted for appropriateness and priority using established ISCD criteria. We evaluated the reasons for DXA referral on all subjects and studied the prevalence of missing information, and the number of referrals for DXA deemed to be inappropriate at our institution.

RESULTS

Two thousand and twenty-five DXA referrals were reviewed. Information was missing on many requests (e.g., menopausal status, body mass index), and 33 % of the referrals were deemed as inappropriate. Compared to those deemed appropriate, inappropriate referrals were more likely to be younger females, had no risk factors for osteoporosis, had an inappropriate referral reason, and had less/missing information.

CONCLUSIONS

In this study we have noted a concerning number of DXA referrals with limited information or no appropriate indication for such an examination. Education of referring physicians should focus on not only improving referrals for subjects at high risk, but also inappropriate referrals for subjects at low risk.

Changing trends in osteoporosis care from specialty to primary care physicians

BACKGROUND

Inadequate treatment by non-specialty primary care physicians (PCPs) has been a concern in improving osteoporosis care. An increase in outpatient visits by older patients seeking osteoporosis care has been reported. But what percentages of these visits are made to PCPs are unknown. We investigated recent trends of outpatient visits and treatment for osteoporosis in older adults (>50 years) by physician type (PCPs vs. specialty care non-PCPs).

METHODS

A cross-sectional analysis used National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2002 to 2008 in the USA. Patients ≥50 years with osteoporosis were included. Descriptive and logistic analysis reported trends of visits and treatment for osteoporosis care by physician type.

RESULTS

About 9 million weighted visits were reported between 2002 and 2008. An increase in osteoporosis-related visits was noted from 5% in 2002 to 20% in 2008. The majority of patients in these visits were women (89%), between 65 and 84 years of age (56%), of non-Hispanic (88%) and White (81%) ethnic/racial backgrounds and had Medicare (51%) as the source of payment. Almost half (49.5%) of the visits were made to the PCPs. About 74% visits recorded a prescription for osteoporosis treatment. Calcium supplementation was low in the study population, and the lack of data on vitamin D supplements prevented us commenting on the supplementary aspect of osteoporosis management. Non-PCPs were more likely to have prescribed bisphosphonates (p<0.05) during an osteoporosis-related visit compared to PCPs (odds ratio:1.81, 95% CI: 1.12-2.92).

CONCLUSIONS

We report a change with increasing trend of outpatient visits to PCPs for osteoporosis care since the 1990s. Despite a lower percentage of prescriptions by PCPs than non-PCPs, there is an increasing trend of prescribing osteoporosis treatment by PCPs. Growing demand for managing the chronic bone disease mandates a need for assessment of educational interventions to better prepare PCPs for improving skeletal health of the elderly.

Response to oral bisphosphonates in subgroups of younger and older postmenopausal women

BACKGROUND

Although the effects of bisphosphonates in bone are known for postmenopausal women, it is not known if younger postmenopausal women have a similar response. Furthermore, it is not known if the effects of alendronate and risedronate differ in postmenopausal women in regard to age, specifically in women at or younger than the mean age of natural menopause. Our aim was to examine the effects of two oral bisphosphonates in postmenopausal women by age.

METHODS

This was a post-hoc analysis of postmenopausal women <55 or > or =55 years old with low bone mineral density (BMD), randomized to once weekly alendronate 70 mg or risedronate 35 mg for 1 year with 1-year extensions in U.S. and International Fosamax Actonel Comparison Trials.

RESULTS

In both age subgroups of postmenopausal women, alendronate produced significantly greater mean BMD increases from baseline than risedronate at hip trochanter, lumbar spine, total hip, and femoral neck. Changes in BMD were not significantly different between younger and older alendronate-treated women, although treatment differences favoring alendronate were numerically greater for younger than older postmenopausal women at all sites. Significantly greater reductions in bone turnover markers also occurred with alendronate vs. risedronate in both subgroups. Tolerability was similar between treatments.

CONCLUSIONS

In this post-hoc subgroup analysis of older and younger postmenopausal women receiving alendronate or risedronate, larger treatment differences in BMD gain in younger compared with older women suggest that patient age may affect the relative efficacy of these antiresorptive drugs.

Evaluation of Clinical Decision Rules for Bone Mineral Density Testing among White Women

Background. Osteoporosis is a devastating, insidious disease that causes skeletal fragility. Half of women will suffer osteoporotic fractures during their lifetimes. Many fractures occur needlessly, because of inattentiveness to assessment, diagnosis, prevention, and treatment of osteoporosis. Study Purpose. Study Purpose. To evaluate the discriminatory performance of clinical decision rules to determine the need to undergo bone mineral density testing. Methods. A nationally representative sample from the Third National Health and Nutrition Examination Survey consisted of 14,060 subjects who completed surveys, physical examinations, laboratory tests, and bone mineral density exams. Multivariable linear regression tested the correlation of covariates that composed the clinical decision rules with bone mineral density. Results. Increased age and decreased weight were variables in the final regression models for each gender and race/ethnicity. Among the indices, the Osteoporosis Self-Assessment Tool, which is composed of age and weight, performed best for White women. Study Implications. These results have implications for the prevention, assessment, diagnosis, and treatment of osteoporosis. The Osteoporosis Self-Assessment Tool performed best and is inexpensive and the least time consuming to implement.

The prevalence of osteoporosis in Korean adults aged 50 years or older and the higher diagnosis rates in women who were beneficiaries of a national screening program: the Korea National Health and Nutrition Examination Survey 2008-2009

For the prevention of osteoporotic fracture, adequate screening and treatment are important. However, there are few published data on diagnosis and treatment rates of osteoporosis in Asia. We used data from the fourth Korea National Health and Nutrition Examination Survey 2008-2009 to estimate the nationwide prevalence, physician diagnosis rate, and treatment rate of osteoporosis in adults aged 50 years and older. The bone mineral density (BMD) measurements of central skeletal sites (lumbar spine, femoral neck, and total hip) were obtained using dual-energy X-ray absorptiometry (DXA) (Discovery-W; Hologic Inc., Waltham, MA, USA). Diagnosis of osteopenia or osteoporosis was defined by the World Health Organization (WHO) T-score criteria. The prevalence of osteoporosis in adults aged 50 years or older was 35.5% in women and 7.5% in men. The prevalence of osteoporosis in Korea was similar to other East Asian countries but higher than that in Caucasians. Lumbar spine bone density T-scores tended to be lower than those of the femoral neck or hip. The estimated diagnosis rate was 26.2% (women 29.9%, men 5.8%) and the treatment rate was 12.8% (women 14.4%, men 4.0%). The physician diagnosis rate was significantly higher in females aged 66 to 68 years who were the beneficiaries of the national screening program than that in females of other ages (43.6% versus 28.1%, p < 0.05). The national screening program for osteoporosis may have contributed to an increased diagnosis rate in older Korean women. However, it was evident that treatment following a diagnosis of osteoporosis was still inadequate.

PTH 1-84: bone rebuilding as a target for the therapy of severe osteoporosis

Osteoporotic fractures, especially in elderly people, represent a health concern as they are associated with increased morbidity and mortality together with an increased economic burden for the society. During the past 20 years a great effort has been done in order to reduce the risk of fracture and many drugs are now available for this purpose, but osteoporosis is still regarded as an inevitable consequences of the aging process. Osteoporotic fractures occur most frequently in the spine and hip and with lower frequency in the wrist, pelvis, and upper arm. They are associated with significant morbidity and those of the hip and spine are also associated with excess mortality. The correct diagnosis and the adequate treatment of osteoporosis can reduce fracture risk. Together with well known anti-resorptive agents (like bisphosphonates, oestrogen and selective oestrogen receptor modulators) in the past few years anabolic therapy with parathyroid hormone (PTH) has become available for the treatment of severe osteoporosis. Human recombinant intact parathyroid hormone (PTH 1-84) and human recombinant PTH peptide 1-34 (Teriparatide) belong to this group of agents.This paper will review PTH actions together with the anabolic effect of PTH 1-84 both in reducing fracture risk and in promoting fracture healing. Although in primary hyperparathyroidism bone catabolism prevails on bone anabolism, PTH remains a potent stimulator of osteoblasts and its anabolic properties can be seen when it is given at a low dosage and intermittently. Intermittent PTH can stimulate bone formation to a greater extent and earlier than bone resorption, thus creating the so called "anabolic window".The TOP study demonstrated that PTH 1-84 is able to reduce the risk of a new fracture in patients with prevalent vertebral fractures, but the same effect was also seen on the incidence of the first fracture in women without fractures at baseline. Moreover PTH produced a continuous increase of bone mineral density, particularly in the cancellous bone. A positive effect of PTH has been described also on fracture healing, consisting both by a shortened time for fracture repair and by an improving of all the parameters of callus formation and development. Although most of the evidence has been obtained in animals some recent studies in humans confirmed, at least in part, these findings. In elderly patients with osteoporosis and fractures PTH treatment may reduce the healing time, improve clinical outcomes and reduce the time of immobilization together with the risk of complications.

Adherence to the U.S. Preventive Services Task Force 2002 osteoporosis screening guidelines in academic primary care settings

BACKGROUND

Osteoporosis is very common in older women in the United States. Osteoporotic fractures cause significant morbidity and mortality, as well as high healthcare costs. Since 2002, the United States Preventive Services Task Force (USPSTF) has recommended screening for osteoporosis of all women aged ≥65. Our objective was to determine adherence to osteoporosis screening guidelines by primary care internists in a large academic medical center and to assess if adherence varies based on provider gender or practice location.

METHODS

This was a retrospective electronic medical record (EMR) review. All women aged ≥65 who were seen in the General Internal Medicine Center (GIMC) or the Women's Health Care Center (WHCC) at the University of Washington Medical Center by internal medicine attending physicians between January 1, 2006, and February 2, 2008, were included in the study. We determined if the patient had a dual energy x-ray absorptiometry (DEXA) study in the EMR database. We calculated the percentage of patients screened per provider and also compared the rate of screening for male vs. female providers and for GIMC vs. WHCC providers.

RESULTS

Of the 1363 women included in the study, 70% had documentation of a DEXA study. Adherence to screening recommendations for individual providers varied from 33% to 100%. Screening was more likely to occur in the WHCC than in the GIMC (79.2% vs. 66.7%, p<0.001). Although women providers were more likely to screen than their male counterparts (72.2% vs. 66.1%, p=0.023), this relationship did not hold true after excluding women providers from the WHCC.

CONCLUSIONS

We found good adherence to the USPSTF 2002 guidelines for osteoporosis screening in women aged ≥65 years by primary care physicians in a large urban academic medical center. The practice site and not gender of the provider resulted in significantly different screening rates.

Lateral spine radiographs before androgen deprivation treatment detect a high incidence of undiagnosed vertebral fragility fractures in men with advanced prostate cancer

PURPOSE

Baseline bone mineral density scanning in patients about to commence long-term androgen deprivation therapy for advanced/metastatic prostate cancer is reported to show a high incidence of osteoporosis and osteopenia. We investigated the incidence of existing spinal osteoporotic fractures in this population as this is known to be a risk factor for the development of treatment induced fractures.

MATERIALS AND METHODS

Since 2003 we performed lateral thoracolumbar x-rays on all patients before androgen deprivation therapy for prostate cancer. The heights of T4-L5 vertebral bodies were measured, then reanalyzed by the Eastell method to define grade 1 or worse grade 2 vertebral crush fractures. We used a morphometric algorithm including an age stratified random sample of men with normal thoracolumbar x-rays to quantitatively assess fractures.

RESULTS

A total of 202 patients with prostate cancer underwent thoracolumbar x-rays before androgen deprivation therapy. Of the patients 61.9% had 1 or more grade 1 and 60.9% had 1 or more grade 2 wedge fractures. In addition, 46.5% of patients had 1 or more grade 1 and 44.6% had greater than 1 grade 2 biconcavity fractures. Finally 63.9% of patients had 1 or more grade 1 and 47.8% had 1 or more grade 2 compression fractures. With conventional reporting 72.4% of patients had no bony abnormality, 14.9% had 1 and 12.7% multiple vertebral crush fractures. Bone mineral density was significantly less in patients with fracture(s) vs those with no abnormality (p<0.001).

CONCLUSIONS

Routine reporting identifies a high incidence of spinal fractures before commencing androgen deprivation therapy, but this is much greater when quantitative assessment is applied. Thoracolumbar x-rays identify the risk of treatment induced fracture and allow baseline comparison in individuals who experience back pain on androgen deprivation therapy. We advocate more routine adoption of baseline thoracolumbar x-rays in patients with prostate cancer.

Prevalence of risk factors for fractures and use of DXA scanning in Danish women. A regional population-based study

SUMMARY

To determine the relationship between risk factors and use of DXA scans. Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and socio-economic factors are associated with the use of DXA.

INTRODUCTION

To determine the relationship between risk factors for fracture and use of DXA scans in Danish women in relation to distance to DXA clinics and socio-economic factors.

METHODS

From the Danish National Civil Register we randomly selected 5,000 women aged 40-90 years living in the region of Southern Denmark to receive a mailed questionnaire concerning risk factors for fractures.

RESULTS

The respondents rate was 84% and 77% of the invited population were available for analysis. A total of 10.3% of the women without risk factors and only 36% of the women with three or more risk factors had a history of DXA. The likelihood of a history of DXA was higher with increasing FRAX(™) 10-year risk; i.e., 8.7% and 30.2% in patients with a 10-year fracture risk of 0-14.9% and 25-100%, respectively. In women with less than 10 km to nearest DXA facility, 20.2% had a history of DXA, while 11.5% of those with more than 40 km to the nearest scanner had a history of DXA. Logistic regression analysis showed that distance, fracture risk, oral glucocorticoids, low-energy fracture, conditions associated with secondary osteoporosis, low BMI, history of falls, age 65-79 years, spouse status, and income were significantly associated with having a history of DXA.

CONCLUSIONS

Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and a number of socio-economic factors are associated with the use of DXA.

Monitoring pharmacological therapy for osteoporosis

Osteoporosis is a common disease characterized by low bone strength that increases the risk of fractures. The consequences of fractures include increases in morbidity, mortality, and healthcare costs. Randomized clinical trials have shown that pharmacological therapy can reduce the risk of fractures. In clinical practice, however, failure to achieve optimal therapeutic benefit is common for reasons that include taking medication incorrectly, stopping it prematurely, malabsorption, and the presence of unrecognized diseases or conditions with adverse skeletal effects. Monitoring for anti-fracture effectiveness in individual patients is limited by the absence of clinical tools to directly measure bone strength. It is therefore necessary to monitor therapy with biomarkers such as bone mineral density and bone turnover markers. This is a review of the utility of these tools in the care of individual patients.

Health Beliefs about Osteoporosis and Osteoporosis Screening in Older Women and Men

OBJECTIVE: To examine older adults' beliefs about osteoporosis and osteoporosis screening to identify barriers to screening. DESIGN: Cross-sectional mailed survey. SETTING: Western Pennsylvania. METHODS: Surveys were mailed to 1830 women and men aged 60 years and older. The survey assessed sociodemographic characteristics, osteoporosis and general health-related characteristics, and beliefs about osteoporosis severity, susceptibility, screening self-efficacy, and screening response efficacy. Analyses included Wilcoxon rank-sum tests to compare belief dimension scores, and multivariable ordinal logistic regression analyses to evaluate association between osteoporosis beliefs and potential explanatory variables. RESULTS: Surveys were completed by 1268 individuals (69.3 per cent). Mean age of respondents was 73.3 years, and most were female (58.7 per cent). Individuals demonstrated greatest belief in the severity of osteoporosis and least belief in personal susceptibility (P <.001). Older individuals believed less strongly than younger individuals in osteoporosis severity (OR, 0.95 per 1-year increase in age; 95 per cent CI, 0.92-0.97) and response efficacy (OR, 0.97 per 1-year increase in age; 95 per cent CI, 0.95-0.99). Women believed more strongly than men in osteoporosis susceptibility (OR, 1.87; 95 per cent CI, 1.38-2.53) and screening self-efficacy (OR, 2.87; 95 per cent CI, 1.17-7.07). Individuals with high self-rated health status had greater belief than those with low self-rated health status in screening self-efficacy (OR, 3.59; 95 per cent CI, 1.89-6.83). CONCLUSION: Older adults demonstrate several beliefs that may be barriers to osteoporosis screening, including low belief in susceptibility to osteoporosis. These beliefs should be targeted with patient education to improve screening rates.

Predictors of oral bisphosphonate prescriptions in post-menopausal women with osteoporosis in a real-world setting in the USA

SUMMARY

We identified factors associated with oral bisphosphonate treatment in 50+-year-old female patients with a first fracture, osteoporosis diagnosis, or BMD < or =-2.5 in the Geisinger Health System electronic health record database. Treatment was positively associated with age, oral corticosteroids, and smoking, and negatively associated with body mass index and bone mineral density scores.

INTRODUCTION

To identify factors associated with oral bisphosphonate treatment in patients with an indicator for post-menopausal osteoporosis.

METHODS

Females age 50+ years with a first fracture, osteoporosis diagnosis, or bone mineral density (BMD) < or =-2.5 (index date) were identified in the Geisinger Health System electronic health record database. Treatment was defined as an oral bisphosphonate prescription order (risedronate sodium, ibandronate sodium, or alendronate) < or =90 days post-index date. Treatment rates were assessed and a multivariate logistic model was used to identify predictors of treatment separately for patients with fracture (FRAC) and with diagnosis or low BMD (ICD-9-BMD).

RESULTS

The FRAC group had 2,003 female patients with a mean (SD) age of 69.0 (+/-11.3) years and the ICD-9-BMD group had 12,976 female patients with a mean (SD) age of 66.9 (+/-10.0) years. Within 90 days of the index date of fracture, diagnosis, or low BMD score, 188 (9.4%) patients in the FRAC group and 5,395 (41.6%) in the ICD-9-BMD group received treatment. Treatment was positively associated with age and oral corticosteroids and negatively associated with body mass index and subsequent BMD in both groups. Smoking currently was positively associated with treatment in the ICD-9-BMD group.

CONCLUSION

Certain patient characteristics are predictors of physicians prescribing oral bisphosphonates. However, many patients remain untreated.

Lasofoxifene for the prevention and treatment of postmenopausal osteoporosis

Lasofoxifene is a selective estrogen receptor modulator (estrogen agonist/antagonist) that has completed phase III trials to evaluate safety and efficacy for the prevention and treatment of osteoporosis and for the treatment of vaginal atrophy in postmenopausal women. In postmenopausal women with low or normal bone mineral density (BMD), lasofoxifene increased BMD at the lumbar spine and hip and reduced bone turnover markers compared with placebo. In women with postmenopausal osteoporosis, lasofoxifene increased BMD, reduced bone turnover markers, reduced the risk of vertebral and nonvertebral fractures, and decreased the risk of estrogen receptor-positive breast cancer. In postmenopausal women with low bone mass, lasofoxifene improved the signs and symptoms of vulvovaginal atrophy. Clinical trials show that lasofoxifene is generally well tolerated with mild to moderate adverse events that commonly resolve even with drug continuation. Lasofoxifene has been associated with an increase in the incidence of venous thromboembolic events, hot flushes, muscle spasm, and vaginal bleeding. It is approved for the treatment of postmenopausal women at increased risk for fracture in some countries and is in the regulatory review process in others.

Factors associated with diagnosis and treatment of osteoporosis in older adults

Osteoporosis is often undiagnosed and untreated. We surveyed 1,830 adults and identified factors associated with osteoporosis diagnosis and treatment. Individuals with several risk factors, including older age, were not more likely to be diagnosed or treated. Measures should be taken to improve osteoporosis identification and treatment in high-risk patients.

INTRODUCTION

We aimed to identify patient characteristics associated with osteoporosis diagnosis and treatment.

METHODS

Survey was mailed to 1,830 women and men > or =60 years old in Pennsylvania. Multivariable logistic regression analyses were performed to determine odds ratios for osteoporosis diagnosis and treatment for individuals with established osteoporosis risk factors.

RESULTS

Surveys were completed by 1,268 adults (69.3%). Osteoporosis diagnosis was more commonly reported by participants with risk factors of female sex (OR, 3.60; 95% CI 2.31-5.61), prolonged oral steroid use (OR, 3.76, 95% CI 2.06-6.84), low-trauma fracture (OR, 2.14, 95% CI 1.44-3.17), height loss (OR, 1.83, 95% CI 1.28-2.64), and lower weight (OR, 1.35 per 11.4 kg decrease in weight; 95% CI, 1.16-1.56). Age and family history of osteoporosis were not predictive of osteoporosis diagnosis, when adjusting for other risk factors. Osteoporosis treatment was more commonly reported by participants with risk factors of female sex (OR, 5.19; 95% CI, 3.31-8.13), family history (OR, 2.18; 95% CI, 1.55-3.06), height loss (OR, 1.79; 95% CI 1.29-2.49), low-trauma fracture (OR, 1.66; 95% CI, 1.14-2.42), and lower weight (OR, 1.45 per 11.4 kg decrease in weight; 95% CI, 1.27-1.67). Osteoporosis treatment was not significantly associated with age or prolonged oral steroid use.

CONCLUSIONS

Individuals with several established osteoporosis risk factors are more likely to be underdiagnosed or undertreated.

The utilization of appropriate osteoporosis medications improves following a multifaceted educational intervention: the Canadian quality circle project (CQC)

BACKGROUND

Osteoporosis is a serious but treatable condition. However, appropriate therapy utilization of the disease remains suboptimal. Thus, the objective of the study was to change physicians' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines.

METHODS

The Project was a two year cohort study that consisted of five Quality Circle (QC) phases that included: 1) Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session. A total of 340 family physicians formed 34 QCs and participated in the study. Physicians evaluated a total of 8376, 7354 and 3673 randomly selected patient charts at baseline, follow-up #1 and the final follow-up, respectively. Patients were divided into three groups; the high-risk, low-risk, and low-risk without fracture groups. The generalized estimating equations technique was utilized to model the change over time of whether physicians

RESULTS

The odds of appropriate therapy was 1.29 (95% CI: 1.13, 1.46), and 1.41 (95% CI: 1.20, 1.66) in the high risk group, 1.15 (95% CI: 0.97, 1.36), and 1.16 (95% CI: 0.93, 1.44) in the low risk group, and 1.20 (95% CI: 1.01, 1.43), and 1.23 (95% CI: 0.97, 1.55) in the low risk group without fractures at follow-up #1 and the final follow-up, respectively.

CONCLUSION

QCs methodology was successful in increasing physicians' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines.

Osteoporosis screening preferences of older adults

We aimed to examine older adults' osteoporosis screening test preferences, willingness to travel for screening, and willingness to pay for screening. A survey was mailed to 1830 women and men aged 60 yr or older in Pennsylvania, assessing screening test preference (among dual-energy X-ray absorptiometry [DXA], heel quantitative ultrasound [QUS], and risk-assessment tools), willingness to travel 20 miles for a better screening test, and willingness to pay $100 for a better screening test, as well as socio-demographic and health-related characteristics. Analyses included descriptive statistics and multivariable logistic regression analyses to evaluate association between screening test preference, willingness to travel, willingness to pay, and potential explanatory variables. Surveys were completed by 1268 individuals (69.3%). Most respondents indicated a screening test preference (73.9%) and, of these, 78.1% preferred DXA. 78.8% of the respondents indicated that they may be willing to travel 20 miles for a better test, and 51.2% indicated that they may be willing to pay $100 for a better test. Similar trends were observed in analyses including only individuals who had not had prior osteoporosis testing or diagnosis. Many older individuals would prefer the "best" test for osteoporosis screening, and may be willing to travel or pay more to obtain a better test.

Factors associated with osteoporosis screening and recommendations for osteoporosis screening in older adults

BACKGROUND

Osteoporosis screening rates are low, and it is unclear which patient factors are associated with screening and physician recommendations for screening.

OBJECTIVE

To identify patient characteristics associated with osteoporosis screening recommendations and receipt of screening in older adults.

DESIGN

Cross-sectional mailed survey.

PARTICIPANTS

Women and men > or =60 years old living in or near western Pennsylvania.

MEASUREMENTS

Sociodemographic characteristics and osteoporosis-related data, including risk factors, physician recommendations for screening, and receipt of screening. Multivariable logistic regression analyses were performed to determine odds ratios for receipt of screening and screening recommendations for individuals with particular osteoporosis risk factors, adjusting for sociodemographic and other risk factors.

RESULTS

Surveys were completed by 1,268 of the 1,830 adults to whom surveys were mailed (69.3%). Most respondents were white (92.9%), female (58.7%), and believed they were in good to excellent health (88.2%). Only 47.6% said their physician recommended osteoporosis screening, and 62.6% of all respondents reported being screened. Screening recommendations were less likely for older respondents than younger ones (OR, 0.87 per 5-year increase in age; 95% CI, 0.77-0.97). Individuals with osteoporosis risk factors of a history of oral steroid use for >1 month, height loss >2.54 cm, or history of low-trauma fracture were no more likely to report screening recommendations than individuals without these characteristics. Receipt of screening was no more likely for more elderly respondents or respondents with a history of oral steroid use for >1 month than for respondents without these characteristics.

CONCLUSIONS

Individuals with several known osteoporosis risk factors are not being sufficiently targeted for screening.

Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice

CONTEXT

Osteoporosis is a common and costly disease that is associated with high morbidity and mortality. There is a lack of direct evidence supporting the benefits of bone mineral density (BMD) screening on osteoporosis outcomes. However, there is indirect evidence to support screening for osteoporosis given the availability of medications with good antifracture efficacy. This paper addresses the position of the American College of Preventive Medicine (ACPM) on osteoporosis screening.

EVIDENCE ACQUISITION

The medical literature was reviewed for studies examining the benefits and harms of osteoporosis screening. An overview is also provided of available modalities for osteoporosis screening, risk-assessment tools, cost effectiveness, benefits and harms of screening, rationale for the study, and recommendations from leading health organizations and ACPM. A review was done of English language articles published prior to September 2008 that were retrieved via search on PubMed, from references from pertinent review or landmark articles, and from websites of leading health organizations.

EVIDENCE SYNTHESIS

There were no randomized controlled trials (RCTs) of osteoporosis screening on fracture outcomes. However, there was one observational study that demonstrated reduced fracture incidence among recipients of BMD testing. Dual energy x-ray absorptiometry is currently one of the most widely accepted and utilized methods for assessing BMD. Other potential tests for detecting osteoporosis include quantitative ultrasound, quantitative computer tomography, and biochemical markers of bone turnover. Testing via BMD is a cost-effective method for detecting osteoporosis in both men and women. Osteoporosis risk-assessment tools such as the WHO fracture-risk algorithm are useful supplements to BMD assessments as they provide estimates of absolute fracture risks. They can also be used with or without BMD testing to assist healthcare providers and patients in making decisions regarding osteoporosis treatments.

CONCLUSIONS

All adult patients aged >or=50 years should be evaluated for risk factors for osteoporosis. Screening with BMD testing for osteoporosis is recommended in women aged >or=65 years and in men aged >or=70 years. Younger postmenopausal women and men aged 50-69 years should undergo screening if they have at least one major or two minor risk factors for osteoporosis. It is also recommended that clinicians consider using an osteoporosis risk-assessment tool to evaluate absolute fracture risk to determine appropriate osteoporosis therapies.

Full length parathyroid hormone, PTH(1-84), for the treatment of severe osteoporosis in postmenopausal women

OBJECTIVE

To review and analyse the evidence supporting the use of full length parathyroid hormone, PTH(1-84), in the treatment of osteoporosis based on a search of several literature sources; articles selected for review were published between 1990 and 2008.

BACKGROUND

PTH(1-84) is approved for the treatment of osteoporosis in postmenopausal women at high risk of fracture in Europe. It was well tolerated in clinical trials and demonstrated bone building properties and fracture prevention particularly for the lumbar spine in the treatment of postmenopausal women.

RESULTS

The TOP clinical trial showed that PTH(1-84) treatment for 18 months resulted in a 61% reduction (p = 0.001) in new vertebral fracture incidence when compared with placebo and reduced the risk of a first vertebral fracture by 68% (p = 0.006) in women without a prevalent fracture at baseline. PTH(1-84) increased bone mineral density (BMD) at vertebral and non-vertebral sites the lumbar spine BMD increasing regardless of T-score, age, prior osteoporosis therapy or number of years post-menopause. The PaTH study showed that treatment with PTH(1-84) for 12 months increased BMD at the trabecular spine and hip. Lumbar spine BMD gains were largest with sequential administration of PTH(1-84) followed by alendronate but were smaller with concurrent administration involving anabolic and antiresorptive agents. Lumbar spine BMD increases were also seen in trials involving PTH with raloxifene and PTH in combination with hormone replacement therapy.

CONCLUSIONS

PTH(1-84) has demonstrated effective bone building qualities and extends the therapeutic options available to osteoporotic women. The use of PTH(1-84) followed by sequential administration of an antiresorptive has proved effective at increasing trabecular BMD and points towards new treatment regimens offering improvements in BMD and fracture prevention.

Osteoporotic Caucasian and South Asian women: a qualitative study of general practitioners' support

Health professionals face two complicated but contradictory epidemics: obesity and osteoporosis (OP). While obesity is obvious, OP progresses silently affecting one in two UK women. Both South Asian and Caucasian women are at OP risk. This study compared experiences of osteoporotic Caucasian and South Asian women in a purposive sample of 21 volunteers from south east England, aged 43 to 82 years. The women had been diagnosed for eight months to 40 years. Long disease duration was marked by complacent OP dialogue, although OP was objectionable and marked a loss of quality of life. Inductive content analysis of transcripts showed that 'uncertainty'--about one another and about what constituted helpful self-care--affected both GPs and patients. Instead, support groups and the media supported learning about OP care. Beyond providing drug prescriptions, women reported desiring, but rarely feeling, that GPs fully supported their preferences for self-care. Self-care often included specialist exercise classes. Some younger women led their GPs to better understand the range of self-care options. GPs were seen as being unsure about how and when to discuss physical activity (PA). In conclusion, women with OP in this sample are sensitive to their GP's hesitance about offering detailed PA recommendations. Regardless of ethnicity, younger women undertook PA based on personal initiative. Positive PA experiences stimulated an interest in discussing PA with GPs, and these dialogues broke the silence surrounding OP care. By providing important information regarding the OP patient experience, the findings highlight the unmet desire of OP sufferers for better and closer attention from GPs.

Canadian Quality Circle pilot project in osteoporosis: rationale, methods, and feasibility

PROBLEM ADDRESSED Family physicians are not adequately following the 2002 Osteoporosis Canada guidelines for providing optimal care to patients with osteoporosis.

OBJECTIVE OF PROGRAM

The Canadian Quality Circle (CQC) pilot project was developed to assess the feasibility of the CQC project design and to gather information for implementing a national study of quality circles (QCs). The national study would assess whether use ofQCs could improve family physicians' adherence to the osteoporosis guidelines.

PROGRAM DESCRIPTION

The pilot project enrolled 52 family physicians and involved 7 QCs. The project had 3 phases: training and baseline data collection, educational intervention and follow-up data collection, and sessions on implementing strategies for care.

CONCLUSION

Findings from the pilot study showed that the CQC project was well designed and well received. Use of QCs appeared to be feasible for transferring knowledge and giving physicians an opportunity to analyze work-related problems and develop solutions to them.

Osteoporosis preventive care in white and black women in community family medicine settings

BACKGROUND

Osteoporosis has been studied predominantly in white postmenopausal women.

MATERIALS AND METHODS

We performed a cross-sectional survey of a random sample of 400 women aged 45 years and older enrolled in a family medicine community-based research network. Participants responded to 42 items regarding osteoporosis screening and prevention during primary care visits. Odds ratios were calculated comparing black versus white women, adjusting for age, weight, fracture history, family history of osteoporosis, and practice site.

RESULTS

Compared with black women, white women had 5.96 (95% CI 3.01, 11.79) times the adjusted odds of having a past bone density test, 2.97 (95% CI 1.57, 5.60) times the odds of discussing osteoporosis with their doctor, and 2.42 (95% CI 1.30, 4.50) times the odds of a physician recommendation to take calcium.

CONCLUSIONS

Disparities in osteoporosis preventive care were found between black and white women, after adjustment for other osteoporosis risk factors.

Use of decision rules for osteoporosis prevention and treatment: Implications for nurse practitioners

PURPOSE

To describe the current literature regarding the benefits of bone mineral density (BMD) screening and to discuss clinical decision rules for BMD screening.

DATA SOURCES

Extensive review of the scientific literature regarding osteoporosis, BMD screening, and current clinical decision rules.

CONCLUSIONS

Osteoporosis is a disease characterized by deterioration of bone and increased susceptibility to fractures, crippling, and disfigurement. BMD testing is the best predictor for osteoporosis and associated fractures; however, routine global BMD testing is cost-prohibitive. A need exists for a selective and practical clinical decision rule for referral for testing.

IMPLICATIONS FOR PRACTICE

Several effective clinical decision rules are presented, and their uses and applications are described. The osteoporosis self-assessment tool is recommended by the authors because of its predictive power and ease of use.

Epidemiology, treatment and costs of osteoporosis in Germany--the BoneEVA Study

INTRODUCTION

In Germany, accurate data on the prevalence and treatment of osteoporosis, as well as the cost of this illness, are not available. The aim of this study is to give a valid estimation of these items for the year 2003.

METHODS

Routine data from a German sickness fund covering 1.5 million beneficiaries and billing data for outpatient visits were used to obtain estimates of prevalence for osteoporosis. Claims data for patients with osteoporosis (M80, M81) or an osteoporosis-related fracture diagnosis (S22, S32, S42, S52, S72, S82) or treatment with anti-osteoporosis drugs were examined. Costs were calculated from the perspective of the German health insurance system and the German nursing care insurance system, respectively. Only direct costs of osteoporosis were considered.

RESULTS

In 2003, 7.8 million Germans (6.5 million women) were affected by osteoporosis. Of them, 4.3% experienced at least one clinical fracture. Only 21.7% were treated with an anti-osteoporosis drug. The total direct costs attributable to osteoporosis amounted to euros 5.4 billion.

CONCLUSION

This study confirms that osteoporosis is underdiagnosed, undertreated and imposes a considerable economic burden on the health system in Germany. Effective strategies for the prevention and management of this disease are needed.

Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital

BACKGROUND

Patients with fragility fractures secondary to osteoporosis are at risk of recurrent fracture. Osteoporosis is often underrecognized and undertreated. We looked at the levels of awareness, investigation and treatment of patients with fracture.

METHODS

The study group included patients admitted to a tertiary teaching hospital. Postal surveys were sent to female patients over 60 years of age who had been identified in the hospital database as having International Classification of Diseases-10 codes for fracture and discharged between June 1997 and January 2002. The questionnaire had specific questions on the histories of the fractures, the risk factors, the awareness of osteoporosis, bone mineral density testing and the treatment for osteoporosis.

RESULTS

Of 1584 surveys posted, 366 valid questionnaires were returned. The median age of respondents was 81 years with a range of 60-99 years. Fifty-nine per cent reported one fracture, 41% two or more fractures and 65% reported a hip fracture. Forty-eight per cent of patients were aware that they had osteoporosis and 35% reported having a bone density performed. Thirty-seven per cent reported being on treatment for osteoporosis on discharge, with the majority being on treatment with calcium (34%).

CONCLUSION

This postal survey of a high-risk patient group discharged from a tertiary hospital confirm the findings from other population-based and hospital-based studies that a significant proportion of patients at risk of further fracture are not investigated or offered specific treatment for osteoporosis. Lack of awareness of underlying osteoporosis by both treating clinicians and patients is likely to be a major contributing factor.

Primary care house staff attitudes toward osteoporosis management

OBJECTIVE

This study assessed possible institutional and patient-related factors influencing the delivery of postmenopausal osteoporosis (PMO) care and the diagnostic priority placed on addressing PMO, relative to other common medical conditions, by primary care house staff at our institution.

METHODS

A questionnaire was designed and distributed to eligible house staff at our institution.

RESULTS

Approximately 50% (n = 52) of the house staff participated. The supervising clinic attending, patients' lack of insurance, accessibility to medical care, comorbid conditions, and university formulary were reported to influence decisions regarding osteoporosis care. Osteoporosis was ranked 6th of 7 medical issues (hypertension, coronary artery disease, diabetes, hypercholesterolemia, adult immunizations, osteoporosis, thyroid disease) to address during a comprehensive medical visit.

CONCLUSIONS

Our institution's primary care house staff reported multiple influences on decision making regarding osteoporosis care, and an overall low priority to address this issue. Based on PMO's associated morbidity and mortality, primary care training programs are challenged to put resources toward optimizing house staff delivery of osteoporosis care.

Addressing the musculoskeletal components of fracture risk with calcium and vitamin D: a review of the evidence

Osteoporotic fractures are an extremely common and serious health problem in the elderly. This article presents the rationale for calcium and vitamin D supplementation in the prevention and treatment of osteoporotic fractures and reviews the literature evidence on the efficacy of this strategy. Two musculoskeletal risk factors are implicated in osteoporotic fractures in the elderly: the loss of bone mass due to secondary hyperparathyroidism and the increased propensity to falls. Calcium and vitamin D reverse secondary hyperparathyroidism with resultant beneficial effects on bone mineral density (BMD). Additionally, calcium and vitamin D supplementation significantly improves body sway and lower extremity strength, reducing the risk of falls. The effects of combined calcium and vitamin D on parathyroid function and BMD provide a strong rationale for the use of this therapy in the prevention and treatment of osteoporosis and osteoporotic fractures. There is general agreement that, in patients with documented osteoporosis, calcium and vitamin D supplementation should be an integral component of the management strategy, along with antiresorptive or anabolic treatment. Frail elderly individuals constitute another major target population for calcium and vitamin D because evidence from randomized studies in institutionalized elderly subjects demonstrates that these supplements reduce osteoporotic fracture risk, particularly in the presence of dietary deficiencies. However, the results of trials in community-dwelling subjects have been equivocal. Within the primary-care setting, further research is required to establish appropriate target subgroups for calcium and vitamin D supplementation; overall, the data are consistent with a benefit individuals with insufficient calcium and/or vitamin D, although patients with documented osteoporosis will derive further benefit in terms of fracture prevention from the addition of an antiresorptive agent.