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Kline GA, Morin SN, Lix LM, McCloskey EV, Johansson H, Harvey NC, Kanis JA, Leslie WD. General Comorbidity Indicators Contribute to Fracture Risk Independent of FRAX: Registry-Based Cohort Study. J Clin Endocrinol Metab 2023; 108:745-754. [PMID: 36201517 DOI: 10.1210/clinem/dgac582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/28/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT FRAX® estimates 10-year fracture probability from osteoporosis-specific risk factors. Medical comorbidity indicators are associated with fracture risk but whether these are independent from those in FRAX is uncertain. OBJECTIVE We hypothesized Johns Hopkins Aggregated Diagnosis Groups (ADG®) score or recent hospitalization number may be independently associated with increased risk for fractures. METHODS This retrospective cohort study included women and men age ≥ 40 in the Manitoba BMD Registry (1996-2016) with at least 3 years prior health care data and used linked administrative databases to construct ADG scores along with number of hospitalizations for each individual. Incident Major Osteoporotic Fracture and Hip Fracture was ascertained during average follow-up of 9 years; Cox regression analysis determined the association between increasing ADG score or number of hospitalizations and fractures. RESULTS Separately, hospitalizations and ADG score independently increased the hazard ratio for fracture at all levels of comorbidity (hazard range 1.2-1.8, all P < 0.05), irrespective of adjustment for FRAX, BMD, and competing mortality. Taken together, there was still a higher than predicted rate of fracture at all levels of increased comorbidity, independent of FRAX and BMD but attenuated by competing mortality. Using an intervention threshold of major fracture risk >20%, application of the comorbidity hazard ratio multiplier to the patient population FRAX scores would increase the number of treatment candidates from 8.6% to 14.4%. CONCLUSION Both complex and simple measures of medical comorbidity may be used to modify FRAX-based risk estimates to capture the increased fracture risk associated with multiple comorbid conditions in older patients.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine, University of Calgary, Calgary T2N 2T9, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal H3A 1G1, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg R3E 0W2, Canada
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne 3000, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, Southampton SO17 1BJ, UK
- NIHR Southampton Biomedical Research Center, University of Southampton, Southampton SO16 6YD, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne 3000, Australia
| | - William D Leslie
- Department of Community Health Sciences, University of Manitoba, Winnipeg R3E 0W2, Canada
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Kline GA, Lix LM, Morin SN, Leslie WD. Fracture risk in Asian-Canadian women is significantly over-estimated by the Canadian Association of Radiologists-Osteoporosis Canada risk prediction tool: retrospective cohort study. Arch Osteoporos 2022; 17:133. [PMID: 36201065 DOI: 10.1007/s11657-022-01173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/28/2022] [Indexed: 02/03/2023]
Abstract
Fracture risk calculators may not be accurate for all ethnicity groups. The Manitoba bone density registry was used to test the Canadian CAROC tool for predicting fracture risk in Asian-Canadian women. The tool significantly over-estimated fracture risk, suggesting that it may not be ideal for Asian-Canadian patients. PURPOSE Health risk prediction tools based on largely White populations may lead to treatment inequity when applied to non-White populations where outcome rates differ. We examined the calibration of the Canadian Association of Radiologists-Osteoporosis Canada (CAROC) fracture risk prediction tool in self-identified Asian-Canadian women. METHODS Retrospective cohort study of women over age 50 using the Manitoba BMD Registry. At first BMD, the intake questionnaire collected self-identification of ethnicity and fracture risk factors. 10-year fracture risk was estimated using CAROC and categorized into low, medium, or high fracture risk. Linked administrative databases identified incident osteoporotic fractures. Observed fracture rates were compared between White and Asian-Canadians and compared to the original CAROC risk stratification. RESULTS There were 63,632 and 1703 women who self-identified as White-Canadian or Asian-Canadian, respectively, covering approximately 600,000 patient-years follow-up. There were 6588 incident fractures; a similar percentage of patients were assigned to each risk stratum at baseline by CAROC. A progressive rise in 10-year observed fracture rates occurred for each CAROC stratum in the White-Canadian population but much lower fracture rates than predicted in Asian-Canadian patients (p < 0.001). Fracture incidence rate ratios were 1.9-2.6 fold higher in White- vs Asian-Canadian patients for all strata (p < 0.001). In the CAROC moderate and high-risk categories, observed fracture rates in Asian-Canadian patients were typically lower than predicted, indicating poor model calibration. CONCLUSION In Asian-Canadian women, observed osteoporosis fracture rates are lower than predicted when using the CAROC tool. Over-estimation of fracture risk may influence shared decision-making discussions.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Rd SW, Calgary, AB, T2T 5C7, Canada.
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Suzanne N Morin
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - William D Leslie
- Departments of Internal Medicine and Radiology, Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Lewiecki EM, Bouchonville MF. The current role of telehealth in the management of patients with osteoporosis. Expert Rev Endocrinol Metab 2022; 17:245-254. [PMID: 35603903 DOI: 10.1080/17446651.2022.2078304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Telehealth is the use of electronic technologies for communication, storage, and analysis of health-related information. Telemedicine is a form of telehealth that involves remote patient care. This is a review and update of the use of these modalities as they apply to the education of healthcare professionals who provide care for patients with osteoporosis and the delivery of their care. AREAS COVERED This review focuses on technology-enabled collaborative learning and its prototype model, Project ECHO (Extension for Community Healthcare Outcomes). Bone Health TeleECHO and similar programs apply the ECHO model of learning to mentor healthcare professionals on implementation of best practice care for patients with osteoporosis and other skeletal diseases. Telemedicine, which has seen widespread uptake during the COVID-19 pandemic, is an alternative to in-person visits for patients with osteoporosis as well as for those with other conditions. EXPERT OPINION Remote education of healthcare professionals and the remote delivery of patient care provides opportunities, as well as challenges, for achieving the goal of reducing the global burden of osteoporotic fractures.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Matthew F Bouchonville
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Assessment of the Relationship Between Bone Mineral Density and Fracture Risk Factors in the Family Doctor Practice. Fam Med 2021. [DOI: 10.30841/2307-5112.2-3.2021.240767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Osteoporosis is the fourth most common after cardiovascular, cancer and endocrine diseases. According to WHO experts, due to the aging population and the impact of negative environmental factors, the incidence of osteoporosis will increase further.
The objective: determining the relationship between ultrasound densitometry data on the heel cyst and the risk of fractures in older women from different regions of the country.
Materials and methods. The study was based on a survey of women in major cities of Ukraine – Kyiv, Kharkiv, Odessa. 116 women aged 40 to 79 years were included. The average age of the subjects was 56±9,62 years, the average body weight was 74,5±12,9 kg, height 163,1±5,62 cm, the average body mass index (BMI) was 28±4,90. Normal (BMI) 20–24,9 had 35 women (30,2%), rates of preobesity and clinical obesity were in 81 surveyed women (69,8%). All subjects were divided into 4 groups by age: 40–49 years, 50–59 years, 60–69 years, 70–79 years.
Results. Decrease in bone mineral density was found in 59,5% of examined women, of which osteopenia was in 57%, osteoporosis in 2,5% of women, the norm in 40,5% of women. The number of women with low BMD increased with age.
Analyzing the risk factors in women after 40 years revealed a high incidence of hypertension 40,5%, the frequency of previous fractures in the anamnesis was 22,% of respondents, fractures of the femur and other fractures in parents noted 33,6% of women, a decrease in growth by 3 cm during life occurred in 13,7%, early menopause (up to 45 years) in 16,3% of women. Physical activity less than 30 minutes a day was noted by 27,5%. The risk of FRAX and Q-fracture fractures is significantly correlated with densitometry.
Conclusions. Early detection of osteoporosis risk factors in the practice of a family doctor will help prevent an epidemic of this disease in our country and will prevent negative medical and social consequences. All of the above should be considered for planning preventive measures for osteoporosis and its complications, as well as for subsequent diagnostic steps for early detection of the disease.
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Riar S, Feasel AL, Aghajafari F, Frohlich D, Symonds CJ, Kline GA, Billington EO. Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review. CMAJ Open 2021; 9:E711-E717. [PMID: 34162663 PMCID: PMC8248580 DOI: 10.9778/cmajo.20200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences. METHODS We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%-19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories. RESULTS Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%-25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%-43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients. INTERPRETATION Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.
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Affiliation(s)
- Shivraj Riar
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - A Lynn Feasel
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Fariba Aghajafari
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Dean Frohlich
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Christopher J Symonds
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Greg A Kline
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Emma O Billington
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta.
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Sale JEM, Gray M, Mancuso D, Inrig T, Boire G, Beaulieu MC, Funnell L, Bogoch E. Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines. Rheumatol Int 2018; 38:2193-2208. [PMID: 30367203 DOI: 10.1007/s00296-018-4181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/19/2018] [Indexed: 11/25/2022]
Abstract
We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.
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Affiliation(s)
- Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.
| | - Matthew Gray
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Daniel Mancuso
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Gilles Boire
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Room 3853, Sherbrooke, QC, J1H 5N4, Canada
| | - Marie-Claude Beaulieu
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12e Avenue North, Sherbrooke, QC, J1H 5N4, Canada
| | - Larry Funnell
- Osteoporosis Canada, 1200 Eglinton Avenue East, Suite 500, Toronto, ON, M3C 1H9, Canada
| | - Earl Bogoch
- Department of Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
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Stewart DR, Korf BR, Nathanson KL, Stevenson DA, Yohay K. Care of adults with neurofibromatosis type 1: a clinical practice resource of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2018; 20:671-682. [DOI: 10.1038/gim.2018.28] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/22/2018] [Indexed: 12/25/2022] Open
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Lovato C, Lewiecki EM. Emerging anabolic agents in the treatment of osteoporosis. Expert Opin Emerg Drugs 2017; 22:247-257. [DOI: 10.1080/14728214.2017.1362389] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Christina Lovato
- Division of Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Adachi JD, Lau A, Papaioannou A. A Comparison of CAROC and FRAX in Patients with Fragility Fracture. J Rheumatol 2016; 43:1456-1457. [PMID: 27481988 DOI: 10.3899/jrheum.160712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Jonathan D Adachi
- Department of Medicine, McMaster University, Staff Rheumatologist, St. Joseph's Healthcare Hamilton;
| | - Arthur Lau
- Department of Medicine, McMaster University
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