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Beaupre LA, Moradi F, Khong H, Smith C, Evens L, Hanson HM, Juby AG, Kivi P, Majumdar SR. Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework. Arch Osteoporos 2020; 15:83. [PMID: 32488730 DOI: 10.1007/s11657-020-00751-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture. PURPOSE To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance). METHODS Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital. RESULTS Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance). CONCLUSIONS An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.
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Affiliation(s)
- L A Beaupre
- University of Alberta (Physical Therapy), 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
| | - F Moradi
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - H Khong
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - C Smith
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - L Evens
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - H M Hanson
- Seniors Health Strategic Clinical Network™, Alberta Health Services and University of Calgary (Medicine), Calgary, AB, Canada
| | - A G Juby
- University of Alberta (Geriatric Medicine), Edmonton, AB, Canada
| | - P Kivi
- University of Alberta (Family Medicine), Edmonton, AB, Canada
| | - S R Majumdar
- University of Alberta (Medicine), Edmonton, AB, Canada
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Gilani F, Majumdar SR, Johnson JA, Simpson SH. Factors associated with pneumococcal vaccination in 2040 people with type 2 diabetes: A cross-sectional study. Diabetes Metab 2019; 46:137-143. [PMID: 31255692 DOI: 10.1016/j.diabet.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/03/2019] [Accepted: 06/16/2019] [Indexed: 01/10/2023]
Abstract
AIMS Pneumococcal vaccination is recommended in diabetes because of the high risk for invasive pneumococcal disease and mortality; however, vaccination rates are below recommended targets. This study was conducted to identify possible reasons behind the low rate of vaccine uptake. METHODS We examined baseline information from the Alberta Caring for Diabetes study, a prospective cohort study of 2040 adults with type 2 diabetes. Patients were recruited between December 2011 and December 2013. The baseline survey collected information on a wide range of socio-demographic characteristics, disease and management information, as well as health status measurements and health service utilization. Multivariable logistic regression analyses were conducted to identify factors associated with self-reported pneumococcal vaccination status. RESULTS Mean age was 64 (SD 11) years, 45% were women, mean duration of diabetes was 12 (SD 10) years, and 1090 (53%) were vaccinated. Age≥65 years (adjusted odds ratio [aOR] 2.52; 95% CI: 1.98-3.20), respiratory disease (aOR 1.50; 95% CI: 1.17-1.93), and cancer (aOR 1.45; 95% CI: 1.08-1.94) were independently associated with pneumococcal vaccination. In addition, women, retirees, people with diabetes≥10 years, people using antihypertensive medications or insulin, and those who had their HbA1c, kidney function, or their weight or waist circumference measured by a healthcare professional in the past year were more likely to have been vaccinated. CONCLUSION Based on this information, future programs aimed at people aged<65 years old, men, those who are currently working, those recently diagnosed with diabetes, and those with few comorbidities could have the most potential for improving pneumococcal vaccine uptake in people with diabetes.
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Affiliation(s)
- F Gilani
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - S R Majumdar
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada; Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - J A Johnson
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - S H Simpson
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada.
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McAlister FA, Ye C, Beaupre LA, Rowe BH, Johnson JA, Bellerose D, Hassan I, Majumdar SR. Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial. Osteoporos Int 2019; 30:127-134. [PMID: 30232538 DOI: 10.1007/s00198-018-4702-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/11/2018] [Indexed: 11/28/2022]
Abstract
UNLABELLED Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor. INTRODUCTION To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture. METHODS Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients. RESULTS By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not. CONCLUSION While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income. TRIAL REGISTRATION ClinicalTrials.gov : NCT01401556.
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Affiliation(s)
- F A McAlister
- Department of Medicine, University of Alberta, Edmonton, Canada.
- Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, Alberta, T6G 2G3, Canada.
| | - C Ye
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - L A Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - B H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Canada
| | - J A Johnson
- School of Public Health, University of Alberta, Edmonton, Canada
| | - D Bellerose
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - I Hassan
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Canada
| | - S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, Canada
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Leslie WD, Majumdar SR, Morin SN, Lix LM, Schousboe JT, Ensrud KE, Johansson H, McCloskey EV, Kanis JA. Performance of FRAX in clinical practice according to sex and osteoporosis definitions: the Manitoba BMD registry. Osteoporos Int 2018; 29:759-767. [PMID: 29404625 DOI: 10.1007/s00198-018-4415-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Among 62,275 women and 6455 men, FRAX stratified risk for incident major osteoporotic fracture (MOF) and incident hip fracture (HF) without sex interaction. Performance was good in those with osteoporosis regardless of how this was defined. INTRODUCTION Some studies have reported that FRAX performance differs according to sex and/or osteoporosis definitions. We evaluated whether the performance of FRAX to predict incident MOF and HF in women and men was affected by the presence or absence of osteoporosis defined by World Health Organization (WHO) or National Osteoporosis Foundation (NOF) criteria. METHODS We studied women and men age ≥ 40 years with baseline hip and spine DXA scans (1996-2013). Individuals were classified into four non-overlapping subgroups: osteoporosis by WHO criteria, osteoporosis exclusively by NOF criteria, high fracture risk by FRAX (MOF ≥ 20% or HF ≥ 3%, without osteoporosis), and low fracture risk (MOF < 20% and HF < 3% without osteoporosis). In each subgroup, we evaluated stratification (hazard ratios [HR]) and calibration (observed vs predicted 10-year fracture probability) for incident fracture. RESULTS The population included 62,275 women (5345 MOF and 1471 HF) and 6455 men (405 MOF and 108 HF). FRAX scores were strongly predictive of MOF (HR per SD: women 2.12, 95% CI 2.06-2.18; men 1.89, 95% CI 1.73-2.08; sex interaction p value = 0.97) and HF (women 4.78, 95% CI 4.44-5.14; men 4.20, 95% CI 3.22-5.49; sex interaction p value = 0.71). FRAX scores gave similar HRs for MOF among the four subgroups (subgroup interaction p value 0.34 for women, 0.22 for men). Observed versus predicted 10-year MOF and HF probability for the defined subgroups demonstrated a high level of concordance for women and men (all r2 ≥ 0.9). CONCLUSIONS FRAX was a strong and consistent predictor of MOF and HF in both women and men and performed well in those with osteoporosis whether defined by WHO or NOF criteria.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | | | | | - L M Lix
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | | | - K E Ensrud
- University of Minnesota, Minneapolis, USA
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - J A Kanis
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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Chen CB, Eurich DT, Majumdar SR, Johnson JA. Risk of prostate cancer across different racial/ethnic groups in men with diabetes: a retrospective cohort study. Diabet Med 2018; 35:107-111. [PMID: 29078006 DOI: 10.1111/dme.13536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 11/29/2022]
Abstract
AIM To examine the associations between prostate cancer, diabetes and race/ethnicity. METHODS Using administrative data from British Columbia, Canada for the period 1994 to 2012, we identified men aged ≥50 years with and without diabetes. Validated surname algorithms identified men as Chinese, Indian or of other race/ethnicity. Multivariable Cox regression was used to estimate adjusted risks of prostate cancer according to diabetes status and race/ethnicity. RESULTS Our cohort of 160 566 men had a mean (sd) age of 64.7 (9.4) years and a median of 9 years' follow-up. The incidence rates of prostate cancer among those with and without diabetes were 177.4 (171.7-183.4) and 216.0 (209.7-222.5) per 1000 person-years, respectively. The incidence among Chinese men was 120.9 (109.2-133.1), among Indian men it was 144.1 (122.8-169.0) and in men of other ethnicity it was 204.8 (200.2-209.5). Diabetes was independently associated with a lower risk of prostate cancer (adjusted hazard ratio 0.82, 95% CI 0.78-0.86), as was Chinese (adjusted hazard ratio 0.54, 95% CI 0.46,0.63) and Indian (adjusted hazard ratio 0.66, 95% CI 0.49,0.89) race/ethnicity; however, there was no statistically significant interaction between diabetes status and race/ethnicity (all P>0.1). CONCLUSION Diabetes and Chinese and Indian race/ethnicity were each independently associated with a lower risk of prostate cancer.
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Affiliation(s)
- C B Chen
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - D T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - S R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - J A Johnson
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Abstract
UNLABELLED In this large registry-based study, women with diabetes had marginally greater bone mineral density (BMD) loss at the femoral neck but not at other measurement sites, whereas obesity was not associated with greater BMD loss. Our data do not support the hypothesis that rapid BMD loss explains the increased fracture risk associated with type 2 diabetes and obesity observed in prior studies. INTRODUCTION Type 2 diabetes and obesity are associated with higher bone mineral density (BMD) which may be less protective against fracture than previously assumed. Inconsistent data suggest that rapid BMD loss may be a contributing factor. METHODS We examined the rate of BMD loss in women with diabetes and/or obesity in a population-based BMD registry for Manitoba, Canada. We identified 4960 women aged ≥ 40 years undergoing baseline and follow-up BMD assessments (mean interval 4.3 years) without confounding medication use or large weight fluctuation. We calculated annualized rate of BMD change for the lumbar spine, total hip, and femoral neck in relation to diagnosed diabetes and body mass index (BMI) category. RESULTS Baseline age-adjusted BMD was greater in women with diabetes and for increasing BMI category (all P < 0.001). In women with diabetes, unadjusted BMD loss was less at the lumbar spine (P = 0.017), non-significantly greater at the femoral neck (P = 0.085), and similar at the total hip (P = 0.488). When adjusted for age and BMI, diabetes was associated with slightly greater femoral neck BMD loss (- 0.0018 g/cm2/year, P = 0.012) but not at the lumbar spine or total hip. There was a strong linear effect of increasing BMI on attenuated BMI loss at the lumbar spine with negligible effects on hip BMD. CONCLUSIONS Diabetes was associated with slightly greater BMD loss at the femoral neck but not at other measurement sites. BMD loss at the lumbar spine was reduced in overweight and obese women but BMI did not significantly affect hip BMD loss.
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Affiliation(s)
- W D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada.
- St. Boniface Hospital, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | - S N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - L M Lix
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Schacter GI, Leslie WD, Majumdar SR, Morin SN, Lix LM, Hans D. Clinical performance of an updated trabecular bone score (TBS) algorithm in men and women: the Manitoba BMD cohort. Osteoporos Int 2017; 28:3199-3203. [PMID: 28733715 DOI: 10.1007/s00198-017-4166-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 07/17/2017] [Indexed: 01/09/2023]
Abstract
UNLABELLED This is the first study to directly compare the original and recently updated versions of the trabecular bone score (TBS) algorithm. We confirmed improved performance of the new algorithm, especially among men. INTRODUCTION Lumbar spine trabecular bone score (TBS) predicts major osteoporotic fractures (MOFs) and hip fractures (HFs) independent of bone density. The original TBS algorithm (version 1; [TBS-v1]) was optimized for women of average body size. Limitations were identified when used in men or extremes of body mass index (BMI). The current study evaluates an updated TBS algorithm (version 2; [TBS-v2]) modified to address these issues. METHODS From a registry with all DXA results for Manitoba, Canada, we identified 47,736 women and 4348 men age ≥ 40 with baseline spine DXA (GE Prodigy, 1999-2011). Spine TBS was measured using both TBS-v1 and TBS-v2 algorithms. Risk stratification for incident fractures identified from population-based data was assessed from area under the receiver operating characteristic curve (AUROC). RESULTS With the TBS-v1 algorithm, average TBS for men was significantly lower than for women (p < 0.001) and showed significant inverse correlations with BMI (Pearson r-0.40 in men, -0.18 in women [both p < 0.001]). With the TBS-v2 algorithm, average values for men were slightly greater than for women (p < 0.001) and there were no significant correlations with BMI (Pearson r 0.01 in men, -0.01 in women [both p > 0.1]). During mean follow-up of 5 years in men, there were 214 incident MOFs and 47 HFs; during 6 years mean follow-up in women, there were 2895 incident MOFs and 694 HFs. Improvements in fracture prediction were seen with TBS-v2 in both men (change in AUROC for MOFs +0.021 [p = 0.17], HFs +0.046 [p = 0.04]) and women (change in AUROC for MOFs +0.012 [p < 0.001], HFs +0.020 [p < 0.001]). CONCLUSION The updated TBS algorithm is less affected by BMI, gives higher mean results for men than women consistent with their lower fracture risk, and improves fracture prediction in both men and women.
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Affiliation(s)
- G I Schacter
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - W D Leslie
- University of Manitoba, Winnipeg, Manitoba, Canada.
- Department of Medicine (C5121), 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - S R Majumdar
- University of Alberta, Edmonton, Alberta, Canada
| | - S N Morin
- McGill University, Montreal, Quebec, Canada
| | - L M Lix
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - D Hans
- Center of Bone Diseases, Bone and Joints Department, Lausanne University Hospital, Lausanne, Switzerland
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Marrie TJ, Tyrrell GJ, Majumdar SR, Eurich DT. Risk factors for pneumococcal endocarditis. Eur J Clin Microbiol Infect Dis 2017; 37:277-280. [PMID: 29067623 DOI: 10.1007/s10096-017-3128-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
Bacteremia is one of the most common manifestations of invasive pneumococcal disease (IPD). One complication of bacteremia is endocarditis; yet, few studies have evaluated the overall incidence and risk factors for IPD-associated endocarditis. Thus, we evaluated the overall incidence and risk factors of endocarditis compared to those without endocarditis in a large population of IPD patients. We prospectively collected all IPD cases from 2000 to 2014 in Northern Alberta, Canada. Descriptive statistics were used to compare sociodemographic variables, clinical characteristics, and IPD-related outcomes between patients with and without endocarditis. Endocarditis complicated the course of only 28 (0.3%) of 3251 adult patients with IPD. Endocarditis patients were more likely to use illicit drugs and have a higher severity of illness at presentation (i.e., higher rate of altered mental status and rate of intensive care unit [ICU] utilization, p < 0.05); however, no other major risk factors were identified. New murmur development among endocarditis patients was common: 39.3% compared to 2.2% of non-endocarditis patients (p < 0.001). The mortality rate of 39.3% was more than twice that of the rate of 14.7% for the patients with IPD but without endocarditis. There was no pneumococcal serotype predilection for endocarditis. Endocarditis is an uncommon complication of IPD, but, when present, is associated with a significantly increased risk of mortality. Overall, few specific risk factors were identified for IPD-related endocarditis, with the exception of illicit drug use.
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Affiliation(s)
- T J Marrie
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - G J Tyrrell
- The Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta and The Provincial Laboratory for Public Health, Edmonton, AB, Canada
| | - S R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - D T Eurich
- School of Public Health, University of Alberta, 2-040 Li Ka Shing HRIF, Edmonton, AB, T6G 2E1, Canada.
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Leslie WD, Majumdar SR, Morin SN, Lix LM, Johansson H, Oden A, McCloskey EV, Kanis JA. FRAX for fracture prediction shorter and longer than 10 years: the Manitoba BMD registry. Osteoporos Int 2017; 28:2557-2564. [PMID: 28593449 DOI: 10.1007/s00198-017-4091-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/14/2017] [Indexed: 12/26/2022]
Abstract
UNLABELLED In a large clinical registry for the province of Manitoba, Canada, FRAX predicted incident MOF and hip fracture from 1 to 15 years following baseline assessment. A simple linear rescaling of FRAX outputs seems useful for predicting both short- and long-term fracture risk in this population. INTRODUCTION FRAX® estimates 10-year probability of major osteoporotic fracture (MOF) and hip fracture. We examined FRAX predictions over intervals shorter and longer than 10 years. METHODS Using a population-based clinical registry for Manitoba, Canada, we identified 62,275 women and 6455 men 40 years and older with baseline dual-energy X-ray absorptiometry scans and FRAX scores. Incident MOF and hip fracture were assessed up to 15 years from population-based data. We assessed agreement between estimated fracture probability from 1 to 15 years using linearly rescaled FRAX scores and observed cumulative fracture probability. The gradient of risk for FRAX probability and incident fracture was examined overall and for 5-year intervals. RESULTS FRAX predicted incident MOF and hip fracture for all time intervals. There was no attenuation in the gradient of risk for MOF even for years >10. Gradient of risk was slightly lower for hip fracture prediction in years >10 vs years <5, though HRs remained high. Linear agreement was seen in the relationships between observed vs predicted (rescaled) FRAX probabilities (R 2 0.95-1.00). Among women, there was near-perfect linearity in MOF predictions. Deviations from linearity, with a slightly higher observed than predicted MOF probability, were most evident in the first years following a fracture event and after 10 years for hip fracture prediction in women using FRAX with BMD. Simulations showed that results were robust to large differences in fracture rates and moderate differences in mortality rates. CONCLUSIONS FRAX predicts incident MOF and hip fracture up to 15 years and could be adapted to predict fracture over time periods shorter and longer term than 10 years in populations with fracture and mortality epidemiology similar to Canada.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), St Boniface Hospital, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | | | | | - L M Lix
- Department of Medicine (C5121), St Boniface Hospital, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - A Oden
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
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Majumdar SR, Lier DA, Hanley DA, Juby AG, Beaupre LA. Economic evaluation of a population-based osteoporosis intervention for outpatients with non-traumatic non-hip fractures: the "Catch a Break" 1i [type C] FLS. Osteoporos Int 2017; 28:1965-1977. [PMID: 28275838 PMCID: PMC5486946 DOI: 10.1007/s00198-017-3986-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/23/2017] [Indexed: 01/13/2023]
Abstract
UNLABELLED Fracture liaison services (FLS) are advocated to improve osteoporosis treatment after fragility fracture, but there are few economic analyses of different models. A population-based 1i [=type C] FLS for non-hip fractures was implemented and it costs $44 per patient and it was very cost-effective ($9200 per QALY gained). Small operational changes would convert it from cost-effective to cost-saving. INTRODUCTION After fragility fracture, <20% of patients receive osteoporosis treatment. FLS are recommended to address this deficit but there are very few economic analyses of different FLS models. Therefore, we conducted an economic analysis of a 1i (=type C) FLS called "Catch a Break (CaB)." METHODS CaB is a population-based FLS in Alberta, Canada, that case-finds older outpatients with non-traumatic upper extremity, spine, pelvis, or "other" non-hip fractures and provides telephonic outreach and printed educational materials to patients and their physicians. Cost-effectiveness was assessed using Markov decision-analytic models. Costs were expressed in 2014 Canadian dollars and effectiveness based on model simulations of recurrent fractures and quality-adjusted life years (QALYs). Perspective was healthcare payer; horizon was lifetime; and costs and benefits were discounted 3%. RESULTS Over 1 year, CaB enrolled 7323 outpatients (mean age 67 years, 75% female, 69% upper extremity) at average cost of $44 per patient. Compared with usual care, CaB increased rates of bisphosphonate treatment by 4.3 to 17.5% (p < 0.001). Over their lifetime, for every 10,000 patients enrolled in CaB, 4 hip fractures (14 fractures total) would be avoided and 12 QALYs gained. Compared with usual care, incremental cost-effectiveness of CaB was estimated at $9200 per QALY. CaB was cost-effective in 85% of 10,000 probabilistic simulations. Sensitivity analyses showed if "other" fractures were excluded and intervention costs reduced 25% that CaB would become cost-saving. CONCLUSIONS A relatively inexpensive population-based 1i (=type C) FLS was implemented in Alberta and it was very cost-effective. If CaB excluded "other" fractures and decreased intervention costs by 25%, it would be cost-saving, as would any FLS that was more effective and less expensive.
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Affiliation(s)
- S R Majumdar
- The Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-134 Clinical Sciences Building, 11350 - 83rd Avenue, Edmonton, Alberta, T6G 2G3, Canada.
| | - D A Lier
- The Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-134 Clinical Sciences Building, 11350 - 83rd Avenue, Edmonton, Alberta, T6G 2G3, Canada
| | - D A Hanley
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - A G Juby
- The Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-134 Clinical Sciences Building, 11350 - 83rd Avenue, Edmonton, Alberta, T6G 2G3, Canada
| | - L A Beaupre
- The Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
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Wozniak LA, Johnson JA, McAlister FA, Beaupre LA, Bellerose D, Rowe BH, Majumdar SR. Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment. Osteoporos Int 2017; 28:219-229. [PMID: 27423660 PMCID: PMC5206259 DOI: 10.1007/s00198-016-3693-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/28/2016] [Indexed: 02/05/2023]
Abstract
UNLABELLED We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced. INTRODUCTION Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year. METHODS We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison. RESULTS We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time. CONCLUSIONS The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.
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Affiliation(s)
- L A Wozniak
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, T6G 2E1, Edmonton, Alberta, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - J A Johnson
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, T6G 2E1, Edmonton, Alberta, Canada
| | - F A McAlister
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, T6G 2E1, Edmonton, Alberta, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - L A Beaupre
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - D Bellerose
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - B H Rowe
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, T6G 2E1, Edmonton, Alberta, Canada
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - S R Majumdar
- School of Public Health, University of Alberta, 2-040 Li Ka Shing Centre for Health Research Innovation, T6G 2E1, Edmonton, Alberta, Canada.
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
- University of Alberta, 5-134B Clinical Sciences Building, 11350-83rd Avenue, Edmonton, T6G 2G3, Canada.
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Yang S, Leslie WD, Morin SN, Majumdar SR, Lix LM. Antiresorptive therapy and newly diagnosed diabetes in women: a historical cohort study. Diabetes Obes Metab 2016; 18:875-81. [PMID: 27097832 DOI: 10.1111/dom.12678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/12/2016] [Accepted: 02/06/2016] [Indexed: 01/08/2023]
Abstract
AIMS Undercarboxylated osteocalcin (ucOC) promotes increased insulin sensitivity and increased secretion. Since antiresorptive therapy (AT) decreases ucOC levels, AT could increase the risk of diabetes and this would have serious clinical ramifications. We sought to test this hypothesis by examining the association between new use of AT and newly-diagnosed diabetes. METHODS Using a bone mineral density (BMD) registry for Manitoba, Canada, we identified 33 640 women aged ≥50 years without diabetes at their first BMD test for 1998-2013. We linked these women to a province-wide retail pharmacy database to identify new AT exposure each year for up to 5 years after a BMD test. Time-dependent analysis was used to test the independent association between new use of AT and newly diagnosed diabetes. RESULTS This cohort had a mean age of 65 years, a mean body mass index of 26.8 kg/m(2) , and 12% were receiving glucocorticoid and 13% hormone replacement therapy at BMD test. In the first year after BMD test, 29% of women started AT (bisphosphonates, 92%). Over a mean 4.2 years of follow-up, 3.7% new AT users and 4.2% non-users had diabetes (adjusted hazard ratio 1.01, 95% confidence interval 0.87-1.16). Sensitivity analyses using AT dose-response gradients also found no significant associations with diabetes. CONCLUSIONS Despite the plausible biological mechanisms related to ucOC, new use of AT was not a risk factor for diabetes in this cohort. The clinical implications of these findings are reassuring, as AT is widely prescribed for treating osteoporosis in older women who are also at high risk of developing diabetes.
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Affiliation(s)
- S Yang
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - W D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S N Morin
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - L M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Leslie WD, Majumdar SR, Lix LM, Josse RG, Johansson H, Oden A, McCloskey EV, Kanis JA. Direct comparison of FRAX(R) and a simplified fracture risk assessment tool in routine clinical practice: a registry-based cohort study. Osteoporos Int 2016; 27:2689-2695. [PMID: 27108119 DOI: 10.1007/s00198-016-3613-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/20/2016] [Indexed: 01/17/2023]
Abstract
UNLABELLED FRAX(R) incrementally improved prediction of incident major osteoporotic fractures compared with the simplified Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool. INTRODUCTION There is debate over the value of seemingly more complex fracture prediction tools over simpler fracture prediction tools. FRAX(R) and the simplified CAROC tool are both widely used in Canada for estimating 10-year probability of major osteoporotic fractures. We compared the performance of these tools for predicting fracture outcomes. METHODS Using a bone densitometry registry for Manitoba, Canada, we identified 34,060 individuals age ≥50 years not receiving anti-osteoporosis therapy. Fracture Risk Assessment (FRAX) and CAROC were used to classify 10-year fracture risk as low (<10 %), moderate (10-20 %) and high (>20 %). Net reclassification improvement (NRI) was used to quantify the performance of FRAX versus CAROC. RESULTS During mean 9.8 years of follow-up, 3905 individuals sustained fractures. There were 10 (of 35 total) situations where observed fracture risk fell outside of the predicted range, and all 10 discordances favoured FRAX. NRI among incident fracture cases was not significantly changed, but there was a significant improvement in risk categorization for those who remained fracture-free (+1.7 %, P < 0.001) resulting in overall improvement (NRI overall +0.028, P < 0.001). Within nine pre-specified subgroups, there was no case of significant worsening in NRI when using FRAX instead of CAROC. In absolute terms, only 36 individuals would need to be assessed using FRAX instead of CAROC to yield an improvement in prediction (8 among individuals with prior fracture and 4 among those with prolonged glucocorticoid use). CONCLUSIONS FRAX provides improvement in fracture risk prediction compared with the simplified CAROC tool in individuals referred for osteoporosis screening, supporting the use of FRAX as the international reference tool for fracture risk assessment.
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Affiliation(s)
- W D Leslie
- University of Manitoba, Winnipeg, Canada.
- Department of Medicine (C5121), St. Boniface Hospital, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
| | | | - L M Lix
- University of Manitoba, Winnipeg, Canada
| | - R G Josse
- University of Toronto, Toronto, Canada
| | - H Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - A Oden
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - E V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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Dang TT, Majumdar SR, Marrie TJ, Eurich DT. Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients. Drugs Aging 2016; 32:13-9. [PMID: 25491559 DOI: 10.1007/s40266-014-0229-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Community-acquired pneumonia (CAP) is one of the most common reasons for physician visits and hospitalizations in North America. Rates of CAP increase with age and CAP is associated with significant morbidity and mortality, especially in the elderly. Though there is much written about the epidemiology and risk factors of incident (first episode) pneumonia, much less is known about recurrent pneumonia. Rates of recurrent pneumonia within 3-5-years of an episode of CAP are 9-12% with a median time to recurrence of 123-317 days and mortality ranging from 4 to 10%. Age ≥65-years-old and impaired functional status are the only patient characteristics that are independently associated with increased risk of recurrence. In terms of modifiable risk factors, only the use of proton-pump inhibitors and systemic and inhaled corticosteroids have consistently been associated with increased risk of recurrent pneumonia, while angiotensin-converting enzyme (ACE) inhibitors may exert a protective effect. Many chronic medical conditions typically associated with increased incident pneumonia-such as chronic obstructive pulmonary disease (COPD), neurological disease (resulting in dysphagia or silent aspiration), and heart failure-were not associated with increased risk of recurrent pneumonia. However, those who are immune-suppressed (e.g., immunoglobulin deficiencies) may be at increased risk of recurrent pneumonia. In summary, among those who survive an episode of pneumonia, recurrence is not uncommon, particularly in the elderly. Following recovery from an episode of pneumonia, patients should be evaluated for risk factors that would predispose to a second episode including seeking evidence of immunosuppression in younger patients and medication optimization, particularly in the elderly.
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Affiliation(s)
- T T Dang
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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15
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Simpson SH, Lier DA, Majumdar SR, Tsuyuki RT, Lewanczuk RZ, Spooner R, Johnson JA. Cost-effectiveness analysis of adding pharmacists to primary care teams to reduce cardiovascular risk in patients with Type 2 diabetes: results from a randomized controlled trial. Diabet Med 2015; 32:899-906. [PMID: 25594919 DOI: 10.1111/dme.12692] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Adding pharmacists to primary care teams significantly improved blood pressure control and reduced predicted 10-year cardiovascular risk in patients with Type 2 diabetes. This pre-specified sub-study evaluated the economic implications of this cardiovascular risk reduction strategy. METHODS One-year outcomes and healthcare utilization data from the trial were used to determine cost-effectiveness from the public payer perspective. Costs were expressed in 2014 Canadian dollars and effectiveness was based on annualized risk of cardiovascular events derived from the UKPDS Risk Engine. RESULTS The 123 evaluable trial patients included in this analysis had a mean age of 62 ( ± 11) years, 38% were men, and mean diabetes duration was 6 ( ± 7) years. Pharmacists provided 3.0 ( ± 1.9) hours of additional service to each intervention patient, which cost $226 ( ± $1143) per patient. The overall one-year per-patient costs for healthcare utilization were $190 lower in the intervention group compared with usual care [95% confidence interval (CI): -$1040, $668). Intervention patients had a significant 0.3% greater reduction in the annualized risk of a cardiovascular event (95% CI: 0.08%, 0.6%) compared with usual care. In the cost-effectiveness analysis, the intervention dominated usual care in 66% of 10,000 bootstrap replications. At a societal willingness-to-pay of $4000 per 1% reduction in annual cardiovascular risk, the probability that the intervention was cost-effective compared with usual care reached 95%. A sensitivity analysis using multiple imputation to replace missing data produced similar results. CONCLUSIONS Within a randomized trial, adding pharmacists to primary care teams was a cost-effective strategy for reducing cardiovascular risk in patients with Type 2 diabetes. In most circumstances, this intervention may also be cost saving.
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Affiliation(s)
- S H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - D A Lier
- Institute of Health Economics, Edmonton, Canada
| | - S R Majumdar
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
- Institute of Health Economics, Edmonton, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R T Tsuyuki
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R Z Lewanczuk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R Spooner
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - J A Johnson
- Institute of Health Economics, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
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16
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Brennan SL, Yan L, Lix LM, Morin SN, Majumdar SR, Leslie WD. Sex- and age-specific associations between income and incident major osteoporotic fractures in Canadian men and women: a population-based analysis. Osteoporos Int 2015; 26:59-65. [PMID: 25278299 DOI: 10.1007/s00198-014-2914-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED We investigated sex- and age-specific associations between income and fractures at the hip, humerus, spine, and forearm in adults aged ≥50 years. Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women. INTRODUCTION Associations between income and hip fractures are contested, even less is known about other fracture sites. We investigated sex- and age-specific associations between income and major osteoporotic fractures (MOF) at the hip, humerus, spine, and forearm. METHODS Incident fractures were identified from administrative health data for adults aged ≥50 years in Manitoba, Canada, 2000-2007. Mean neighborhood (postal code area) annual household incomes were extracted from 2006 census files and categorized into quintiles. We calculated age-adjusted and age-specific sex-stratified fracture incidence across income quintiles. We estimated relative risks (RR) and 95% CI for income quintile 1 (Q1, lowest income) vs. income quintile 5 (Q5) and tested the linear trend across quintiles. RESULTS We identified 15,094 incident fractures (4736 hip, 3012 humerus, 1979 spine, and 5367 forearm) in 2718 men and 6786 women. For males, the RR of fracture for the lowest vs. highest income quintile was 1.63 (95% CI 1.42-1.87) and the negative trend was statistically significant (p < 0.0001); individual skeletal sites showed similar associations. For females, the RR of fracture for the lowest vs. highest income quintile was 1.14 (95% CI 1.01-1.28), with a statistically significant negative trend (p = 0.0291); however, the only skeletal site associated with income in women was the forearm (Q1 vs. Q5 RR 1.09, 95% CI 1.01-1.28). CONCLUSIONS Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women. For men, these effect sizes seem large enough to warrant public health concern.
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Affiliation(s)
- S L Brennan
- School of Medicine, Deakin University, Geelong, Australia
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17
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Leslie WD, Morin SN, Lix LM, Majumdar SR. Does diabetes modify the effect of FRAX risk factors for predicting major osteoporotic and hip fracture? Osteoporos Int 2014; 25:2817-24. [PMID: 25092059 DOI: 10.1007/s00198-014-2822-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/23/2014] [Indexed: 01/09/2023]
Abstract
UNLABELLED In an observational study population of 62,413 individuals (6,455 [10 %] with diabetes), diabetes was independently associated with major osteoporotic fractures (MOFs) but did not significantly modify the effect of FRAX(TM) risk factors or prior fracture site. However, the presence of diabetes exerted a much stronger effect on hip fracture risk in younger versus older individuals. INTRODUCTION Diabetes mellitus increases fracture risk independent of risk factors that comprise the WHO FRAX(TM) tool. We explored whether diabetes modifies the effect of FRAX clinical risk factors on MOF and hip fracture risk. METHODS Using a registry of clinical dual-energy X-ray absorptiometry (DXA) results for Manitoba, Canada, we identified women and men aged 40 years and older undergoing baseline DXA in 1996-2011. Health services data were used to identify diabetes diagnosis, FRAX risk factors and incident fractures using previously validated algorithms. Prior fracture was stratified as clinical vertebral, hip, humerus, forearm, pelvis and 'other'. Cox proportional hazards models were used to test for statistical interactions of diabetes with FRAX clinical risk factors and prior fracture site. RESULTS During a mean follow-up of 6 years, there were 4,218 MOF and 1,108 hip fractures. Diabetes was a significant independent risk factor for MOF adjusted for FRAX risk factors including bone mineral density (BMD) (adjusted hazard ratio [aHR] 1.32 [95 % confidence interval (CI) 1.20-1.46]). No significant interactions of FRAX risk factors or prior fracture site with diabetes were identified in analyses of MOF. For predicting hip fractures, age significantly modified the effect of diabetes (aHR age <60, 4.67 [95 % CI 2.76-7.89], age 60-69, 2.68 [1.77-4.04], age 70-79, 1.57 [1.20-2.04], age >80, 1.42 [1. 10-1.99]; pinteraction <0.001). CONCLUSIONS Diabetes is an independent risk factor for MOFs and does not significantly modify the effect of FRAX risk factors or prior fracture site. However, diabetes exerts a much stronger effect on hip fracture risk in younger than older individuals which needs to be considered in hip fracture prediction.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada,
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Weir DL, Majumdar SR, McAlister FA, Marrie TJ, Eurich DT. The impact of multimorbidity on short-term events in patients with community-acquired pneumonia: prospective cohort study. Clin Microbiol Infect 2014; 21:264.e7-264.e13. [PMID: 25658532 DOI: 10.1016/j.cmi.2014.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/06/2014] [Accepted: 11/01/2014] [Indexed: 10/24/2022]
Abstract
The impact of multimorbidity on patients with community-acquired pneumonia has not been well characterised. Thus, our aim was to explore the relationship between multimorbidity and adverse events within 90 days of discharge. Data were prospectively collected for a population-based cohort of all adults discharged from any of the seven emergency departments (ED) or six hospitals in Edmonton (Alberta, Canada) with community-acquired pneumonia. Multivariable Cox regression models were used to examine the independent association between multimorbidity (defined as two or more chronic conditions) and subsequent 90-day mortality, hospitalisation, or ED visits after treatment of pneumonia. The cohort included 5565 patients, mean age was 57 years (SD 20), 54% were male, and 59% were treated as outpatients; 1602 (29%) patients had multimorbidity. Within 90 days, 255 (5%) patients died, 1205 (22%) were hospitalised, 1280 (23%) died or were hospitalised, and 2049 (37%) were admitted to the ED. The presence of multimorbidity was independently associated with an increased risk of death or hospitalisation within 90 days (37% vs. 17% for those without multimorbidity, adjusted hazard ratio: 1.43, 95% confidence interval: 1.26 to 1.62) as well as ED visits (45% vs. 34%, adjusted hazard ratio: 1.40, 95% confidence interval: 1.26 to 1.56). Multimorbidity was present in one-third of all patients with pneumonia in our study, and it was independently associated with death, hospitalisation, or return to ED within 90 days of discharge. Our findings suggest that multimorbidity is strongly related to prognosis and should be considered when making site-of-care decisions in the ED or deciding upon readiness for discharge.
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Affiliation(s)
- D L Weir
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada
| | - S R Majumdar
- Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - F A McAlister
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - T J Marrie
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - D T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada.
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Leslie WD, Aubry-Rozier B, Lix LM, Morin SN, Majumdar SR, Hans D. Spine bone texture assessed by trabecular bone score (TBS) predicts osteoporotic fractures in men: the Manitoba Bone Density Program. Bone 2014; 67:10-4. [PMID: 24998455 DOI: 10.1016/j.bone.2014.06.034] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 06/06/2014] [Accepted: 06/25/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION One quarter of osteoporotic fractures occur in men. TBS, a gray-level measurement derived from lumbar spine DXA image texture, is related to microarchitecture and fracture risk independently of BMD. Previous studies reported the ability of spine TBS to predict osteoporotic fractures in women. Our aim was to evaluate the ability of TBS to predict clinical osteoporotic fractures in men. METHODS 3620 men aged ≥50 (mean 67.6years) at the time of baseline DXA (femoral neck, spine) were identified from a database (Province of Manitoba, Canada). Health service records were assessed for the presence of non-traumatic osteoporotic fracture after BMD testing. Lumbar spine TBS was derived from spine DXA blinded to clinical parameters and outcomes. We used Cox proportional hazard regression to analyze time to first fracture adjusted for clinical risk factors (FRAX without BMD), osteoporosis treatment and BMD (hip or spine). RESULTS Mean followup was 4.5years. 183 (5.1%) men sustain major osteoporotic fractures (MOF), 91 (2.5%) clinical vertebral fractures (CVF), and 46 (1.3%) hip fractures (HF). Correlation between spine BMD and spine TBS was modest (r=0.31), less than correlation between spine and hip BMD (r=0.63). Significantly lower spine TBS were found in fracture versus non-fracture men for MOF (p<0.001), HF (p<0.001) and CVF (p=0.003). Area under the receiver operating characteristic curve (AUC) for incident fracture discrimination with TBS was significantly better than chance (MOF AUC=0.59, p<0.001; HF AUC=0.67, p<0.001; CVF AUC=0.57, p=0.032). TBS predicted MOF and HF (but not CVF) in models adjusted for FRAX without BMD and osteoporosis treatment. TBS remained a predictor of HF (but not MOF) after further adjustment for hip BMD or spine BMD. CONCLUSION We observed that spine TBS predicted MOF and HF independently of the clinical FRAX score, HF independently of FRAX and BMD in men. Studies with more incident fractures are needed to confirm these findings.
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Affiliation(s)
- W D Leslie
- University of Manitoba, Winnipeg, Canada.
| | - B Aubry-Rozier
- Lausanne University Hospital, Bone Disease Unit, Lausanne, Switzerland
| | - L M Lix
- University of Manitoba, Winnipeg, Canada
| | | | | | - D Hans
- Lausanne University Hospital, Bone Disease Unit, Lausanne, Switzerland
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Majumdar SR, McAlister FA, Johnson JA, Weir DL, Bellerose D, Hanley DA, Russell AS, Rowe BH. Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials. Osteoporos Int 2014; 25:2173-9. [PMID: 24803330 DOI: 10.1007/s00198-014-2728-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/17/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers. INTRODUCTION In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors. METHODS Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year. RESULTS Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment. CONCLUSIONS The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.
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Affiliation(s)
- S R Majumdar
- The Department of Medicine, University of Alberta in Edmonton, 5-134B Clinical Sciences Building, 11350-83rd Avenue, Edmonton, Alberta, T6G 2G3, Canada,
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Dang TT, Eurich DT, Weir DL, Marrie TJ, Majumdar SR. Rates and risk factors for recurrent pneumonia in patients hospitalized with community-acquired pneumonia: population-based prospective cohort study with 5 years of follow-up. Clin Infect Dis 2014; 59:74-80. [PMID: 24729503 DOI: 10.1093/cid/ciu247] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The rates and risk factors for developing recurrent pneumonia following hospitalization with community-acquired pneumonia (CAP) are poorly understood. METHODS We examined a population-based cohort of patients with CAP who survived hospital admission and who were free of pneumonia for at least 3 months. We collected clinical, functional, and medication-related information and pneumonia severity index (PSI). Using linked databases we followed patients for 5 years and captured any clinical episode of pneumonia 90 days or more post-discharge. We used Cox proportional hazards models (adjusted for age, sex, PSI, functional status, medications) to determine rates and independent correlates of recurrent pneumonia. RESULTS The final cohort included 2709 inpatients; 43% were 75 years or older, 34% were not fully independent, and 56% had severe pneumonia. Over 5 years of follow-up, 245 (9%; 95% confidence interval [CI], 8%-10%) patients developed recurrent pneumonia, and 156 (64%) of these episodes required hospitalization. Rate of recurrence was 3.0/100 person-years and median time to recurrence was 317 days (interquartile range, 177-569); 32 (13%) patients had 2 or more recurrences. In multivariable analyses only age >75 years (adjusted P = .047) and less than fully independent functional status (12% recurrence rate with impaired functional status vs 7% for fully independent; adjusted hazard ratio, 1.7; 95% CI, 1.3-2.2; P < .001) were significantly associated with recurrent pneumonia. CONCLUSIONS One of 11 patients who survived CAP hospitalization had recurrent pneumonia over 5 years and those with impaired functional status were at particularly high risk. Recurrent pneumonia is common and more attention to preventive strategies at discharge and closer follow-up over the long-term seem warranted.
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Affiliation(s)
- T T Dang
- Department of Medicine, Faculty of Medicine and Dentistry
| | - D T Eurich
- School of Public Health, University of Alberta, Edmonton
| | - D L Weir
- School of Public Health, University of Alberta, Edmonton
| | - T J Marrie
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S R Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry School of Public Health, University of Alberta, Edmonton
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Warkentin LM, Das D, Majumdar SR, Johnson JA, Padwal RS. The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials. Obes Rev 2014; 15:169-82. [PMID: 24118750 DOI: 10.1111/obr.12113] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 08/28/2013] [Accepted: 09/01/2013] [Indexed: 12/28/2022]
Abstract
The aim of this study was to examine the effect of weight loss on health-related quality of life (HRQL) in randomized controlled intervention trials (RCTs). MEDLINE, HealthStar and PsycINFO were searched. RCTs of any weight loss intervention and 20 HRQL instruments were examined. Contingency tables were constructed to examine the association between statistically significant weight loss and statistically significant HRQL improvement within five HRQL categories. In addition, Short Form-36 (SF-36) outcomes were pooled using random-effects models. Fifty-three trials were included. Seventeen studies reported statistically significant weight loss and HRQL improvement. No statistically significant associations between weight loss and HRQL improvement were found in any contingency table. Because of suboptimal endpoint reporting, quantitative data pooling could only be performed using 25% of SF-36 trials in any one model. Significant improvements in physical health were found: mean difference 2.83 points, 95% CI 0.55-5.1, for the physical component score, and mean difference 6.81 points, 95% CI 2.99-10.63, for the physical functioning domain score. Conversely, no significant improvements in mental health were found. No significant association was found between weight loss and overall HRQL improvement. Weight loss may be associated with modest improvements in physical, but not mental, health.
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Affiliation(s)
- L M Warkentin
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Alberta Diabetes Institute, Edmonton, Alberta, Canada
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Abstract
Osteoporotic fractures are associated with excess mortality and decreased functional capacity and quality of life. Age-standardized incidence rates of fragility fractures, particularly of the hip and forearm, have been noted to be decreasing in the last decade across many countries with the notable exception of Asia. The causes for the observed changes in fracture risk have not been fully identified but are likely the result of multiple factors, including birth cohort and period effects, increasing obesity, and greater use of anti-osteoporosis medications. Changing rates of fragility fractures would be expected to have an important impact on the burden of osteoporosis.
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Majumdar SR, Morin SN, Lix LM, Leslie WD. Influence of recency and duration of glucocorticoid use on bone mineral density and risk of fractures: population-based cohort study. Osteoporos Int 2013; 24:2493-8. [PMID: 23572142 DOI: 10.1007/s00198-013-2352-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 02/20/2013] [Indexed: 10/27/2022]
Abstract
UNLABELLED Although systemic glucocorticoids are commonly used, it is difficult to obtain accurate exposure history. In 50,000 patients, we confirmed that glucocorticoids were associated with reductions in bone mineral density (BMD) and increases in fracture and documented that recent and prolonged durations of exposure were particularly associated with adverse events-dose information did not improve risk prediction. INTRODUCTION Systemic glucocorticoid use, defined as ever having taken supra-physiologic doses for 90-days or more, is a risk factor for low BMD and fractures. This definition does not distinguish recent (vs remote) exposure. METHODS Within a population-based clinical BMD registry in Manitoba, Canada, we identified all adults over age 40 years tested between 1998 and 2007 and then undertook a cohort study. We identified all oral glucocorticoid dispensations from 1995 to 2009 and stratified exposure by timing ("recent" if within 12 months vs "remote") and duration (short [<90 days] vs prolonged [≥90 days]). Osteoporosis-related risk factors and treatments and major fractures were obtained using administrative health data. RESULTS A total of 12,818 of 52,070 (25%) subjects had used glucocorticoids prior to BMD testing; the most common exposure was remote short (n = 6453) vs recent prolonged (n = 2896) vs recent short (n = 2644) vs remote prolonged (n = 825). Compared to 39,252 never-users, only recent prolonged glucocorticoid use was significantly associated with femoral neck T-score (ANCOVA-adjusted difference -0.13, 95% CI -0.16 to -0.10, p < 0.001). There were 2,842 major (566 hip) fractures over median 5-year follow-up. Compared with never-users, only recent prolonged glucocorticoid use was significantly associated with BMD-independent increases in risk of incident major fracture (5.4 vs 7.7%, adjusted HR 1.25, 95% CI 1.07-1.45, p = 0.004) and hip fracture (1.1 vs 1.8%, adjusted HR 1.61, 95% CI 1.18-2.20, p = 0.003). CONCLUSIONS Recent and prolonged glucocorticoid use (but neither remote nor recent short courses) was independently associated with reduced BMD and increased risk of fractures. These findings should permit clinicians to identify a high-risk group of patients that might benefit from osteoporosis prevention.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Leslie WD, Lix LM, Finlayson GS, Metge CJ, Morin SN, Majumdar SR. Direct healthcare costs for 5 years post-fracture in Canada: a long-term population-based assessment. Osteoporos Int 2013; 24:1697-705. [PMID: 23340947 DOI: 10.1007/s00198-012-2232-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/23/2012] [Indexed: 11/24/2022]
Abstract
UNLABELLED High direct incremental healthcare costs post-fracture are seen in the first year, but total costs from a third-party healthcare payer perspective eventually fall below pre-fracture levels. We attribute this to higher mortality among fracture cases who are already the heaviest users of healthcare ("healthy survivor bias"). Economic analyses that do not account for the possibility of a long-term reduction in direct healthcare costs in the post-fracture population may systematically overestimate the total economic burden of fracture. INTRODUCTION High healthcare costs in the first 1-2 years after an osteoporotic fracture are well recognized, but long-term costs are uncertain. We evaluated incremental costs of non-traumatic fractures up to 5 years from a third-party healthcare payer perspective. METHODS A total of 16,198 incident fracture cases and 48,594 matched non-fracture controls were identified in the province of Manitoba, Canada (1997-2002). We calculated the difference in median direct healthcare costs for the year pre-fracture and 5 years post-fracture expressed in 2009 Canadian dollars with adjustment for expected age-related healthcare cost increases. RESULTS Incremental median costs for a hip fracture were highest in the first year ($25,306 in women, $21,396 in men), remaining above pre-fracture baseline to 5 years in women but falling below pre-fracture costs by 5 years in men. In those who survived 5 years following a hip fracture, incremental costs remained above pre-fracture costs at 5 years ($12,670 in women, $7,933 in men). Incremental costs were consistently increased for 5 years after spine fracture in women. Total incremental healthcare costs for all incident fractures combined showed a large increase over pre-fracture costs in the first year ($137 million in women, $57 million in men), but fell below pre-fracture costs within 3-4 years. Elevated total healthcare costs were seen at year 5 in women after wrist, humerus and spine fractures, but these were somewhat offset by decreases in total healthcare costs for other fractures. CONCLUSIONS High direct healthcare costs post-fracture are seen in the first year, but total costs eventually fall below pre-fracture levels. Among those who survive 5 years following a fracture, healthcare costs remain above pre-fracture levels.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, Canada.
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Ladhani NN, Majumdar SR, Johnson JA, Tsuyuki RT, Lewanczuk RZ, Spooner R, Simpson SH. Adding pharmacists to primary care teams reduces predicted long-term risk of cardiovascular events in type 2 diabetic patients without established cardiovascular disease: results from a randomized trial. Diabet Med 2012; 29:1433-9. [PMID: 22486226 DOI: 10.1111/j.1464-5491.2012.03673.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine the impact of adding pharmacists to primary care teams on predicted 10-year risk of cardiovascular events in patients with Type 2 diabetes without established cardiovascular disease. METHODS This was a pre-specified secondary analysis of randomized trial data. The main study found that, compared with usual care, addition of a pharmacist resulted in improvements in blood pressure, dyslipidaemia, and hyperglycaemia for primary care patients with Type 2 diabetes. In this sub-study, predicted 10-year risk of cardiovascular events at baseline and 1 year were calculated for patients free of cardiovascular disease at enrolment. The primary outcome was change in UK Prospective Diabetes Study (UKPDS) risk score; change in Framingham risk score was a secondary outcome. RESULTS Baseline characteristics were similar between the 102 intervention patients and 93 control subjects: 59% women, median (interquartile range) age 57 (50-64) years, diabetes duration 3 (1-6.5) years, systolic blood pressure 128 (120-140) mmHg, total cholesterol 4.34 (3.75-5.04) mmol/l and HbA(1c) 54 mmol/mol (48-64 mmol/mol) [7.1% (6.5-8.0%)]. Median baseline UKPDS risk score was 10.2% (6.0-16.7%) for intervention patients and 9.5% (5.8-15.1%) for control subjects (P = 0.80). One-year post-randomization, the median absolute reduction in UKPDS risk score was 1.0% greater for intervention patients compared with control subjects (P = 0.032). Similar changes were seen with the Framingham risk score (median reduction 1.2% greater for intervention patients compared with control subjects, P = 0.048). The two risk scores were highly correlated (rho = 0.83; P < 0.001). CONCLUSION Adding pharmacists to primary care teams for 1 year significantly reduced the predicted 10-year risk of cardiovascular events for patients with Type 2 diabetes without established cardiovascular disease.
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Affiliation(s)
- N N Ladhani
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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Kahlon S, Eurich DT, Padwal RS, Malhotra A, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Obesity and outcomes in patients hospitalized with pneumonia. Clin Microbiol Infect 2012; 19:709-16. [PMID: 22963453 DOI: 10.1111/j.1469-0691.2012.04003.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Studies suggest obesity is paradoxically associated with better outcomes for patients with pneumonia. Therefore, we examined the impact of obesity on short-term mortality in patients hospitalized with pneumonia. For 2 years clinical and radiographic data were prospectively collected on all consecutive adults admitted with pneumonia to six hospitals in Edmonton, Alberta, Canada. We identified 907 patients who also had body mass index (BMI, kg/m(2)) collected and categorized them as underweight (BMI < 18.5), normal (18.5 to <25), overweight (25 to <30) and obese (>30). Overall, 65% were >65 years, 52% were female, and 15% reported recent weight loss. Eighty-four (9%) were underweight, 358 (39%) normal, 228 (25%) overweight, and 237 (26%) obese. Two-thirds had severe pneumonia (63% PSI Class IV/V) and 79 (9%) patients died. In-hospital mortality was greatest among those that were underweight (12 [14%]) compared with normal (36 [10%]), overweight (21 [9%]) or obese (10 [4%], p <0.001 for trend). Compared with those of normal weight, obese patients had significantly lower rates of in-hospital mortality in multivariable logistic regression analyses: adjusted odds ratio (OR), 0.46; 95% CI, 0.22-0.97; p 0.04. However, compared with patients with normal weight, neither underweight (adjusted OR, 1.13; 95% CI, 0.54-2.4; p 0.7) nor overweight (adjusted OR, 0.94; 95% CI, 0.52-1.69; p 0.8) were associated with in-hospital mortality. In conclusion, in patients hospitalized with pneumonia, obesity was independently associated with lower short-term mortality, while neither being underweight nor overweight were. This suggests a protective influence of BMIs > 30 kg/m(2) that requires better mechanistic understanding.
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Affiliation(s)
- S Kahlon
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, AB, Canada
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Morin S, Lix LM, Azimaee M, Metge C, Majumdar SR, Leslie WD. Institutionalization following incident non-traumatic fractures in community-dwelling men and women. Osteoporos Int 2012; 23:2381-6. [PMID: 22008882 DOI: 10.1007/s00198-011-1815-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 09/19/2011] [Indexed: 10/16/2022]
Abstract
UNLABELLED Institutionalization after hip fracture occurs in at least 30% of patients in the year following hospital discharge. We demonstrate that the risk of transfer to a long-term care facility, after adjustment for age and burden of co-morbidity, is also increased following fractures at other osteoporotic sites in men and women. For most fractures, men are at greater risk than women. INTRODUCTION High institutionalization rates have been documented following non-traumatic hip fractures; however, there is lack of knowledge regarding the frequency of transfer to long-term care institutions of patients who sustain such fractures at other anatomical sites. METHODS Using the comprehensive health care databases of the province of Manitoba, Canada, we performed a retrospective matched cohort study of community-dwelling men and women aged 50 years and older who sustained an incident non-traumatic fracture between April 1, 1986, and March 31, 2006. Using Cox proportional hazards regression analysis, we estimated the sex-specific relative risk of transfers to long-term care institutions in the year following fracture at osteoporotic sites. RESULTS We identified a total of 70,264 individuals with incident fractures (70.0% in women) among whom 3,996 new admissions to long-term care institutions were documented in the year following the index fracture. New admissions increased over time (p < 0.0001 for temporal trends). The age- and co-morbidity-adjusted hazard ratio (HR) of institutionalization following a hip fracture was 4.89 (95% confidence interval [CI], 4.19 to 5.69) in men, and this risk was consistently at least twice that of controls for all other fracture sites (all p < 0.0001). In women, the relative risks were highest subsequent to a hip (HR, 2.79; 95% CI, 2.56 to 3.04) or vertebral fracture (HR, 2.18; 95% CI, 1.82 to 2.62). CONCLUSIONS Non-traumatic fractures at any site have serious consequences, including institutionalization. Men are at greater risk of transfer to long-term care following fracture than women.
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Affiliation(s)
- S Morin
- Division of General Internal Medicine, McGill University Health Center (MUHC), 1650 Cedar Ave., Montreal, QC, Canada.
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Majumdar SR, Lix LM, Yogendran M, Morin SN, Metge CJ, Leslie WD. Population-based trends in osteoporosis management after new initiations of long-term systemic glucocorticoids (1998-2008). J Clin Endocrinol Metab 2012; 97:1236-42. [PMID: 22298803 DOI: 10.1210/jc.2011-2645] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Our objective was to describe changes in glucocorticoid-induced osteoporosis (GIOP) preventive care from 1998-2008 including rates and correlates of bone mineral density (BMD) testing and osteoporosis treatment in new long-term glucocorticoid initiations. METHODS A population-based study of adults aged 20 yr or older in Manitoba, Canada, was conducted using linked healthcare databases. Subjects with new long-term (≥90 d) systemic glucocorticoid initiations were identified within each fiscal year. High-quality GIOP preventive care was defined by the composite of BMD testing or osteoporosis treatment within 6 months of starting glucocorticoids. For each initiation, we identified sociodemographic and clinical characteristics, prednisone dose equivalents, and prescriber specialty. Multivariable Poisson regression models were used to calculate adjusted incidence rate ratios (aIRR). RESULTS We studied 17,736 new long-term glucocorticoid initiations; one third were at least 10 mg prednisone daily, and most (64%) were prescribed by general practitioners. Overall, 6-month rates of BMD testing were 6%, osteoporosis treatment 22%, and the composite of testing or treatment 25%. From 1998-2008, there were modest increases in BMD testing (from 4 to 6%), osteoporosis treatment (from 15 to 24%), and testing or treatment [from 17 to 27%; aIRR = 1.51; 95% confidence interval (CI) = 1.40-1.63]. High-quality GIOP preventive care varied significantly by age (16% for those <50 yr vs. 27% for those ≥70 yr; aIRR = 0.57; 95% CI = 0.52-0.63), sex (13% for men vs. 34% for women; aIRR = 0.40; 95% CI = 0.37-0.43), and prescriber (23% general practice vs. 44% rheumatology; aIRR = 0.56; 95% CI = 0.52-0.60). CONCLUSIONS Quality of GIOP preventive care has improved but remains suboptimal with only one quarter of those starting long-term glucocorticoids receiving BMD testing or osteoporosis treatment. Interventions to improve GIOP prevention, especially targeting younger patients, men, and nonspecialists, are needed.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, 2F1.24 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta, Canada T6G 2B7.
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Beaupre LA, Majumdar SR, Dieleman S, Au A, Morrish DW. Diagnosis and treatment of osteoporosis before and after admission to long-term care institutions. Osteoporos Int 2012; 23:573-80. [PMID: 21380637 DOI: 10.1007/s00198-011-1582-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 02/01/2011] [Indexed: 01/13/2023]
Abstract
SUMMARY Bisphosphonate treatment rates were examined before and after admission to long-term residential care. Bisphosphonate treatment rates were low (16%) pre-admission but doubled after long-term residential care admission (30%). Men were very undertreated for osteoporosis, while a history of falls with injury was not associated with treatment. INTRODUCTION To determine the rates and independent correlates of bisphosphonate treatment in elderly residents before and after admission to long-term care (LTC) institutions. METHODS Information was collected from records of 421 residents of four LTC institutions in Edmonton, Alberta, Canada. Osteoporosis-related diagnoses, treatments, and risk factors including falls in LTC and any adulthood fractures were abstracted. Osteoporosis was defined by physician diagnosis or documented fractures of the hip, spine, or upper extremity. Multivariable analyses were undertaken to determine factors independently associated with bisphosphonate treatment. RESULTS Mean age was 84 ± 8 years and 290 (70%) were female. Overall, 142 (34%) had previous fractures, 170 (41%) had physician-diagnosed osteoporosis, and 227 (54%) residents met the study's clinical definition of osteoporosis. Of those with osteoporosis, 44 (19%) were men. Before admission, 36 (16%) patients with osteoporosis were treated with bisphosphonates; after admission another 31 (14%) were started on bisphosphonates by LTC physicians. Women were far more likely than men to start bisphosphonate treatment [30 (97%) women vs. 1 (3%) man, adjusted odds ratio (aOR) = 9.20 (95% confidence intervals 1.2,70.5)]. Falls with injury were common [72/227 (31%)] but not associated with bisphosphonate treatment (adjusted p value > 0.5). CONCLUSION Rates of pre-admission bisphosphonate treatment were low, but did double after LTC admission. Women were almost ten times more likely to start bisphosphonate treatment than men, although one fifth of those with documented osteoporosis were men. Although falls cause most fractures, a history of falls with injury was not associated with bisphosphonate treatment. Our findings suggest that targeting men and residents with falls for treatment with bisphosphonates might be warranted.
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Affiliation(s)
- L A Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada.
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Jaglal SB, Donescu OS, Bansod V, Laprade J, Thorpe K, Hawker G, Majumdar SR, Meadows L, Cadarette SM, Papaioannou A, Kloseck M, Beaton D, Bogoch E, Zwarenstein M. Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial. Osteoporos Int 2012; 23:87-95. [PMID: 21779817 PMCID: PMC3249212 DOI: 10.1007/s00198-011-1726-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 06/01/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management. INTRODUCTION To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control). METHODS A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications. RESULTS Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0). CONCLUSIONS A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.
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Affiliation(s)
- S B Jaglal
- Toronto Rehabilitation Institute, Toronto, ON, Canada.
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Leslie WD, Majumdar SR, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA. High fracture probability with FRAX usually indicates densitometric osteoporosis: implications for clinical practice. Osteoporos Int 2012; 23:391-7. [PMID: 21365460 DOI: 10.1007/s00198-011-1592-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 02/07/2011] [Indexed: 01/14/2023]
Abstract
UNLABELLED Most patients designated as high risk of fracture using fracture risk assessment tool (FRAX) with femoral neck bone mineral density (BMD) (i.e., 10-year major osteoporotic fracture probability exceeding 20% or hip fracture exceeding 3%) have one or more T-scores in the osteoporotic range; conversely, almost no high risk patients have normal T-scores at all bone mineral density measurement sites. INTRODUCTION We determined the agreement between a FRAX designation of high risk of fracture [defined as 10-year major osteoporotic fracture probability (≥ 20%) or hip fracture probability (≥ 3%)] and the WHO categorizations of bone mineral density according to T-score. METHODS Ten-year FRAX probabilities calculated with femoral neck BMD were derived using both Canadian and US white tools for a large clinical cohort of 36,730 women and 2,873 men age 50 years and older from Manitoba, Canada. Individuals were classified according to FRAX fracture probability and BMD T-scores alone. RESULTS Most individuals designated by FRAX as high risk of major osteoporotic fracture had a T-score in the osteoporotic range at one or more BMD measurement sites (85% with Canadian tool and 83% with US white tool). The majority of individuals deemed at high risk of hip fracture had one or more T-scores in the osteoporotic range (66% with Canadian tool and 64% with US white tool). Conversely, there were extremely few individuals (<1%) who were at high risk of major osteoporotic or hip fracture with normal T-scores at all BMD measurement sites. CONCLUSIONS A FRAX designation of high risk of fracture is usually associated with a densitometric diagnosis of osteoporosis.
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Affiliation(s)
- W D Leslie
- University of Manitoba, Winnipeg, Canada.
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Majumdar SR. A T-2 translational research perspective on interventions to improve post-fracture osteoporosis care. Osteoporos Int 2011; 22 Suppl 3:471-6. [PMID: 21847768 DOI: 10.1007/s00198-011-1700-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 06/17/2011] [Indexed: 11/25/2022]
Abstract
The objectives of this paper are to: quickly outline the extent of the care gap in osteoporosis; define T-2 (knowledge) translation and its relationship to quality improvement; discuss the barriers to best practice in osteoporosis care after a fracture; convey the importance of rigor in design and evaluation of translational interventions by drawing upon examples from the broader literature; describe in some detail a series of post-fracture intervention trials conducted in Alberta, Canada; and make some conclusions specifically about osteoporosis interventions and more generally about T-2 translational research.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, 2F1.24 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta, T6G 2B7, Canada.
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Adler RA, Bates DW, Dell RM, LeBoff MS, Majumdar SR, Saag KG, Solomon DH, Suarez-Almazor ME. Systems-based approaches to osteoporosis and fracture care: policy and research recommendations from the workgroups. Osteoporos Int 2011; 22 Suppl 3:495-500. [PMID: 21847772 DOI: 10.1007/s00198-011-1708-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/22/2011] [Indexed: 10/17/2022]
Abstract
Participants in the conference selected to attend two different working group sessions. The working groups discussed different perspectives of system-based approaches to osteoporosis and fracture care. The group on postfracture case management recommended that nurse case managers be used to improve communication among patients, orthopaedic surgeons, and those providing ongoing clinical care. The hospital working group discussed the impact of and barriers to improved postfracture management in the hospital setting. The health systems group emphasized the difference between a closed system in which long-term benefits of interventions were more likely to be appreciated than in fee for service systems. The health information technology group discussed the advantages and challenges of electronic health records. The working group on consumer and provider education discussed interventions for both primary and secondary prevention of fractures. Recommendations were produced by most groups for improving postfracture care.
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Affiliation(s)
- R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
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Majumdar SR, Lier DA, Rowe BH, Russell AS, McAlister FA, Maksymowych WP, Hanley DA, Morrish DW, Johnson JA. Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture. Osteoporos Int 2011; 22:1799-808. [PMID: 20878389 DOI: 10.1007/s00198-010-1412-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/18/2010] [Indexed: 12/17/2022]
Abstract
UNLABELLED In a randomized trial, a multifaceted intervention tripled rates of osteoporosis treatment in older patients with wrist fracture. An economic analysis of the trial now demonstrates that the intervention tested "dominates" usual care: over a lifetime horizon, it reduces fracture, increases quality-adjusted life years, and saves the healthcare system money. INTRODUCTION In a randomized trial (N = 272), we reported a multifaceted quality improvement intervention directed at older patients and their physicians could triple rates of osteoporosis treatment within 6 months of a wrist fracture when compared with usual care (22% vs 7%). Alongside the trial, we conducted an economic evaluation. METHODS Using 1-year outcome data from our trial and micro-costing time-motion studies, we constructed a Markov decision-analytic model to determine cost-effectiveness of the intervention compared with usual care over the patients' remaining lifetime. We took the perspective of third-party healthcare payers. In the base case, costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars. One-way deterministic and probabilistic sensitivity analyses were conducted. RESULTS Median age of patients was 60 years, 77% were women, and 72% had low bone mineral density (BMD). The intervention cost $12 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients receiving the intervention, three fractures (one hip fracture) would be prevented, 1.1 quality-adjusted life year gained, and $26,800 saved by the healthcare system over their remaining lifetime. The intervention dominated usual care across numerous one-way sensitivity analyses: with respect to cost, the most influential parameter was drug price; in terms of effectiveness, the most influential parameter was rate of BMD testing. The intervention was cost saving in 80% of probabilistic model simulations. CONCLUSIONS For outpatients with wrist fractures, our multifaceted osteoporosis intervention was cost-effective. Healthcare systems implementing similar interventions should expect to save money, reduce fractures, and gain quality-adjusted life expectancy.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Beaupre LA, Morrish DW, Hanley DA, Maksymowych WP, Bell NR, Juby AG, Majumdar SR. Oral bisphosphonates are associated with reduced mortality after hip fracture. Osteoporos Int 2011; 22:983-91. [PMID: 21052642 DOI: 10.1007/s00198-010-1411-2] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 09/01/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED Intravenous bisphosphonates reduce mortality following hip fracture. We determined whether new use of oral bisphosphonates was also associated with reductions in mortality in 209 hip fracture patients. Oral bisphosphonate exposure led to relative reduction of 8% per month of use (p = 0.001) or about a 60% reduction in mortality per year of use. INTRODUCTION Intravenous bisphosphonates reduce mortality following hip fracture. Using prospectively collected long-term data from a randomized trial of osteoporosis quality improvement for hip fracture, we determined whether new use of oral bisphosphonates was associated with reductions in mortality or the composite outcome of death or new fracture. METHODS Originally, 220 hip fracture patients were randomized to case manager (n = 110) or usual care followed by facilitated bone mineral density (BMD) testing (n = 110) interventions. All were eligible for bisphosphonate treatment. Post-randomization, we followed patients for 3 years and ascertained bisphosphonate treatment, medication adherence and persistence, all-cause mortality, and new clinical fractures. Proportional hazards analyses with time-varying treatment status were undertaken. RESULTS The final study cohort included 209 patients: 136 (65%) females, 104 (50%) older than 75 years, 90 (43%) with poor self-reported health, and 38 (18%) underweight. Of these, 76 (36%) had a previous fracture before hip fracture and 132 (81%) had low BMD. A total of 101 (46%) patients started oral bisphosphonates and 65 (64%) remained on treatment at the final evaluation. Overall, 24 (11%) patients died, 19 (9%) had new fractures, and 42 (20%) reached the composite outcome of death or fracture. Compared to no treatment, bisphosphonate exposure was independently associated with reduced mortality (17[16%] vs. 7[7%]; adjusted hazard ratio (aHR) = 0.92 per month treated; 95%CI, 0.88-0.97) and composite endpoints (28[26%] vs. 5[15%]; aHR = 0.94 per month treated; 95%CI, 0.91-0.97). CONCLUSION Like intravenous bisphosphonates after hip fracture, our study suggests that oral bisphosphonates may be associated with reductions in all-cause mortality.
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Affiliation(s)
- L A Beaupre
- Department of Physical Therapy, University of Alberta, 1F1.52 WMC, 8440 112 ST, Edmonton, AB T6G2B7, Canada.
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Majumdar SR, Johnson JA, Bellerose D, McAlister FA, Russell AS, Hanley DA, Garg S, Lier DA, Maksymowych WP, Morrish DW, Rowe BH. Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study. Osteoporos Int 2011; 22:223-30. [PMID: 20358359 DOI: 10.1007/s00198-010-1212-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 02/03/2010] [Indexed: 11/24/2022]
Abstract
UNLABELLED Few outpatients with fractures are treated for osteoporosis in the years following fracture. In a randomized pilot study, we found a nurse case-manager could double rates of osteoporosis testing and treatment compared with a proven efficacious quality improvement strategy directed at patients and physicians (57% vs 28% rates of appropriate care). INTRODUCTION Few patients with fractures are treated for osteoporosis. An intervention directed at wrist fracture patients (education) and physicians (guidelines, reminders) tripled osteoporosis treatment rates compared to controls (22% vs 7% within 6 months of fracture). More effective strategies are needed. METHODS We undertook a pilot study that compared a nurse case-manager to the multifaceted intervention using a randomized trial design. The case-manager counseled patients, arranged bone mineral density (BMD) tests, and prescribed treatments. We included controls from our first trial who remained untreated for osteoporosis 1-year post-fracture. Primary outcome was bisphosphonate treatment and secondary outcomes were BMD testing, appropriate care (BMD test-treatment if bone mass low), and costs. RESULTS Forty six patients untreated 1-year after wrist fracture were randomized to case-manager (n = 21) or multifaceted intervention (n = 25). Median age was 60 years and 68% were female. Six months post-randomization, 9 (43%) case-managed patients were treated with bisphosphonates compared with 3 (12%) multifaceted intervention patients (relative risk [RR] 3.6, 95% confidence intervals [CI] 1.1-11.5, p = 0.019). Case-managed patients were more likely than multifaceted intervention patients to undergo BMD tests (81% vs 52%, RR 1.6, 95%CI 1.1-2.4, p = 0.042) and receive appropriate care (57% vs 28%, RR 2.0, 95%CI 1.0-4.2, p = 0.048). Case-management cost was $44 (CDN) per patient vs $12 for the multifaceted intervention. CONCLUSIONS A nurse case-manager substantially increased rates of appropriate testing and treatment for osteoporosis in patients at high-risk of future fracture when compared with a multifaceted quality improvement intervention aimed at patients and physicians. Even with case-management, nearly half of patients did not receive appropriate care. TRIAL REGISTRY clinicaltrials.gov identifier: NCT00152321.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, 8440-112th Street, Edmonton, Alberta, T6G 2B7, Canada.
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Majumdar SR. Waiting for evidence? CMAJ 2010; 182:700. [DOI: 10.1503/cmaj.110-2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Eurich DT, Gamble JM, Marrie TJ, Majumdar SR. Dysglycaemia and 90 day and 1 year risks of death or readmission in patients hospitalised for community-acquired pneumonia. Diabetologia 2010; 53:497-503. [PMID: 19936702 DOI: 10.1007/s00125-009-1598-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 10/08/2009] [Indexed: 10/20/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to investigate whether dysglycaemia at admission is associated with adverse events at 90 days or 1 year in a population-based cohort of patients hospitalised with community-acquired pneumonia (CAP). METHODS Clinical and laboratory data were prospectively collected on all 2,366 adults without diabetes admitted with CAP to six hospitals in Edmonton (AB, Canada) and grouped according to admission glucose: 4.0 to <6.1 mmol/l(n=778, reference group), 6.1 to <7.8 mmol/l (n=924); 7.8 to<11.1 mmol/l (n=535); and 11.1 to 20 mmol/l (n=129). Multivariable Cox models were used to examine the relationship between dysglycaemia and mortality or CAP readmission during follow-up. RESULTS The mean age was 69 (SD 18) years and 48% of participants were female. Compared with those with glucose <6.1 mmol/l (114 [15%] deaths), no differences in 90 day mortality were observed in the dysglycaemia groups: 143 deaths (15%) in the 6.1-7.8 mmol/l group (adjusted HR [aHR] 0.92, 95% CI 0.72-1.18), 111 deaths (21%) in the 7.8-11.1 mmol/l group (aHR 1.05, 0.81-1.37)and 34 deaths (26%) in the 11.1-20 mmol/l group (aHR 1.30, 0.88-1.93). Similarly, compared with those in the <6.1 mmol/l group (198 [25%] deaths), no difference in 1 year mortality was observed: 233 deaths (25%) in the 6.1 to <7.8 mmol/l group (aHR 0.86, 0.71-1.04), 164 deaths (31%) in the 7.8 to <11.1 mmol/l group (aHR 0.92, 0.75-1.14) and 49 deaths (38%) in the 11.1 to 20 mmol/l group (aHR 1.12, 0.81-1.55). Readmissions for CAP were also similar at 1 year: compared with 10% (70/707) in the 6.1 mmol/l group, the frequencies were 8% (66/842), 9% (45/474) and 10% (11/107) in the 6.1 to <7.8 mmol/l, 7.8 to <11.1 mmol/l, and 11.1 to 20 mmol/l groups, respectively (p>0.05 for all comparisons). CONCLUSIONS/INTERPRETATION Although previously associated with inpatient morbidity and mortality, admission dysglycaemia was not associated with an increased risk of death or CAP readmission at 90 days or 1 year among those who survived hospitalisation for pneumonia.
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Affiliation(s)
- D T Eurich
- Department of Public Health Sciences, School of Public Health, University of Alberta, 13-103 Clinical Sciences Bldg, Edmonton T6G 2G3 AB, Canada.
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Yuksel N, Majumdar SR, Biggs C, Tsuyuki RT. Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial. Osteoporos Int 2010; 21:391-8. [PMID: 19499272 DOI: 10.1007/s00198-009-0977-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 04/23/2009] [Indexed: 10/20/2022]
Abstract
SUMMARY This study evaluated the effect of a multifaceted intervention (screening and patient education) by community pharmacists on testing or treatment of osteoporosis. One hundred and twenty-nine patients randomized to receive the intervention were compared to 133 patients who did not receive the intervention. Twice as many patients who got the intervention received further testing or treatment for osteoporosis. INTRODUCTION The objective of this study was to determine the effect of a community pharmacist screening program on testing and treatment of osteoporosis. METHODS In this randomized, controlled trial, 262 patients meeting bone mineral density (BMD) testing guidelines [men or women aged > or = 65 years or 50-64 years with one major risk factor including previous fracture, family history of osteoporosis, glucocorticoids for > 3 months, or early menopause] were allocated to intervention (129) or control (133). Intervention consisted of printed materials, education, and quantitative ultrasound. Primary outcome was a composite endpoint of BMD or prescription for osteoporosis medication within 4 months. RESULTS Primary endpoint of BMD or osteoporosis treatment was achieved by 28 intervention patients (22%) compared with 14 controls (11%) (RR 2.1, 95% CI 1.1-3.7). This was driven by BMD testing (28 (22%) vs. 13 (10%) for controls, p = 0.011). Calcium intake increased more among intervention patients than controls (30% vs. 19%, RR 1.6, 95% CI 1.0-2.5). There was no effect on knowledge or quality of life. CONCLUSION A pharmacist screening program doubled the number of patients tested for osteoporosis. Nevertheless, many patients eligible for BMD did not receive appropriate care suggesting more intensive interventions are needed.
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Affiliation(s)
- N Yuksel
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3126 Dentistry/Pharmacy Centre, Edmonton, AB, T6G 2N8, Canada.
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Abstract
AIM To compare population-based rates of all-cause and cardiovascular (CV) mortality in newly treated patients with type 2 diabetes according to levels of insulin exposure. METHODS Using the administrative databases of Saskatchewan Health, 12272 new users of oral antidiabetic therapy were identified between 1991 and 1996 and grouped according to cumulative insulin exposure based on total insulin dispensations per year: no exposure (reference group); low exposure (0 to <3); moderate exposure (3 to <12) and high exposure (> or =12). Time-varying multivariable Cox proportional hazards models were used to examine the relationship between insulin exposure and all-cause, CV-related and non-vascular mortality after adjustment for demographics, medications and comorbidities. RESULTS Average age was 65 (s.d. 13.9) years, 45% were female, and mean follow-up was 5.1 (s.d. 2.2) years. In total, 1443 (12%) subjects started insulin, and 2681 (22%) deaths occurred. The highest mortality rates were in the high exposure group; 95 deaths/1000 person-years compared with 40 deaths/1000 person-years in the no exposure group [unadjusted hazard ratio (HR): 2.32; 95% confidence interval (CI): 1.96-2.73]. After adjustment, we observed a graded risk of mortality associated with increasing exposure to insulin: low exposure [adjusted HR (aHR): 1.75; 95% CI: 1.24-2.47], moderate exposure (aHR: 2.18; 1.82-2.60) and high exposure (aHR: 2.79; 2.36-3.30); p = 0.005 for trend. Analyses restricted to CV-related (p = 0.042 for trend) and non-vascular (p = 0.004 for trend) mortality showed virtually identical results. CONCLUSIONS We observed a significant and graded association between mortality risk and insulin exposure level in an inception cohort of patients with type 2 diabetes that persisted despite multivariable adjustment.
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Affiliation(s)
- J-M Gamble
- Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Ciaschini PM, Straus SE, Dolovich LR, Goeree RA, Leung KM, Woods CR, Zimmerman GM, Majumdar SR, Spadafora S, Fera LA, Lee HN. Community-based intervention to optimise falls risk management: a randomised controlled trial. Age Ageing 2009; 38:724-30. [PMID: 19767629 DOI: 10.1093/ageing/afp176] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND falls are the leading causes of accidental death and fragility fractures in older adults. Interventions that assess and reduce falls risk are underutilised. OBJECTIVE to evaluate the impact of a multifaceted community-based programme aimed at optimising evidence-based management of patients at risk for fall-related fractures. DESIGN this was a randomised trial performed from 2003 to 2006. SETTING community-based intervention in Ontario, Canada. PARTICIPANTS eligible patients were community-dwelling, aged > or =55 years and identified to be at risk for fall-related fractures. A total of 201 patients were allocated to the intervention group or to usual care. INTERVENTION components of the intervention included assessment of falls risk, functional status and home environment, and patient education. MEASUREMENTS primary outcome was the implementation of appropriate falls risk assessment at 6 months. Secondary outcomes included falls and fractures at 6 and 12 months. RESULTS the mean age of participants was 72 years, and 41% had fallen with injury in the previous year. Compared to usual care, the intervention increased the number of referrals made to physiotherapy [21% (21/101) vs 6.0% (6/100); relative risk (RR) 3.47, 95% confidence interval (CI) 1.46-8.22] and occupational therapy [15% (15/101) vs 0%; RR 30.7, 95% CI 1.86 to >500]. At 12 months, the number of falls in the intervention group was greater than in the usual care group [23% (23/101) vs 11% (11/100); RR 2.07, 95% CI 1.07-4.02]. CONCLUSIONS compared to usual care, a multi-faceted intervention increased referrals to physiotherapy and occupational therapy but did not reduce risk of falls. Similar falls reduction interventions cannot be recommended based on the results of this study.
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Affiliation(s)
- P M Ciaschini
- Algoma District Medical Group, Sault Ste. Marie, Canada
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Ciaschini PM, Straus SE, Dolovich LR, Goeree RA, Leung KM, Woods CR, Zimmerman GM, Majumdar SR, Spadafora S, Fera LA, Lee HN. Community-based randomised controlled trial evaluating falls and osteoporosis risk management strategies. Trials 2008; 9:62. [PMID: 18983670 PMCID: PMC2612651 DOI: 10.1186/1745-6215-9-62] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 11/04/2008] [Indexed: 01/06/2023] Open
Abstract
Background Osteoporosis-related fractures are a significant public health concern. Interventions that increase detection and treatment of osteoporosis, as well as prevention of fractures and falls, are substantially underutilized. This paper outlines the protocol for a pragmatic randomised trial of a multifaceted community-based care program aimed at optimizing the evidence-based management of falls and fractures in patients at risk. Design 6-month randomised controlled study. Methods This population-based study was completed in the Algoma District of Ontario, Canada a geographically vast area with Sault Ste Marie (population 78 000) as its main city. Eligible patients were allocated to an immediate intervention protocol (IP) group, or a delayed intervention protocol (DP) group. The DP group received usual care for 6 months and then was crossed over to receive the interventions. Components of the intervention were directed at the physicians and their patients and included patient-specific recommendations for osteoporosis therapy as outlined by the clinical practice guidelines developed by Osteoporosis Canada, and falls risk assessment and treatment. Two primary outcomes were measured including implementation of appropriate osteoporosis and falls risk management. Secondary outcomes included quality of life and the number of falls, fractures, and hospital admissions over a twelve-month period. The patient is the unit of allocation and analysis. Analyses will be performed on an intention to treat basis. Discussion This paper outlines the protocol for a pragmatic randomised trial of a multi-faceted, community-based intervention to optimize the implementation of evidence based management for patients at risk for falls and osteoporosis. Trial Registration This trial has been registered with clinicaltrials.gov (ID: NCT00465387)
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Affiliation(s)
- P M Ciaschini
- Algoma District Medical Group, Sault Ste. Marie, Canada.
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Johnstone J, Majumdar SR, Fox JD, Marrie TJ. Human Metapneumovirus Pneumonia in Adults: Results of a Prospective Study. Clin Infect Dis 2008; 46:571-4. [DOI: 10.1086/526776] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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McAlister FA, Majumdar SR, Eurich DT, Johnson JA. The effect of specialist care within the first year on subsequent outcomes in 24,232 adults with new-onset diabetes mellitus: population-based cohort study. Qual Saf Health Care 2007; 16:6-11. [PMID: 17301194 PMCID: PMC2464930 DOI: 10.1136/qshc.2006.018648] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although specialty care has been shown to improve short-term outcomes in patients hospitalised with acute medical conditions, its effect on patients with chronic conditions treated in the ambulatory care setting is less clear. OBJECTIVE To examine whether specialty care (ie, consultative care provided by an endocrinologist or a general internist in concert with a patient's primary care doctor) within the first year of diagnosis is associated with improved outcomes after the first year for adults with diabetes mellitus treated as outpatients. DESIGN Population-based cohort study using linked administrative data. SETTING The province of Saskatchewan, Canada. SAMPLE 24 232 adults newly diagnosed with diabetes mellitus between 1991 and 2001. METHOD The primary outcome was all-cause mortality. Analyses used multivariate Cox proportional hazards models with time-dependent covariates, propensity scores and case mix variables (demographic, disease severity and comorbidities). In addition, restriction analyses examined the effect of specialist care in low-risk subgroups. RESULTS The median age of patients was 61 years, and over a mean follow-up of 4.9 years 2932 (12%) died. Patients receiving specialty care were younger, had a greater burden of comorbidities, and visited doctors more often before and after their diabetes diagnosis (all p< or =0.001). Compared with patients seen by primary care doctors alone, patients seen by specialists and primary care doctors were more likely to receive recommended treatments (all p< or =0.001), but were more likely to die (13.1% v 11.7%, adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.08 to 1.27). This association persisted even in patients without comorbidities or target organ damage (adjusted HR 1.16, 95% CI 1.01 to 1.34). CONCLUSION Specialty care was associated with better disease-specific process measures but not improved survival in adults with diabetes cared for in ambulatory care settings.
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Affiliation(s)
- F A McAlister
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Majumdar SR, Johnson JA, Lier DA, Russell AS, Hanley DA, Blitz S, Steiner IP, Maksymowych WP, Morrish DW, Holroyd BR, Rowe BH. Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial. Osteoporos Int 2007; 18:261-70. [PMID: 17086470 DOI: 10.1007/s00198-006-0248-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 10/02/2006] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention. METHODS We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon. RESULTS Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained. CONCLUSIONS A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.
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Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Jaremko JL, Lambert RGW, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol 2007; 62:65-72. [PMID: 17145266 DOI: 10.1016/j.crad.2006.08.013] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 08/08/2006] [Accepted: 08/15/2006] [Indexed: 12/28/2022]
Abstract
AIM To investigate whether radiographic deformities suggesting inadequate reduction would be associated with adverse clinical outcomes. MATERIALS AND METHODS Consecutive patients over 50 years of age (n=74) with non-operatively managed distal radius fractures were enrolled in a prospective cohort study. They had radiographs at cast removal ( approximately 6 weeks) and completed DASH (Disabilities of the Arm, Shoulder and Hand), SF-12 (health-related quality of life), and satisfaction surveys 6-months post-fracture. A reference-standard musculoskeletal radiologist, blinded to outcomes status, measured palmar (dorsal) tilt, radial angle, radial height, ulnar height, and intra-articular step and gap. Radiographic indices were correlated to each other and to the various patient-reported outcomes in univariate and multivariate regression analyses. DASH score was the primary study outcome. RESULTS Of the cohort studied (n=74, mean age 68.5 years, primarily white women), 71% had at least one "unacceptable" radiographic deformity by traditional criteria. Acceptable reduction varied from 60-99% depending on which single index was reported, and 44% of patients had more than two indices reported as unacceptable. Despite these radiographic findings, 6-months post-reduction, self-reported disability was low (DASH=24+/-17), health-related quality of life was near normal, and 72% were satisfied with their care. No radiographic index of wrist deformity (alone or in combination) was significantly correlated to any of the patient-reported outcomes. CONCLUSION Self-reported outcomes in older adults with conservatively managed wrist fractures were not related to the "acceptability" of radiographic fracture reduction. The proportion of acceptable reductions varied by 40% depending on which index was reported. Consequently, detailed reporting of these indices in older adults with distal radius fracture may be inefficient or perhaps even unnecessary.
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Affiliation(s)
- J L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
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Abstract
AIM Self-monitoring of blood glucose is often considered a cornerstone of self-care for patients with diabetes. We assessed whether provision of free testing strips would improve glycaemic control in non-insulin-treated Type 2 diabetic patients. METHODS Adults with Type 2 diabetes, excluding those with private insurance or using insulin, were recruited through community pharmacies and randomized to receive free testing strips for 6 months or not; all patients received similar baseline education and a glucose meter. Primary outcome was change in HbA(1c) over 6 months. RESULTS We randomized 262 patients (131 intervention and 131 control subjects). Mean age was 68.4 years (sd 10.9), 48% were male, mean duration of diabetes was 8.2 years (sd 7.2), 97% used oral glucose-lowering agents and mean baseline HbA(1c) was 7.4% (sd 1.2). After 6 months, we observed no difference in HbA(1c) between intervention and control patients, after adjusting for baseline HbA(1c)[adjusted difference 0.03, 95% confidence interval (CI) -0.16, 0.22; P = 0.78]. A per protocol analysis of study completers (152/262; 60%) yielded similar results. Intervention patients reported testing 0.64 days per week more often than control subjects (95% CI 0.18, 1.10; P = 0.007), although testing was not associated with better glycaemic control (Pearson r = -0.10, P = 0.12). CONCLUSIONS Reducing financial barriers by providing free testing strips did not improve glycaemic control in patients with Type 2 diabetes not using insulin. Our results question the value of policies that reduce financial barriers to testing supplies in this population.
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Affiliation(s)
- J A Johnson
- Department of Public Health Sciences, University of Alberta, Alberta, Canada.
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Johnson JA, Simpson SH, Eurich DT, Majumdar SR. Comment on: Evans JM, Ogston SA, Emslie-Smith A, Morris A (2006) risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin. Diabetologia 49:930-936. Diabetologia 2006; 49:2805-6. [PMID: 16788800 DOI: 10.1007/s00125-006-0323-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 04/19/2006] [Indexed: 11/28/2022]
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Affiliation(s)
- S Kwong
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, T6G 2B7
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