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Sprague BL, Kerlikowske K, Bowles EJA, Rauscher GH, Lee CI, Tosteson ANA, Miglioretti DL. Trends in Clinical Breast Density Assessment From the Breast Cancer Surveillance Consortium. J Natl Cancer Inst 2019; 111:629-632. [PMID: 30624682 PMCID: PMC6579740 DOI: 10.1093/jnci/djy210] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/19/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
Changes to mammography practice, including revised Breast Imaging Reporting and Data System (BI-RADS) density classification guidelines and implementation of digital breast tomosynthesis (DBT), may impact clinical breast density assessment. We investigated temporal trends in clinical breast density assessment among 2 990 291 digital mammography (DM) screens and 221 063 DBT screens interpreted by 722 radiologists from 144 facilities in the Breast Cancer Surveillance Consortium. After age-standardization, 46.3% (95% CI = 44.1% to 48.6%) of DM screens were assessed as dense (heterogeneously/extremely dense) during the BI-RADS 4th edition era (2005-2013), compared to 46.5% (95% CI = 43.8% to 49.1%) during the 5th edition era (2014-2016) (P = .93 from two-sided generalized score test). Among DBT screens in the BI-RADS 5th edition era, 45.8% (95% CI = 42.0% to 49.7%) were assessed as dense (P = .77 from two-sided generalized score test) compared to 46.5% (95% CI = 43.8% to 49.1%) dense on DM in BI-RADS 5th edition era. Results were similar when examining all four density categories and age subgroups. Clinicians, researchers, and policymakers may reasonably expect stable density distributions across screened populations despite changes to the BI-RADS guidelines and implementation of DBT.
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Affiliation(s)
- B L Sprague
- Departments of Surgery and Radiology, University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - K Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics and General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA
| | - E J A Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, DLM
| | - G H Rauscher
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - C I Lee
- Department of Radiology, University of Washington School of Medicine, and the Hutchinson Institute for Cancer Outcomes Research, Seattle, WA
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - D L Miglioretti
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA
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Hiligsmann M, Reginster JY, Tosteson ANA, Bukata SV, Saag KG, Gold DT, Halbout P, Jiwa F, Lewiecki EM, Pinto D, Adachi JD, Al-Daghri N, Bruyère O, Chandran M, Cooper C, Harvey NC, Einhorn TA, Kanis JA, Kendler DL, Messina OD, Rizzoli R, Si L, Silverman S. Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation. Osteoporos Int 2019; 30:45-57. [PMID: 30382319 PMCID: PMC6331734 DOI: 10.1007/s00198-018-4744-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023]
Abstract
Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards. INTRODUCTION This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards. METHODS A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted. RESULTS Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed. CONCLUSION While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.
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Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - S V Bukata
- UCLA Orthopaedic Center, Santa Monica, CA, USA
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D T Gold
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F Jiwa
- Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - D Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, USA
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- UKNIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - T A Einhorn
- New York University Langone Health, New York, USA
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - D L Kendler
- University of British Columbia, Vancouver, Canada
| | - O D Messina
- Cosme Argerich Hospital and IRO medical research centre, Buenos Aires, Argentina
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - L Si
- The George Institute for Global Health, University of New South Wales, Kensington, NH, Australia
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - S Silverman
- Cedars-Sinai Medical Center, UCLA School of Medicine and the OMC Clinical Research Center, Los Angeles, CA, USA
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Munson JC, Bynum JPW, Bell JE, McDonough C, Wang Q, Tosteson T, Tosteson ANA. Impact of prescription drugs on second fragility fractures among US Medicare patients. Osteoporos Int 2018; 29:2771-2779. [PMID: 30232537 PMCID: PMC6277051 DOI: 10.1007/s00198-018-4697-0] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/03/2018] [Indexed: 12/21/2022]
Abstract
UNLABELLED Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture. INTRODUCTION Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. METHODS We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. RESULTS Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). CONCLUSION Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.
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Affiliation(s)
- J C Munson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- Department of Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Suite 5C, Lebanon, NH, 03756, USA.
| | - J P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - J-E Bell
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - C McDonough
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - T Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Onega T, Zhu W, Weiss JE, Goodrich M, Tosteson ANA, DeMartini W, Virnig BA, Henderson LM, Buist DSM, Wernli KJ, Kerlikowske K, Hubbard RA. Preoperative breast MRI and mortality in older women with breast cancer. Breast Cancer Res Treat 2018. [PMID: 29516372 DOI: 10.1007/s10549-018-4732-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 11/29/2022]
Abstract
PURPOSE The survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial. METHODS We followed a cohort of 4454 women diagnosed with non-metastatic breast cancer (stage I-III) from 2/2005-6/2010 in five registries of the breast cancer surveillance consortium (BCSC). BCSC clinical and registry data were linked to Medicare claims and enrollment data. We estimated the cumulative probability of breast cancer-specific and all-cause mortality. We tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model. RESULTS 917 (20.6%) women underwent preoperative MRI. No significant difference in the cumulative probability of breast cancer-specific mortality was found. We observed no significant difference in the hazard of all-cause mortality during the follow-up period after adjusting for sociodemographic and clinical factors among women with MRI (HR 0.90; 95% CI 0.72-1.12) compared to those without MRI. CONCLUSION Our findings of no breast cancer-specific or all-cause mortality benefit supplement prior results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the results of this analysis highlight the importance of exploring the benefit of preoperative MRI in patient-reported outcomes such as women's decision quality and confidence levels with decisions involving treatment choices.
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Affiliation(s)
- T Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8 - DHMC, Lebanon, 03756, USA.,Norris Cotton Cancer Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - W Zhu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - J E Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8 - DHMC, Lebanon, 03756, USA
| | - M Goodrich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8 - DHMC, Lebanon, 03756, USA.
| | - A N A Tosteson
- Norris Cotton Cancer Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - W DeMartini
- Department of Radiology, Stanford University, Palo Alto, CA, USA
| | - B A Virnig
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - L M Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill, NC, USA
| | - D S M Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - K J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - K Kerlikowske
- Department of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - R A Hubbard
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Svedbom A, Borgstöm F, Hernlund E, Ström O, Alekna V, Bianchi ML, Clark P, Curiel MD, Dimai HP, Jürisson M, Kallikorm R, Lember M, Lesnyak O, McCloskey E, Sanders KM, Silverman S, Solodovnikov A, Tamulaitiene M, Thomas T, Toroptsova N, Uusküla A, Tosteson ANA, Jönsson B, Kanis JA. Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS. Osteoporos Int 2018; 29:557-566. [PMID: 29230511 DOI: 10.1007/s00198-017-4317-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [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: 06/08/2017] [Accepted: 11/13/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months. INTRODUCTION The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture. METHODS Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture. RESULTS Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types. CONCLUSIONS Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.
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Affiliation(s)
| | - F Borgstöm
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | | | - O Ström
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | - V Alekna
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - M L Bianchi
- Bone Metabolism Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - P Clark
- Clinical Epidemiology Unit, Hospital Infantil Federico Gómez and Faculty of Medicine UNAM, Mexico City, Mexico
| | - M D Curiel
- Servicio de Medicina Interna/Enfermedades Metabolicas Oseas, Fundacion Jimenez Diaz, Madrid, Spain
- Catedra de Enfermedades Metabolicas Óseas, Universidad Autonoma, Madrid, Spain
| | - H P Dimai
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - M Jürisson
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - R Kallikorm
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - M Lember
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - O Lesnyak
- Ural State Medical University, Yekaterinburg, Russia
- North West Mechnikov State Medical University, St. Petersburg, Russia
| | - E McCloskey
- Academic Unit of Bone Metabolism, Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - K M Sanders
- Institute for Health and Ageing, Australian Catholic University, Melbourne, 3000, Australia
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - M Tamulaitiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - T Thomas
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Service de Rhumatologie, CHU de Saint-Etienne, Université de Lyon, Saint-Etienne, France
| | - N Toroptsova
- FSBSI "Scientific Research Institute of Rheumatology named after V.A.Nasonova, Moscow, Russia
| | - A Uusküla
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, PA, USA
| | - B Jönsson
- Stockholm School of Economics, Stockholm, Sweden
| | - J A Kanis
- Institute for Health and Ageing, Australian Catholic University, Melbourne, 3000, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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Lott JP, Wang Q, Titus LJ, Onega T, Nelson HD, Weinstock MA, Elmore JG, Tosteson ANA. Temporal trends in healthcare utilization following primary melanoma diagnosis among Medicare beneficiaries. Br J Dermatol 2017; 177:845-853. [PMID: 28369774 DOI: 10.1111/bjd.15530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about the impact of primary melanoma diagnosis on healthcare utilization and changes in utilization over time. OBJECTIVES To evaluate population-based temporal trends in healthcare utilization following primary melanoma diagnosis. METHODS We conducted a before-and-after multiple time series study of Medicare beneficiaries aged ≥ 66 years with primary melanoma diagnoses between 2000 and 2009 using the Surveillance, Epidemiology, and End Results Medicare database. Primary exposure was time from primary melanoma diagnosis at 3-6 months and 6-24 months postdiagnosis. Covariates included tumour-, patient- and geographical-level characteristics and healthcare utilization in the 6 months before diagnosis. Poisson regression was used to estimate population-based risk-adjusted utilization rates for skin biopsies, benign skin excisions, internal medicine office visits and dermatology office visits. RESULTS The study population included 56 254 patients with first diagnoses of primary melanoma. Most patients were ≥ 75 years old (56·8%), male (62·1%), and had in situ melanoma (42·4%) or localized invasive melanoma (45·9%). From 2000 to 2009, risk-adjusted skin biopsy rates 24 months postdiagnosis increased from 358·3 to 541·3 per 1000 person-years (P < 0·001), and dermatology visits increased from 989·0 to 1535·6 per 1000 person-years (P < 0·001). Benign excisions and internal medicine visits remained stable. In 2000, risk-adjusted skin biopsy rates 6 months postdiagnosis increased by 208·5 relative to the 6 months before diagnosis (148·7 vs. 357·2) compared with an observed absolute increase of 272·5 (290·9 vs. 563·1) in 2009. Trends in dermatology visits were similar. CONCLUSIONS Utilization of skin biopsies and dermatology office visits following primary melanoma diagnosis has increased substantially over time. These results may inform optimization of care delivery for melanoma within the Medicare population.
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Affiliation(s)
- J P Lott
- Cornell Scott-Hill Health Center, New Haven, CT, U.S.A
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A
| | - L J Titus
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - T Onega
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - H D Nelson
- Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Portland, OR, U.S.A.,Department of Medical Informatics, Oregon Health & Science University, Portland, OR, U.S.A.,Department of Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, U.S.A.,Providence Cancer Center, Providence Health and Services, Portland, OR, U.S.A
| | - M A Weinstock
- Dermatoepidemiology Unit, US Department of Veterans Affairs Medical Center, Providence, RI, U.S.A.,Department of Dermatology, Rhode Island Hospital, Providence, RI, U.S.A.,Department of Dermatology, Brown University School of Medicine, Providence, RI, U.S.A.,Department of Epidemiology, Brown University School of Medicine, Providence, RI, U.S.A
| | - J G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
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7
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Weinstock MA, Lott JP, Wang Q, Titus LJ, Onega T, Nelson HD, Pearson L, Piepkorn M, Barnhill RL, Elmore JG, Tosteson ANA. Skin biopsy utilization and melanoma incidence among Medicare beneficiaries. Br J Dermatol 2017; 176:949-954. [PMID: 27639256 DOI: 10.1111/bjd.15077] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Melanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis. OBJECTIVES To use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports. METHODS Examination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009. RESULTS The skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern. CONCLUSIONS Increased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.
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Affiliation(s)
- M A Weinstock
- Center for Dermatoepidemiology, US Department of Veterans Affairs Medical Center, Providence, RI, U.S.A.,Department of Dermatology, Rhode Island Hospital, Providence, RI, U.S.A.,Departments of Dermatology and Epidemiology, Brown University, Providence, RI, U.S.A
| | - J P Lott
- Cornell Scott-Hill Health Center, New Haven, CT, U.S.A
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - L J Titus
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - T Onega
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - H D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, U.S.A.,Providence Cancer Center, Providence Health and Services, Portland, OR, U.S.A
| | - L Pearson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - M Piepkorn
- Department of Medicine, Division of Dermatology, University of Washington School of Medicine, Seattle, WA, U.S.A.,Dermatopathology Northwest, Bellevue, WA, U.S.A
| | - R L Barnhill
- Department of Pathology, Institut Curie, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - J G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
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Orwig D, Mangione KK, Baumgarten M, Terrin M, Fortinsky R, Kenny AM, Gruber-Baldini AL, Beamer B, Tosteson ANA, Shardell M, Magder L, Binder E, Koval K, Resnick B, Craik RL, Magaziner J. Improving community ambulation after hip fracture: protocol for a randomised, controlled trial. J Physiother 2017; 63:45-46. [PMID: 27964962 PMCID: PMC5388063 DOI: 10.1016/j.jphys.2016.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/03/2016] [Accepted: 10/10/2016] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.
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Affiliation(s)
- D Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - KK Mangione
- Department of Physical Therapy, College of Health Sciences, Arcadia University, Glenside
| | - M Baumgarten
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - M Terrin
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - R Fortinsky
- UConn Center on Aging, UConn Health, Farmington
| | - AM Kenny
- Department of Medicine, UConn Health, Farmington
| | - AL Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - B Beamer
- Gerontology Research, Education and Clinical Center (GRECC) at Baltimore Veterans Affairs Medical Center,Division of Geriatric Medicine and Gerontology at University of Maryland School of Medicine
| | - ANA Tosteson
- Department of Medicine,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover
| | - M Shardell
- National Institute on Aging, National Institutes of Health, Baltimore
| | - L Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - E Binder
- Division of Geriatrics and Gerontology, Washington University School of Medicine, St Louis
| | - K Koval
- Department of Orthopaedic Surgery, Orlando Regional Medical Centre, Orlando
| | - B Resnick
- University of Maryland School of Nursing, Baltimore, USA
| | - RL Craik
- Department of Physical Therapy, College of Health Sciences, Arcadia University, Glenside
| | - J Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Bynum JPW, Bell JE, Cantu RV, Wang Q, McDonough CM, Carmichael D, Tosteson TD, Tosteson ANA. Second fractures among older adults in the year following hip, shoulder, or wrist fracture. Osteoporos Int 2016; 27:2207-2215. [PMID: 26911297 PMCID: PMC5008031 DOI: 10.1007/s00198-016-3542-6] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED We report on second fracture occurrence in the year following a hip, shoulder or wrist fracture using insurance claims. Among 273,330 people, 4.3 % had a second fracture; risk did not differ by first fracture type. Estimated adjusted second fracture probabilities may facilitate population-based evaluation of secondary fracture prevention strategies. INTRODUCTION The purpose of this study was estimate second fracture risk for the older US population in the year following a hip, shoulder, or wrist fracture. METHODS Observational cohort study of Medicare fee-for-service beneficiaries with an index hip, shoulder, or wrist fragility fracture in 2009. Time-to-event analyses using Cox proportional hazards models to characterize the relationship between index fracture type (hip, shoulder, wrist) and patient factors (age, gender, and comorbidity) on second fracture risk in the year following the index fracture. RESULTS Among 273,330 individuals with fracture, 11,885 (4.3 %) sustained a second hip, shoulder or wrist fracture within one year. Hip fracture was most common, regardless of the index fracture type. Comparing adjusted second fracture risks across index fracture types reveals that the magnitude of second fracture risk within each age-comorbidity group is similar regardless of the index fracture. Men and women face similar risks with frequently overlapping confidence intervals, except among women aged 85 years or older who are at greater risk. CONCLUSIONS Regardless of index fracture type, second fractures are common in the year following hip, shoulder or wrist fracture. Secondary fracture prevention strategies that take a population perspective should be informed by these estimates which take competing mortality risks into account.
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Affiliation(s)
- J P W Bynum
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5 One Medical Center Drive, Lebanon, NH, 03756, USA.
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - J-E Bell
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - R V Cantu
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5 One Medical Center Drive, Lebanon, NH, 03756, USA
| | - C M McDonough
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5 One Medical Center Drive, Lebanon, NH, 03756, USA
- The Health and Disability Research Institute, Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - D Carmichael
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5 One Medical Center Drive, Lebanon, NH, 03756, USA
| | - T D Tosteson
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Research Building, Level 5 One Medical Center Drive, Lebanon, NH, 03756, USA
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Morden NE, Munson JC, Smith J, Mackenzie TA, Liu SK, Tosteson ANA. Oral bisphosphonates and upper gastrointestinal toxicity: a study of cancer and early signals of esophageal injury. Osteoporos Int 2015; 26:663-72. [PMID: 25349053 PMCID: PMC4511107 DOI: 10.1007/s00198-014-2925-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 06/09/2014] [Accepted: 09/29/2014] [Indexed: 12/14/2022]
Abstract
SUMMARY We evaluated the association between bisphosphonate use and (1) upper gastrointestinal cancer, (2) upper endoscopy, (3) incident Barrett's esophagus, and (4) prescription antacid initiation among Medicare beneficiaries. We found no bisphosphonate-cancer association and negative bisphosphonate-Barrett's association. INTRODUCTION Bisphosphonates can irritate the esophagus; a cancer association has been suggested. Widespread bisphosphonates use compels continued investigation of upper gastrointestinal toxicity. METHODS Using a 40% Medicare random sample denominator, inpatient, outpatient (2003-2011), and prescription (2006-2011) claims, we studied patients age 68 and older with osteoporosis and/or oral bisphosphonate use. Inverse propensity weighting estimated marginal structural models for the effect of bisphosphonate intensity (pills per month) and cumulative bisphosphonate pills received on upper gastrointestinal cancer risk. Secondary analyses of sub-cohorts without past bisphosphonates or upper endoscopy assessed bisphosphonate initiation and risk of (1) upper endoscopy, (2) incident Barrett's esophagus, and (3) prescription antacid initiation. RESULTS The cohort included 1.64 million beneficiaries: 87.9% women, mean age, 76.8 (standard deviation (SD) 9.3); mean follow-up, 39.6 months; 38.1% received oral bisphosphonates. Cumulative bisphosphonate receipt, among users, ranged from 4 to 252 pills (5th to 95th percentile). We identified 2,308 upper gastrointestinal cancers (0.43/1000 person years). We found no association between cumulative bisphosphonate pills and cancer, odds ratio (OR) for each additional pill 1.00 (95% confidence interval (CI) 1.00, 1.00). In sub-cohorts, compared to none, lowest cumulative bisphosphonate use (one to nine pills) was associated with higher risk of endoscopy (OR 1.11, 95% CI 1.08-1.14) and antacid initiation (OR 1.13, 95% CI 1.10-1.16); higher intensity conferred no increased risk. Higher intensity and higher cumulative bisphosphonate category were associated with lower Barrett's risk. CONCLUSIONS We found no bisphosphonate-cancer association and negative bisphosphonate-Barrett's association. Bisphosphonate initiation appears to identify patients susceptible to early irritating effects; clinicians might offer alternatives and delay endoscopy or antacids.
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Affiliation(s)
- N E Morden
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, 35 Centerra Parkway, Room 3088, Lebanon, NH, 03766, USA,
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Kerlikowske K, Hubbard R, Tosteson ANA. Higher Mammography Screening Costs Without Appreciable Clinical Benefit: The Case of Digital Mammography. J Natl Cancer Inst 2014; 106:dju191. [DOI: 10.1093/jnci/dju191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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12
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Borgström F, Lekander I, Ivergård M, Ström O, Svedbom A, Alekna V, Bianchi ML, Clark P, Curiel MD, Dimai HP, Jürisson M, Kallikorm R, Lesnyak O, McCloskey E, Nassonov E, Sanders KM, Silverman S, Tamulaitiene M, Thomas T, Tosteson ANA, Jönsson B, Kanis JA. The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)--quality of life during the first 4 months after fracture. Osteoporos Int 2013; 24:811-23. [PMID: 23306819 DOI: 10.1007/s00198-012-2240-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [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] [Received: 06/28/2012] [Accepted: 10/17/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss. INTRODUCTION The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS. METHODS ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire. RESULTS The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not. CONCLUSIONS The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.
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Affiliation(s)
- F Borgström
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden.
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13
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Dawson-Hughes B, Looker AC, Tosteson ANA, Johansson H, Kanis JA, Melton LJ. The potential impact of the National Osteoporosis Foundation guidance on treatment eligibility in the USA: an update in NHANES 2005-2008. Osteoporos Int 2012; 23:811-20. [PMID: 21717247 DOI: 10.1007/s00198-011-1694-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [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: 03/31/2011] [Accepted: 06/01/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED This analysis of National Health and Nutrition Examination Survey (NHANES) 2005-2008 data describes the prevalence of risk factors for osteoporosis and the proportions of men and postmenopausal women age 50 years and older who are candidates for treatment to lower fracture risk, according to the new Fracture Risk Assessment Tool (FRAX)-based National Osteoporosis Foundation Clinician's Guide. INTRODUCTION It is important to update estimates of the proportions of the older US population considered eligible for pharmacologic treatment for osteoporosis for purposes of understanding the health care burden of this disease. METHODS This is a cross-sectional study of the NHANES 2005-2008 data in 3,608 men and women aged 50 years and older. Variables in the analysis included race/ethnicity, age, lumbar spine and femoral neck bone mineral density, risk factor profiles, and FRAX 10-year fracture probabilities. RESULTS The prevalence of osteoporosis of the femoral neck ranged from 6.0% in non-Hispanic black to 12.6% in Mexican American women. Spinal osteoporosis was more prevalent among Mexican American women (24.4%) than among either non-Hispanic blacks (5.3%) or non-Hispanic whites (10.9%). Treatment eligibility was similar in Mexican American and non-Hispanic white women (32.0% and 32.8%) and higher than it was in non-Hispanic black women (11.0%). Treatment eligibility among men was 21.1% in non-Hispanic whites, 12.6% in Mexican Americans, and 3.0% in non-Hispanic blacks. CONCLUSIONS Nineteen percent of older men and 30% of older women in the USA are at sufficient risk for fracture to warrant consideration for pharmacotherapy.
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Affiliation(s)
- B Dawson-Hughes
- Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA.
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14
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McDonough CM, Grove MR, Elledge AD, Tosteson ANA. Predicting EQ-5D-US and SF-6D societal health state values from the Osteoporosis Assessment Questionnaire. Osteoporos Int 2012; 23:723-32. [PMID: 21484360 PMCID: PMC4017660 DOI: 10.1007/s00198-011-1619-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 08/31/2010] [Accepted: 02/14/2011] [Indexed: 11/24/2022]
Abstract
SUMMARY Linear regression was applied to data from 275 persons with osteoporosis-related fracture to estimate EQ-5D-US and SF-6D health state values from the Osteoporosis Assessment Questionnaire. The models explained 56% and 58% of the variance in scores, respectively, and root mean square error values (0.096 and 0.085) indicated adequate prediction for use when actual values are unavailable. INTRODUCTION This study was conducted to provide models that predict EQ-5D-US and SF-6D societal health state values from the Osteoporosis Assessment Questionnaire (OPAQ). METHODS OPAQ, EQ-5D, and SF-6D data from individuals at two centers with prior osteoporosis-related fracture were used. Fractures were classified by type as hip/hip-like, spine/spine-like, or wrist/wrist-like. Spearman rank correlations between preference-based system (EQ-5D and SF-6D) dimensions and OPAQ subscales were estimated. Linear regression was used to estimate preference-based system health state values based on OPAQ subscales. We assessed models including age, sex, and fracture type and chose the model with the best performance based on the root mean square error (RMSE) estimate. RESULTS Among the 275 participants (198 women), with mean age of 68 years (range 50-94), the distribution of fracture types included 10% hip/5% hip-like, 18% spine/11% spine-like, and 24% wrist/18% wrist-like. The final regression model for EQ-5D-US included three OPAQ attributes (physical function, emotional status, and symptoms), predicted 56% of the variance in EQ-5D-US scores, and had a RMSE of 0.096. The final model for SF-6D, which included all four OPAQ dimensions, predicted 58% of the variance in SF-6D scores and had a RMSE of 0.085. CONCLUSIONS Two models were developed to estimate EQ-5D-US and SF-6D health state values from OPAQ and demonstrated adequate prediction for use when actual values are not available.
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Affiliation(s)
- C M McDonough
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH 03756, USA.
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15
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Looker AC, Dawson-Hughes B, Tosteson ANA, Johansson H, Kanis JA, Melton LJ. Hip fracture risk in older US adults by treatment eligibility status based on new National Osteoporosis Foundation guidance. Osteoporos Int 2011; 22:541-9. [PMID: 20480142 DOI: 10.1007/s00198-010-1288-0] [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: 11/13/2009] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED This analysis of National Health and Nutrition Examination Survey III data found a significant risk of incident hip fracture in adults aged 65 years and older who are candidates for treatment to lower fracture risk, according to the new National Osteoporosis Foundation Clinician's Guide. INTRODUCTION The relationship between treatment eligibility by the new National Osteoporosis Foundation (NOF) Guide to the Prevention and Treatment of Osteoporosis and the risk of subsequent hip fracture is unknown. METHODS The study sample consisted of 3,208 men and women ages 65 years and older who were examined in the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994), a nationally representative survey. Risk factors used to define treatment eligibility at baseline were measured in NHANES III or were simulated using World Health Organization study cohorts. Incident hip fractures were ascertained using linked mortality and Medicare records that were obtained for NHANES III participants through December 31, 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of hip fracture by treatment eligibility status. RESULTS The RR for subsequent hip fracture was 4.9 (95% CI 3.30, 7.94) in treatment-eligible vs treatment-ineligible persons. The increased risk for treatment-eligible persons remained statistically significant when examined by sex or age: RR(men) = 5.5 (2.6, 11.4) and RR(women) = 4.3 (2.2, 8.4); RR(65-79 y) = 4.8 (2.6, 8.7) and RR(80+ y) = 4.6 (2.1, 10.1). CONCLUSIONS Treatment-eligible persons were about five times more likely to experience a subsequent hip fracture than the non-eligible persons. The new NOF guidelines appear to predict future hip fracture risk equally in men as in women, and fracture risk prediction did not appear to diminish with age.
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Affiliation(s)
- A C Looker
- National Center for Health Statistics, Centers for Disease Control and Prevention, Rm 4310, 3311 Toledo Rd, Hyattsville, MD 20782, USA.
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Ivergård M, Ström O, Borgström F, Burge RT, Tosteson ANA, Kanis J. Identifying cost-effective treatment with raloxifene in postmenopausal women using risk algorithms for fractures and invasive breast cancer. Bone 2010; 47:966-74. [PMID: 20691296 DOI: 10.1016/j.bone.2010.07.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [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: 05/05/2010] [Revised: 07/27/2010] [Accepted: 07/27/2010] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The National Osteoporosis Foundation (NOF) recommends considering treatment in women with a 20% or higher 10-year probability of a major fracture. However, raloxifene reduces both the risk of vertebral fractures and invasive breast cancer so that raloxifene treatment may be clinically appropriate and cost-effective in women who do not meet a 20% threshold risk. The aim of this study was to identify cost-effective scenarios of raloxifene treatment compared to no treatment in younger postmenopausal women at increased risk of invasive breast cancer and fracture risks below 20%. METHOD A micro-simulation model populated with data specific to American Caucasian women was used to quantify the costs and benefits of 5-year raloxifene treatment. The population evaluated was selected based on 10-year major fracture probability as estimated with FRAX® being below 20% and 5-year invasive breast cancer risk as estimated with the Gail risk model ranging from 1% to 5%. RESULTS The cost per QALY gained ranged from US $22,000 in women age 55 with 5% invasive breast cancer risk and 15-19.9% fracture probability, to $110,000 in women age 55 with 1% invasive breast cancer risk and 5-9.9% fracture probability. Raloxifene was progressively cost-effective with increasing fracture risk and invasive breast cancer risk for a given age cohort. At lower fracture risk in combination with lower invasive breast cancer risk or when no preventive raloxifene effect on invasive breast cancer was assumed, the cost-effectiveness of raloxifene worsened markedly and was not cost-effective given a willingness-to-pay of US $50,000. At fracture risk of 15-19.9% raloxifene was cost-effective also in women at lower invasive breast cancer risk. CONCLUSIONS Raloxifene is potentially cost-effective in cohorts of young postmenopausal women, who do not meet the suggested NOF 10-year fracture risk threshold. The cost-effectiveness is contingent on their 5-year invasive breast cancer risk. The result highlights the importance of considering a woman's full risk profile when considering anti-osteoporosis treatment.
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Tosteson ANA, Do TP, Wade SW, Anthony MS, Downs RW. Persistence and switching patterns among women with varied osteoporosis medication histories: 12-month results from POSSIBLE US. Osteoporos Int 2010; 21:1769-80. [PMID: 20101492 DOI: 10.1007/s00198-009-1133-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [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: 06/26/2009] [Accepted: 10/27/2009] [Indexed: 01/22/2023]
Abstract
UNLABELLED During the first year of Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBE US), many women transitioned (i.e., discontinued or switched) from their baseline osteoporosis medication. Participants not on stable therapy at entry, with side effects, and with poor physical status were at higher risk of transitioning. Understanding factors associated with persistence may lead to improved outcomes. INTRODUCTION Postmenopausal osteoporosis (PMO) medication use patterns may differ by treatment history and drug class. We describe these patterns among patients in primary care settings using patient-reported data. METHODS Data from 3,006 participants of the POSSIBLE US were used to estimate the probability of a baseline PMO medication transition (i.e., discontinuation or switch) and hazard ratios (HRs) for predictors of these transitions. RESULTS One year after study entry, the probability of persisting with a baseline medication was 66% (95% CI: 64-68%). After adjusting for age and osteoporosis diagnosis, factors at entry independently associated with a higher risk of baseline medication transition were treatment status cohort, side effect severity, and OPAQ-SV physical function score. Compared to participants stable on therapy at entry, others had a higher risk, ranging from HR = 1.59 (95% CI: 1.36-1.85) for those new to therapy to HR = 2.00 (95% CI: 1.27-3.15) for those who recently augmented therapy at entry. Participants reporting moderate (HR = 1.31, 95% CI: 1.09-1.57) or severe (HR = 1.88, 95% CI: 1.49-2.39) side effects had a higher risk than those not reporting side effects. Participants reporting Osteoporosis Assessment Questionnaire-Short Version physical function scores in the lowest tertile had a higher risk (HR = 1.27, 95% CI: 1.07-1.52) than those reporting scores in the highest tertile. CONCLUSION Baseline osteoporosis medication transitions were common in the first year of POSSIBLE US. Participants not on stable therapy at entry, or who reported severe side effects, or had poor physical health status were at higher risk for these transitions.
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Affiliation(s)
- A N A Tosteson
- HB 7505 Clinical Research, Dartmouth Medical School, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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Dawson-Hughes B, Looker AC, Tosteson ANA, Johansson H, Kanis JA, Melton LJ. The potential impact of new National Osteoporosis Foundation guidance on treatment patterns. Osteoporos Int 2010; 21:41-52. [PMID: 19705046 DOI: 10.1007/s00198-009-1034-7] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [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: 04/06/2009] [Accepted: 07/27/2009] [Indexed: 01/11/2023]
Abstract
UNLABELLED This analysis of National Health and Nutrition Examination Survey III data describes the prevalence of risk factors for osteoporosis and the proportions of men and postmenopausal women age 50 years and older who are candidates for treatment to lower fracture risk, according to the new FRAX-based National Osteoporosis Foundation Clinician's Guide. INTRODUCTION Little information is available on prevalence of osteoporosis risk factors or proportions of US men and women who are potential candidates for treatment. METHODS The prevalence of risk factors used in the new National Osteoporosis Foundation (NOF) FRAX-based Guide to the Prevention and Treatment of Osteoporosis was estimated using data from the third National Health and Nutrition Examination Survey (NHANES III). Risk factors not measured in NHANES III were simulated using World Health Organization cohorts. The proportion of US men and postmenopausal women age 50+ years who are treatment candidates by the new NOF Guide were calculated; for non-Hispanic white (NHW) women, the proportion eligible by the new NOF Guide was compared with that based on an earlier NOF Guide. RESULTS Twenty percent of men and 37% of women were potential candidates for treatment to prevent fractures by the new NOF Guide. Among NHW women, 53% were potential candidates by the previous NOF Guide compared with 41% by the new guide. CONCLUSIONS One fifth of men and 37% of postmenopausal women are eligible for osteoporosis treatment consideration by the new NOF Guide. However, fewer NHW women are eligible by the new guide than by the previous NOF Guide.
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Affiliation(s)
- B Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA 02111, USA.
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Barrett-Connor E, Ensrud K, Tosteson ANA, Varon SF, Anthony M, Daizadeh N, Wade S. Design of the POSSIBLE UStrade mark Study: postmenopausal women's compliance and persistence with osteoporosis medications. Osteoporos Int 2009; 20:463-72. [PMID: 18607669 DOI: 10.1007/s00198-008-0674-3] [Citation(s) in RCA: 15] [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: 12/17/2007] [Accepted: 05/29/2008] [Indexed: 11/30/2022]
Abstract
UNLABELLED Failure to take prescribed medication is common. The POSSIBLE US study is evaluating the impact of physician and patient characteristics on patient-reported compliance and persistence with osteoporosis medications. We report our study design and the baseline characteristics of 4,994 postmenopausal women recruited from primary care physician offices in 33 states. INTRODUCTION The Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US) is a longitudinal cohort study of osteoporosis therapy in primary care. METHODS Between 2004 and 2007, 134 physicians (in 33 states) enrolled postmenopausal women initiating, changing, or continuing osteoporosis medications. After completing a baseline questionnaire, participants will provide data semi-annually for up to 3 years through 2008. Physicians provide patient data at baseline and routine follow-up visits. Participants from 23 sites also signed a release regarding administrative claims data for economic analyses and validation of self-reported data. BASELINE RESULTS Four thousand nine hundred and ninety-four evaluable women were recruited from internal medicine (n = 1,784), family practice (n = 1,556), obstetrics/gynecology (n = 1,556), and from one rheumatology practice (n = 98). Mean participant age was 64.3 years (SD = 9.97); 89% were Caucasian; 59% had some college education. Sixty-three percent used a single osteoporosis agent, usually a bisphosphonate. For monotherapy patients, concordance between clinic- and patient-reported medication use was lowest for patients prescribed estrogen therapy (70%) or calcium/vitamin D (72%). Obstetrician/gynecologists enrolled younger women, who were more likely to use estrogen therapy than patients enrolled by other physicians. The 934 women (19%) prescribed only calcium/vitamin D were younger than women prescribed pharmacologic therapy. CONCLUSIONS POSSIBLE US provides a unique foundation for evaluating longitudinal use of osteoporosis medications and related outcomes.
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Affiliation(s)
- E Barrett-Connor
- Division of Epidemiology, Department of Family and Preventive Medicine, School of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0607, USA.
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Tosteson ANA, Melton LJ, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, Lindsay RL. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 2008; 19:437-47. [PMID: 18292976 PMCID: PMC2729707 DOI: 10.1007/s00198-007-0550-6] [Citation(s) in RCA: 298] [Impact Index Per Article: 18.6] [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: 11/05/2007] [Accepted: 12/20/2007] [Indexed: 12/18/2022]
Abstract
UNLABELLED A United States-specific cost-effectiveness analysis, which incorporated the cost and health consequences of clinical fractures of the hip, spine, forearm, shoulder, rib, pelvis and lower leg, was undertaken to identify the 10-year hip fracture probability required for osteoporosis treatment to be cost-effective for cohorts defined by age, sex, and race/ethnicity. A 3% 10-year risk of hip fracture was generally required for osteoporosis treatment to cost less than $60,000 per QALY gained. INTRODUCTION Rapid growth of the elderly United States population will result in so many at risk of osteoporosis that economically efficient approaches to osteoporosis care warrant consideration. METHODS A Markov-cohort model of annual United States age-specific incidence of clinical hip, spine, forearm, shoulder, rib, pelvis and lower leg fractures, costs (2005 US dollars), and quality-adjusted life years (QALYs) was used to assess the cost-effectiveness of osteoporosis treatment ($600/yr drug cost for 5 years with 35% fracture reduction) by gender and race/ethnicity groups. To determine the 10-year hip fracture probability at which treatment became cost-effective, average annual age-specific probabilities for all fractures were multiplied by a relative risk (RR) that was systematically varied from 0 to 10 until a cost of $60,000 per QALY gained was observed for treatment relative to no intervention. RESULTS Osteoporosis treatment was cost-effective when the 10-year hip fracture probability reached approximately 3%. Although the RR at which treatment became cost-effective varied markedly between genders and by race/ethnicity, the absolute 10-year hip fracture probability at which intervention became cost-effective was similar across race/ethnicity groups, but tended to be slightly higher for men than for women. CONCLUSIONS Application of the WHO risk prediction algorithm to identify individuals with a 3% 10-year hip fracture probability may facilitate efficient osteoporosis treatment.
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Affiliation(s)
- A N A Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, NH 03756, USA.
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Dawson-Hughes B, Tosteson ANA, Melton LJ, Baim S, Favus MJ, Khosla S, Lindsay RL. Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int 2008; 19:449-58. [PMID: 18292975 DOI: 10.1007/s00198-008-0559-5] [Citation(s) in RCA: 287] [Impact Index Per Article: 17.9] [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: 11/05/2007] [Accepted: 12/21/2007] [Indexed: 01/13/2023]
Abstract
UNLABELLED Application of the WHO fracture prediction algorithm in conjunction with an updated US economic analysis indicates that osteoporosis treatment is cost-effective in patients with fragility fractures or osteoporosis, in older individuals at average risk and in younger persons with additional clinical risk factors for fracture, supporting existing practice recommendations. INTRODUCTION The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment. METHODS The WHO fracture prediction algorithm was calibrated to the US population using national age-, sex- and race-specific death rates and age- and sex-specific hip fracture incidence rates from the largely white population of Olmsted County, MN. Fracture incidence for other races was estimated by ratios to white women and men. The WHO algorithm estimated the probability (%) of a hip fracture (or a major osteoporotic fracture) over 10 years, given specific age, gender, race and clinical profiles. The updated economic model suggested that osteoporosis treatment was cost-effective when the 10-year probability of hip fracture reached 3%. RESULTS It is cost-effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared to postmenopausal white women. CONCLUSIONS This analysis generally endorsed existing clinical practice recommendations, but specific treatment decisions must be individualized. An estimate of the patient's 10-year fracture risk should facilitate shared decision-making.
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Affiliation(s)
- B Dawson-Hughes
- Bone Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA 02111, USA.
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Tosteson ANA, Gottlieb DJ, Radley DC, Fisher ES, Melton LJ. Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int 2007; 18:1463-72. [PMID: 17726622 PMCID: PMC2729704 DOI: 10.1007/s00198-007-0429-6] [Citation(s) in RCA: 158] [Impact Index Per Article: 9.3] [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: 11/09/2006] [Accepted: 04/23/2007] [Indexed: 01/15/2023]
Abstract
UNLABELLED We evaluated the long-term excess mortality associated with hip fracture, using prospectively collected data on pre-fracture health and function from a nationally representative sample of U.S. elders. Although mortality was elevated for the first six months following hip fracture, we found no evidence of long-term excess mortality. INTRODUCTION The long-term excess mortality associated with hip fracture remains controversial. METHODS To assess the association between hip fracture and mortality, we used prospectively collected data on pre-fracture health and function from a representative sample of U.S. elders in the Medicare Current Beneficiary Survey (MCBS) to perform survival analyses with time-varying covariates. RESULTS Among 25,178 MCBS participants followed for a median duration of 3.8 years, 730 sustained a hip fracture during follow-up. Both early (within 6 months) and subsequent mortality showed significant elevations in models adjusted only for age, sex and race. With additional adjustment for pre-fracture health status, functional impairments, comorbid conditions and socioeconomic status, however, increased mortality was limited to the first six months after fracture (hazard ratio [HR]: 6.28, 95% CI: 4.82, 8.19). No increased mortality was evident during subsequent follow-up (HR: 1.04, 95% CI: 0.88, 1.23). Hip-fracture-attributable population mortality ranged from 0.5% at age 65 among men to 6% at age 85 among women. CONCLUSIONS Hip fracture was associated with substantially increased mortality, but much of the short-term risk and all of the long-term risk was explained by the greater frailty of those experiencing hip fracture.
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Affiliation(s)
- A N A Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Dartmouth Medical School, Lebanon, NH 03756, USA.
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Melton LJ, Gabriel SE, Crowson CS, Tosteson ANA, Johnell O, Kanis JA. Cost-equivalence of different osteoporotic fractures. Osteoporos Int 2003; 14:383-8. [PMID: 12730750 DOI: 10.1007/s00198-003-1385-4] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.2] [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: 08/01/2002] [Accepted: 12/30/2002] [Indexed: 10/26/2022]
Abstract
METHODS Among 985 Olmsted County, Minnesota, residents who experienced an osteoporotic fracture (distal forearm, humerus, clavicle/scapula/sternum, ribs, vertebrae, pelvis, hip, other femur or tibia/fibula [the latter in women only]), we estimated the incremental cost of direct medical care in the following year compared with age- and sex-matched controls without a fracture randomly sampled from the same community. RESULTS The overall median incremental (case minus control) cost in the succeeding year was $2,390, with a particularly high incremental cost for hip fractures ($11,241). There was fair concordance between the incremental cost of the different fractures, relative to hip fracture alone, and the previously published disutility associated with each fracture type relative to hip fracture. Overall, the incremental cost for all osteoporotic fractures combined was 46% greater than that for hip fractures alone in women and 47% greater in men. This is consistent with the earlier report that overall morbidity from all osteoporotic fractures combined is 47% and 39% greater in women and men, respectively, than the morbidity attributable solely to hip fractures. CONCLUSION These data lend support to the notion that other osteoporotic fractures can be quantified relative to hip fracture on the basis of their cost, as well as their morbidity and mortality. This may simplify health economic analyses by allowing all fracture outcomes to be modeled relative to hip fractures (i.e., hip fracture 'equivalents') and will provide a more comprehensive assessment of osteoporosis outcomes than is possible by focusing only on hip fractures.
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Affiliation(s)
- L J Melton
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Hersh AL, Tala-Heikkilä M, Tala E, Tosteson ANA, Fordham von Reyn C. A cost-effectiveness analysis of universal versus selective immunization with Mycobacterium bovis bacille Calmette-Guérin in Finland. Int J Tuberc Lung Dis 2003; 7:22-9. [PMID: 12701831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
SETTING Mycobacterium bovis bacille Calmette-Gueŕin (BCG) is provided to all infants born in Finland. OBJECTIVE To analyze the cost-effectiveness of universal versus selective BCG immunization. DESIGN A Markov model was developed to simulate rates of tuberculosis (TB) and non-tuberculous mycobacterial disease (NTM), and to examine the cost-effectiveness in terms of cost per case averted of three different strategies: universal BCG, selective BCG (10% of infants at higher TB risk than other infants) or no BCG immunization. RESULTS In a cohort of 60,000 infants over 15 years, the model predicts five cases each of TB and NTM disease with universal immunization, 8-21 TB and 31 NTM cases with various strategies of selective immunization, and 25 TB and 34 NTM cases with no BCG immunization. BCG side-effects are predicted in 5, 0.5 and 0 infants, respectively. The cost per case averted for immunization strategies ranges from a cost of 38,311 US dollars to a savings of 323 dollars as selective immunization becomes more efficient at targeting infants at highest risk of TB. CONCLUSIONS In a country with a low incidence of pediatric tuberculosis, selective BCG immunization is a more cost-effective strategy than universal BCG immunization for the prevention of tuberculosis, but results in an increase in NTM cases.
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Affiliation(s)
- A L Hersh
- Infectious Disease Section, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA
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von Reyn CF, Arbeit RD, Horsburgh CR, Ristola MA, Waddell RD, Tvaroha SM, Samore M, Hirschhorn LR, Lumio J, Lein AD, Grove MR, Tosteson ANA. Sources of disseminated Mycobacterium avium infection in AIDS. J Infect 2002; 44:166-70. [PMID: 12099743 DOI: 10.1053/jinf.2001.0950] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [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: 11/11/2022]
Abstract
OBJECTIVES To identify the sources of disseminated Mycobacterium avium complex (MAC) infection in AIDS. METHODS HIV positive subjects with CD4 counts <100/mm(3) in Atlanta, Boston, New Hampshire and Finland were entered in a prospective cohort study. Subjects were interviewed about potential MAC exposures, had phlebotomy performed for determination of antibody to mycobacterial lipoarabinomannin and for culture. Patient-directed water samples were collected from places of residence, work and recreation. Patients were followed for the development of disseminated MAC. Univariate and multivariate risk factors for MAC were analyzed. RESULTS Disseminated MAC was identified in 31 (9%) subjects. Significant risks in univariate analysis included prior Pneumocystis carinii pneumonia (PCP) (hazard ratio 1.821), consumption of spring water (4.909), consumption of raw seafood (34.3), gastrointestinal endoscopy (2.894), and showering outside the home (0.388). PCP, showering and endoscopy remained significant in a Cox proportional hazards model. There was no association between M. avium colonization of home water and risk of MAC. In patients with CD4<25, median OD antibody levels to lipoarabinomannin at baseline were 0.054 among patients who did not develop MAC and 0.021 among patients who did develop MAC (P=0.077). CONCLUSIONS MAC infection results from diverse and likely undetectable environmental and nosocomial exposures. Mycobacterial infection before HIV infection may confer protection against disseminated MAC in advanced AIDS.
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Affiliation(s)
- C F von Reyn
- Infectious Disease Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Abstract
Osteoporotic fractures are a major cause of morbidity in the elderly, the most rapidly growing segment of our population. We characterized the incremental direct medical costs following such fractures in a population-based cohort of men and women in Olmsted County, Minnesota. Cases included all County residents 50 years of age and older with an incident fracture due to minimal or moderate trauma between January 1, 1989 and January 1, 1992. For each case, a control of the same age (+/- 1 year) and sex who was attended in the local medical system in the same year was identified. Total incremental costs (cases - controls) in the year after fracture were estimated. Unit costs for each health service/procedure were obtained through the Mayo Cost Data Warehouse, which provides a standardized, inflation-adjusted estimate reflecting the national average cost of providing the service. Regression analysis was used to identify factors associated with incremental costs. There were 1263 case/control pairs; their average age was 73.8 years and 78% were female. Median total direct medical costs were $761 and $625, respectively, for cases and nonfracture controls in the year prior to fracture, and $3884 and $712, respectively, in the year following fracture. The highest median incremental costs were for distal femur ($11756) and hip fractures ($11241), whereas the lowest were for rib fractures ($213). Although hip fractures resulted in more incremental cost than any other fracture type, this amounted to only 37% of the total incremental cost of all moderate-trauma fractures combined. Regression analyses revealed that age, prior year costs and type of fracture were significant predictors of incremental costs (p<0.03 for all comparisons). The incremental costs of osteoporotic fractures are therefore substantial. Whereas hip fractures contributed disproportionately, they accounted for only one-third of the total incremental cost of fractures in our cohort. The use of incremental costs in economic analyses will provide a more accurate reflection of the true cost-effectiveness of osteoporosis prevention.
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Affiliation(s)
- S E Gabriel
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905, USA.
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