The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

A meta-analysis of previous falls and subsequent fracture risk in cohort studies

The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm.

INTRODUCTION

Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD).

METHODS

The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients.

RESULTS

Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33-1.51) and men (HR 1.53, 95% CI 1.41-1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27-1.84) in men vs. HR 1.32 (95% CI 1.20-1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men.

CONCLUSIONS

A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction.

Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX

A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX.

INTRODUCTION

The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD).

METHODS

We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β-coefficients.

RESULTS

A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72-2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69-2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63-2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62-2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination.

CONCLUSION

A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.

The Consumption of Animal and Plant Foods in Areas of High Prevalence of Stroke and Colorectal Cancer

Diets of red and processed meat have been reported as important risk factors for developing colorectal cancer. Given the racial and ethnic differences in the incidence of colorectal cancer, patterns of food consumption, and areas of residence, particularly in the South, more data is needed on the relationship between residing in a high stroke area, colorectal cancer incidence levels, and red meat and processed meat consumption. We created online surveys to ascertain meat, red meat, and healthy food consumption levels. We used OLS regression to evaluate the association between residence in Stroke Belt states and colorectal cancer incidence quartiles with food consumption. We further used path analysis using structural equation modeling to evaluate if age, sex, race/ethnicity, income, and comorbidity index mediated the association between residence in the eight-state Stroke Belt, colorectal cancer incidence groups, and meat consumption. Our sample included 923 participants, with 167 (18.1%) residing in the Stroke Belt and 13.9% being in the highest colorectal cancer incidence group. The findings show that residing in a Stroke Belt state is predictive of the consumption of overall meat 0.93 more days per week or red meat 0.55 more days per week compared to those not residing in a Stroke Belt state. These data can be used to develop future diet interventions in these high-risk areas to reduce rates of colorectal cancer and other negative health outcomes.

Efficacy of Early Preventive Dental Services in Primary Medical Care Setting: Results From Alabama's 1st Look Program

Purpose: To evaluate early preventive dental services (PDS) provided by primary care providers (PCPs) in reducing future caries treatments among Alabama Medicaid recipients. Methods: Data from 2009 to 2019 Alabama Medicaid were used to evaluate effectiveness of 1st Look Program on PDS before age three years and incidence of caries treatments after age three years. PDS groups consisted of 1st Look-involved (PDS claims from PCPs), dentist-only (PDS claims from dental providers), and no early fluoride treatment participants (no PDS claims before age three years). Outcomes included frequency and expenditures of fluoride applications, simple restorations, and extensive treatments. Regression models were used to evaluate associations between PDS groups and outcomes while controlling for covariates. Results: Children in 1st Look- involved received more fluoride (3.0 versus 2.1 times; P<0.001) and were applied earlier (12.1 versus 22.9 months old; P<0.001) than dentist-only group. After adjusting for covariates, compared to dentist-only, 1st Look-involved group received earlier fluoride (beta value equals -11.1 months; 95 percent confidence interval [95% CI] equals -11.25 to -10.97) with greater frequency (incident rate ratio equals 1.49; 95% CI equals 1.47 to 1.51). Caries treatment counts were highest in dentist-only followed by 1st Look-involved and no early fluoride treatment groups in both simple restorations (2.7 versus 2.0 versus 0.2 times; P<0.001) and extensive treatments (2.8 versus 2.3 versus 0.2 times; P<0.001), which were consistent after adjusting for covariates. Conclusions: PDS were provided earlier by PCPs in Medicaid-qualified children, with reduced caries treatments on primary teeth, compared to PDS by dental providers only.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

The Relationship Between Prior Cancer Diagnosis and All-Cause Dementia Progression Among US Adults

BACKGROUND

Cancer-related cognitive impairment (CRCI), a frequent effect of cancer and its treatments, shares common cognitive symptoms with dementia syndromes. Cross-sectional studies demonstrate an inverse relationship between cancer and dementia. However, the longitudinal relationship between dementia decline and cancer has not been investigated.

OBJECTIVE

To evaluate the association between cancer and longitudinal progression of dementia.

METHODS

We extracted electronic health record data from July 2003 to February 2020 from a single academic medical center. We identified dementia and cancer history prior to dementia using ICD-9/10 codes. We measured cognitive decline with the Alabama Brief Cognitive Screener (ABCs). We used adjusted linear mixed models to estimate baseline cognition and rate of progression by cancer history, including differences by race.

RESULTS

The study included 3,809 participants with dementia, of which 672 (17.6%) had cancer history. Those with cancer history had higher baseline cognition (β: 0.62, 95% CI: -0.02-1.25), but similar rate of decline. Non-Hispanic Blacks had lower cognitive scores at baseline and throughout follow-up regardless of cancer status compared to non-Hispanic Whites and other races/ethnicities with and without cancer history.

CONCLUSION

In this longitudinal retrospective study, participants with cancer history demonstrate better cognition at dementia diagnosis and no difference in cognitive decline than those without cancer history. Smoking and comorbidities attenuate this association and results indicate non-Hispanic Blacks have worse cognitive outcomes in dementia regardless of cancer history than other race/ethnicity groups. Further exploration of the role of smoking, comorbidities, and race/ethnicity on cancer and dementia-related cognitive decline is needed.

Racial and Ethnic Disparities in Bone Health and Outcomes in the United States

Osteoporosis is a bone disease classified by deterioration of bone microarchitecture and decreased bone strength, thereby increasing subsequent risk of fracture. In the United States, approximately 54 million adults aged 50 years and older have osteoporosis or are at risk due to low bone mass. Osteoporosis has long been viewed as a chronic health condition affecting primarily non-Hispanic white (NHW) women; however, emerging evidence indicates racial and ethnic disparities in bone outcomes and osteoporosis management. The primary objective of this review is to describe disparities in bone mineral density (BMD), prevalence of osteoporosis and fracture, as well as in screening and treatment of osteoporosis among non-Hispanic black (NHB), Hispanic, and Asian adults compared with NHW adults living on the US mainland. The following areas were reviewed: BMD, osteoporosis prevalence, fracture prevalence and incidence, postfracture outcomes, DXA screening, and osteoporosis treatments. Although there are limited studies on bone and fracture outcomes within Asian and Hispanic populations, findings suggest that there are differences in bone outcomes across NHW, NHB, Asian, and Hispanic populations. Further, NHB, Asian, and Hispanic populations may experience suboptimal osteoporosis management and postfracture care, although additional population-based studies are needed. There is also evidence that variation in BMD and osteoporosis exists within major racial and ethnic groups, highlighting the need for research in individual groups by origin or background. Although there is a clear need to prioritize future quantitative and qualitative research in these populations, initial strategies for addressing bone health disparities are discussed. © 2021 American Society for Bone and Mineral Research (ASBMR).

The Contribution of Patient, Primary Care Physician, and Primary Care Clinic Factors to Good Bone Health Care

BACKGROUND/OBJECTIVE

Patient, provider, and system factors can contribute to chronic care management and outcomes. Few studies have examined these multilevel associations with osteoporosis care and outcomes. We examined how key process and structural factors at the patient, primary care physician (PCP), and primary care clinic (PCC) levels were associated with guideline concordant osteoporosis pharmacotherapy, daily calcium intake, vitamin D supplementation, and weekly exercise sessions at 52 weeks following enrollment in a cluster randomized controlled trial.

METHODS

We conducted a secondary analysis of observational data from 1 site of the trial. The study sample included 1996 men and women ≥ 50 years of age at the time of recruitment following completion of a dual-energy x-ray absorptiometry (DXA) scan and who had complete data at baseline and 52 weeks. Our primary independent variable was "relationship continuity": the DXA-ordering provider was the patient's PCP. Hierarchical linear and logistic regression accounted for patient, provider, and primary care clinic characteristics.

RESULTS

In multivariable regression analyses, relationship continuity (ie, the PCP ordered the study DXA) was associated with higher average daily calcium intake and likelihood of vitamin D supplementation at 52 weeks. No PCP or primary care clinic factors were associated with osteoporosis care.

CONCLUSIONS

The relationship continuity, in which the provider ordering a DXA is the patient's PCP and therefore also presents the results of a DXA, may help to promote patient behaviors associated with good bone health.

Chlamydia Prevalence by Age and Correlates of Infection Among Pregnant Women

BACKGROUND

There is a paucity of population-based data on chlamydia in pregnancy despite rising rates in US women. Our objectives were to assess chlamydia prevalence by age group and to identify factors associated with infection in pregnant women to inform screening guidelines.

METHODS

This cross-sectional study included pregnant women tested for chlamydia who delivered at the University of Alabama at Birmingham between November 1, 2012, and December 31, 2017. The primary outcome was chlamydia prevalence, defined as a positive urogenital chlamydia nucleic acid amplification test result documented in the electronic medical record. Multivariable logistic regression was used to identify factors associated with infection.

RESULTS

Among 17,796 women who delivered during the study period, 13,657 (77%) had chlamydia testing performed at the University of Alabama at Birmingham. Chlamydia prevalence (95% confidence interval) was 7.4% (7.0%-7.9%). Age-stratified prevalence rates were 14.6%, 4.3%, and 1.7% for women younger than 25 years, 25 to 29 years, and 30 years or older, respectively. Chlamydia in pregnancy remained strongly associated with age (adjusted odds ratio [95% confidence interval], 7.2 [5.6-9.2] for age <25 years, and 2.3 [1.7-3.0] for ages 25-29 years, when compared with >30 years) after adjustment for race, urban residence, and insurance status.

CONCLUSIONS

Among pregnant women living in the southeastern United States, chlamydia was detected in 1 of 14 women who were tested. Chlamydia positivity was highest among women younger than 30 years. Study findings support broad screening for chlamydia in pregnancy.

Secular Trends in the Incidence of Hip Fracture Among Nursing Home Residents

A recent study suggested a decline in the incidence of hip fracture among US women between 2002 and 2012, followed by a leveling in the incidence rate from 2013 to 2015. Newly admitted nursing home residents are particularly vulnerable to hip fracture, and it is unclear whether that trend is observed in this high risk group. The purpose of our study was to describe trends in hip fracture rates and postfracture mortality among 2.6 million newly admitted US nursing home residents from 2007 to 2015, and to examine whether these trends could be explained by differences in resident characteristics. Medicare claims data were linked with the Minimum Data Set (MDS), a clinical assessment performed quarterly on all nursing home residents. In each year (2007-2015), we identified newly admitted long-stay (ie, 100 days in the same facility) nursing home residents. Hip fracture was defined using Medicare Part A diagnostic codes. Follow-up time was calculated from the index date until the first event of hospitalized hip fracture, Medicare disenrollment, death, or until 1 year. Poisson regression was used to adjust rates of hip fracture for age and sex. The number of newly admitted nursing home residents ranged from 324,508 in 2007 to 257,350 in 2015. Although mean age remained similar (83 years), residents were more functionally dependent over time. There was a small absolute decrease in the incidence rate of hip fracture between 2007 (3.32/100 person-years) and 2013 (2.82/100 person-years), with an increase again in 2015 (3.03/100 person-years). Adjusting for patient characteristics somewhat attenuated these trends. One-year mortality was high following fracture in all years (42.6% in 2007, 42.1% in 2014). In summary, we observed a recent slight rise in the incidence rates of hip fracture among nursing home residents that was at least partially explained by differences in resident characteristics over time. © 2020 American Society for Bone and Mineral Research.

Serial Bone Density Measurement and Incident Fracture Risk Discrimination in Postmenopausal Women

IMPORTANCE

Repeated bone mineral density (BMD) testing to screen for osteoporosis requires resources. For patient counseling and optimal resource use, it is important for clinicians to know whether repeated BMD measurement (compared with baseline BMD measurement alone) improves the ability to discriminate between postmenopausal women who will and will not experience a fracture.

OBJECTIVE

To assess whether a second BMD measurement approximately 3 years after the initial assessment is associated with improved ability to estimate fracture risk beyond the baseline BMD measurement alone.

DESIGN, SETTING, AND PARTICIPANTS

The Women's Health Initiative is a prospective observational study. Participants in the present cohort study included 7419 women with a mean (SD) follow-up of 12.1 (3.4) years between 1993 and 2010 at 3 US clinical centers. Data analysis was conducted between May 2019 and December 2019.

MAIN OUTCOMES AND MEASURES

Incident major osteoporotic fracture (ie, hip, clinical spine, forearm, or shoulder fracture), hip fracture, baseline BMD, and absolute change in BMD were assessed. The area under the receiver operating characteristic curve (AU-ROC) for baseline BMD, absolute change in BMD, and the combination of baseline BMD and change in BMD were calculated to assess incident fracture risk discrimination during follow-up.

RESULTS

Of 7419 participants, the mean (SD) age at baseline was 66.1 (7.2) years, the mean (SD) body mass index was 28.7 (6.0), and 1720 (23%) were nonwhite individuals. During the study follow-up (mean [SD] 9.0 [3.5] years after the second BMD measurement), 139 women (1.9%) experienced hip fractures, and 732 women (9.9%) experienced major osteoporotic fracture. In discriminating between women who experience hip fractures and those who do not, AU-ROC values were 0.71 (95% CI, 0.67-0.75) for baseline total hip BMD, 0.61 (95% CI, 0.56-0.65) for change in total hip BMD, and 0.73 (95% CI, 0.69-0.77) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar discrimination for hip fracture. For discrimination of major osteoporotic fracture, AU-ROC values were 0.61 (95% CI, 0.59-0.63) for baseline total hip BMD, 0.53 (95% CI, 0.51-0.55) for change in total hip BMD, and 0.61 (95% CI, 0.59-0.63) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar ability to discriminate between women who experienced major osteoporotic fracture and those who did not. Associations between change in bone density and fracture risk did not differ by subgroup, including diabetes, age, race/ethnicity, body mass index, or baseline BMD T score.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a second BMD assessment approximately 3 years after the initial measurement was not associated with improved discrimination between women who did and did not experience subsequent hip fracture or major osteoporotic fracture beyond the baseline BMD value alone and should not routinely be performed.

Factors associated with the contemplative stage of readiness to initiate osteoporosis treatment

We investigated the factors associated with readiness for initiating osteoporosis treatment in women at high risk of fracture. We found that women in the contemplative stage were more likely to report previously being told having osteoporosis or osteopenia, acknowledge concern about osteoporosis, and disclose prior osteoporosis treatment.

INTRODUCTION

Understanding factors associated with reaching the contemplative stage of readiness to initiate osteoporosis treatment may inform the design of behavioral interventions to improve osteoporosis treatment uptake in women at high risk for fracture.

METHODS

We measured readiness to initiate osteoporosis treatment using a modified form of the Weinstein Precaution Adoption Process Model (PAPM) among 2684 women at high risk of fracture from the Activating Patients at Risk for OsteoPOroSis (APROPOS) clinical trial. Pre-contemplative participants were those who self-classified in the unaware and unengaged stages of PAPM (stages 1 and 2). Contemplative participants were those in the undecided, decided not to act, or decided to act stages of PAPM (stages 3, 4, and 5). Using multivariable logistic regression, we evaluated participant characteristics associated with levels of readiness to initiate osteoporosis treatment.

RESULTS

Overall, 24% (N = 412) self-classified in the contemplative stage of readiness to initiate osteoporosis treatment. After adjusting for age, race, education, health literacy, and major osteoporotic fracture in the past 12 months, contemplative women were more likely to report previously being told they had osteoporosis or osteopenia (adjusted odds ratio [aOR] (95% CI) 11.8 (7.8-17.9) and 3.8 (2.5-5.6), respectively), acknowledge concern about osteoporosis (aOR 3.5 (2.5-4.9)), and disclose prior osteoporosis treatment (aOR 4.5 (3.3-6.3)) than women who self-classified as pre-contemplative.

CONCLUSIONS

For women at high risk for future fractures, ensuring women's recognition of their diagnosis of osteoporosis/osteopenia and addressing their concerns about osteoporosis are critical components to consider when attempting to influence stage of behavior transitions in osteoporosis treatment.

Association of e-cigarette use with oral health: a population-based cross-sectional questionnaire study

BACKGROUND

The impact of daily or intermittent electronic cigarette (e-cigarette) use on oral health is unknown.

METHODS

We performed a cross-sectional analysis using the 2016 Behavioral Risk Factor Surveillance System data. Poor oral health was determined by the number of permanent teeth removed due to non-traumatic causes, and e-cigarette use determined by daily or intermittent use within 30 days prior to survey administration. We performed logistic regression analysis to test associations between e-cigarette use and oral health with adjustment for factors associated with poor oral health, survey clustering, strata and weight.

RESULTS

We included survey responses from 456 343 adults. Over half of respondents (51.5%) reported having at least one permanent tooth removed because of tooth decay or gum disease in their lifetime. Daily e-cigarette use was reported by 4957 (1.1%) of respondents. In multivariable analysis, daily e-cigarette use, was independently associated with a 78% higher odds of poor oral health (adjusted OR = 1.78, 95% CI: 1.39-2.30; P < 0.001).

CONCLUSIONS

In a population-based health survey of US adults, self-reported health behavior and outcomes, daily use, but not intermittent use of e-cigarettes was independently associated with poor oral health. Care must be exercised in seeking 'healthier' cigarette alternatives.

Racial Disparities Exist in Outcomes After Major Fragility Fractures

BACKGROUND

Fractures associated with postmenopausal osteoporosis (PMO) are associated with pain, disability, and increased mortality. A recent, nationwide evaluation of racial difference in outcomes after fracture has not been performed.

OBJECTIVE

To determine if 1-year death, debility, and destitution rates differ by race.

DESIGN

Observational cohort study.

SETTING

US Medicare data from 2010 to 2016.

PARTICIPANTS

Non-Hispanic black and white women with PMO who have sustained a fragility fracture of interest: hip, pelvis, femur, radius, ulna, humerus, and clinical vertebral.

MEASUREMENTS

Outcomes included 1-year: (1) mortality, identified by date of death in Medicare vital status information, (2) debility, identified as new placement in long-term nursing facilities, and (3) destitution, identified as becoming newly eligible for Medicaid.

RESULTS

Among black and white women with PMO (n = 4,523,112), we identified 399,000 (8.8%) women who sustained a major fragility fracture. Black women had a higher prevalence of femur (9.0% vs 3.9%; P < .001) and hip (30.7% vs 28.0%; P < .001) fractures and lower prevalence of radius/ulna (14.7% vs 17.0%; P < .001) and clinical vertebral fractures (28.8% vs 33.5%; P < .001) compared with white women. We observed racial differences in the incidence of 1-year outcomes after fracture. After adjusting for age, black women had significantly higher risk of mortality 1 year after femur, hip, humerus, and radius/ulna fractures; significantly higher risk of debility 1 year after femur and hip fractures; and significantly higher risk of destitution for all fractures types.

CONCLUSIONS

In a sample of Medicare data from 2010 to 2016, black women with PMO had significantly higher rates of mortality, debility, and destitution after fracture than white women. These findings are a first step toward understanding and reducing disparities in PMO management, fracture prevention, and clinical outcomes after fracture. J Am Geriatr Soc 68:1803-1810, 2020.

Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis

OBJECTIVES

Hospital-associated disability (HAD), defined as loss of independence in activities of daily living (ADL) following acute hospitalization, is observed among older adults. The study objective is to determine overall prevalence of HAD among older adults hospitalized in acute care, and to assess the impact of study initiation year in moderation of prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, and prospective cohort studies. English-language searches to identify included studies were completed February 2018 and updated May 2018 of electronic databases and reference lists of studies and reviews. Included studies were human subjects investigations that measured ADL ≥2 time points before or during and after hospitalization and reported prevalence of ADL decline among older adults.

SETTING

Acute care hospital units.

PARTICIPANTS

Adults aged ≥65 years hospitalized in medical-surgical acute care; total sample size across all included studies was 7375.

METHODS

Independence in ADL was assessed using the Katz Index of Independence in Activities of Daily Living and Barthel Index of Independence in Activities of Daily Living.

RESULTS

Random effects meta-analysis across included studies identified combined prevalence of HAD as 30% (95% CI 24%, 33%; P < .001). The effect of study initiation year on the prevalence rate was minimal. A large amount of heterogeneity was observed between studies, which may be due in part to nonstandardized measurement of ADL impairment or other methodological differences.

CONCLUSIONS AND IMPLICATIONS

Hospitalization in acute care poses a significant risk to functional independence of older adults, and this risk is unchanged despite shorter lengths of stay. The evidence supports the continued need for hospital-based programs that provide assessment of functional ability and identification of at-risk older adults in order to better treat and prevent HAD.

Temporal Trends and Factors Associated with Bisphosphonate Discontinuation and Restart

Adverse events related to long-term use of bisphosphonates have raised interest in temporary drug discontinuation. Trends in bisphosphonate discontinuation and restart, as well factors associated with these decisions, are not fully understood at a population level. We investigated temporal trends of bisphosphonate discontinuation from 2010 to 2015 and identified factors associated with discontinuation and restart of osteoporosis therapy. Our cohort consisted of long-term bisphosphonate users identified from 2010 to 2015 Medicare data. We defined discontinuation as ≥12 months without bisphosphonate prescription claims. We used conditional logistic regression to compare factors associated with alendronate discontinuation or osteoporosis therapy restart in the 120-day period preceding discontinuation or restart referent to the 120-day preceding control periods. Among 73,800 long-term bisphosphonate users, 59,251 (80.3%) used alendronate, 6806 (9.2%) risedronate, and 7743 (10.5%) zoledronic acid, exclusively. Overall, 26,281 (35.6%) discontinued bisphosphonates for at least 12 months. Discontinuation of bisphosphonates increased from 1.7% in 2010, reaching a peak of 14% in 2012 with levels plateauing through 2015. The factors most strongly associated with discontinuation of alendronate were: benzodiazepine prescription (adjusted odds ratio [aOR] = 2.5; 95% confidence interval [CI] 2.1, 3.0), having a dual-energy X-ray absorptiometry (DXA) scan (aOR = 1.8; 95% CI 1.7, 2.0), and skilled nursing facility care utilization (aOR = 1.8; 95% CI 1.6, 2.1). The factors most strongly associated with restart of osteoporosis therapy were: having a DXA scan (aOR = 9.9; 95% CI 7.7, 12.6), sustaining a fragility fracture (aOR = 2.8; 95% CI 1.8, 4.5), and an osteoporosis or osteopenia diagnosis (aOR = 2.5; 95% CI 2.0, 3.1). Our national evaluation of bisphosphonate discontinuation showed that an increasing proportion of patients on long-term bisphosphonate therapy discontinue medications. The factors associated with discontinuation of alendronate were primarily related to worsening of overall health status, whereas traditional factors associated with worsening bone health were associated with restarting osteoporosis medication. © 2019 American Society for Bone and Mineral Research.

The Design and Validation of a New Algorithm to Identify Incident Fractures in Administrative Claims Data

Our study validated a claims-based algorithm for the identification of incident and recurrent fractures in administrative data. We used Centers for Medicare and Medicaid (CMS) claims from 2005 to 2014 linked to the Reasons for Geographic and Racial Differences in Stroke (REGARDS) database. Case qualifying (CQ) fractures were identified among participants with ≥12 months of fee-for-service coverage before first fracture claim and ≥6 months after. Recurrent fractures were defined as the first CQ fracture that occurred following a clean period of at least 90 days from the last claim associated with the preceding incident fracture. We used medical records (discharge summary, imaging, and surgical report) to adjudicate fractures. We calculated positive predictive values (PPVs) for incident and recurrent fractures. Our study was not designed to assess the algorithm sensitivity or negative predictive value. We identified 2049 potential incident fractures from claims among 1650 participants. Record retrieval was attempted for 728 (35.5%) suspected incident fractures (prioritizing more recent CQ fractures associated with osteoporosis, but without explicitly requiring any osteoporosis ICD-9 diagnosis code). Our final sample included 520 claims-identified fractures with medical records, of which 502 (96.5%) were confirmed. The PPVs (95% CI) of the hip, wrist, humerus, and clinical vertebra-all exceeded 95%. We identified 117 beneficiaries with 292 ≥2 CQ fracture episodes at the same site, and attempted retrieval on 105 (36.0%) episodes. Our analytic sample included 72 (68.5%) CQ episodes from 33 participants. The PPVs for identifying recurrent clinical vertebral, hip/femur, and nonvertebral fractures with a 90-day clean period exceeded 95%. Although we could not ascertain sensitivity, our updated fracture identification algorithms had high PPV for the identification of incident and recurrent fractures of the same site. Although medical record review and clinical adjudication remain a gold standard, our claims-based algorithm provides an alternative approach to fracture ascertainment when high PPV is desired. © 2019 American Society for Bone and Mineral Research.

Characteristics of older adults using patient web portals to view their DXA results

Background

Sharing test results with patients via patient web portals is a new trend in healthcare. No research has been done examining patient web portal use with bone density test results. The objective of our study was to identify patient characteristics associated with the use of patient web portals to view their bone density test results.

Methods

A secondary analysis of data from a pragmatic randomized controlled trial of 7749 participants ≥50 years old that had presented for a dual energy X-ray absorptiometry (DXA) bone density test. Patients were interviewed at enrollment and 12 weeks later. Multivariable logistic regression identified patient characteristics that differentiated those who used the web portal from those who did not.

Results

Our sample included 4669 patients at the two (University of Iowa [UI], and Kaiser Permanente of Georgia [KPGA]) clinical sites that had patient web portals. Of these patients, 3399 (72.8%) reported knowing their test results 12 weeks post-DXA, with 649 (13.9%) reporting that they viewed their DXA results using the web portal. Web portal users were more likely to be from UI than KPGA, and were younger, more educated, had higher health literacy, had osteopenia, and had the same sex as their referring physician (all p < 0.05).

Conclusion

Only 19.1% of the 3399 patients who knew their DXA results used the available patient web portals to find out about them. Web portal users differed from non-users on several characteristics. This suggests that simply making patient web portals available for use may not be sufficient to appreciably enhance patient awareness of their test results. Based on these findings, a better understanding of the reasons why older, less educated, and less activated patients do not access their test results through patient web portals is needed.

Disentangling the genetics of lean mass

Background

Lean body mass (LM) plays an important role in mobility and metabolic function. We previously identified five loci associated with LM adjusted for fat mass in kilograms. Such an adjustment may reduce the power to identify genetic signals having an association with both lean mass and fat mass.

Objectives

To determine the impact of different fat mass adjustments on genetic architecture of LM and identify additional LM loci.

Methods

We performed genome-wide association analyses for whole-body LM (20 cohorts of European ancestry with n = 38,292) measured using dual-energy X-ray absorptiometry) or bioelectrical impedance analysis, adjusted for sex, age, age2, and height with or without fat mass adjustments (Model 1 no fat adjustment; Model 2 adjustment for fat mass as a percentage of body mass; Model 3 adjustment for fat mass in kilograms).

Results

Seven single-nucleotide polymorphisms (SNPs) in separate loci, including one novel LM locus (TNRC6B), were successfully replicated in an additional 47,227 individuals from 29 cohorts. Based on the strengths of the associations in Model 1 vs Model 3, we divided the LM loci into those with an effect on both lean mass and fat mass in the same direction and refer to those as "sumo wrestler" loci (FTO and MC4R). In contrast, loci with an impact specifically on LM were termed "body builder" loci (VCAN and ADAMTSL3). Using existing available genome-wide association study databases, LM increasing alleles of SNPs in sumo wrestler loci were associated with an adverse metabolic profile, whereas LM increasing alleles of SNPs in "body builder" loci were associated with metabolic protection.

Conclusions

In conclusion, we identified one novel LM locus (TNRC6B). Our results suggest that a genetically determined increase in lean mass might exert either harmful or protective effects on metabolic traits, depending on its relation to fat mass.

Correction to: Hip fracture trends in the United States, 2002 to 2015

The name of the first author, E.M. Lewiecki, was rendered incorrectly in the original publication. The publisher regrets any inconvenience and is pleased to correct the error here.

Factors associated with physical inactivity in adult breast cancer survivors-A population-based study

Background

Physical activity has been shown to reduce the risk of breast cancer‐specific mortality. Although factors associated with physical inactivity in breast cancer survivors have been studied, a detailed examination at the population level is still lacking.

Methods

We addressed this gap in 1236 women with a diagnosis of breast cancer from the 2016 Behavioral Risk Factor Surveillance System Cancer Survivorship module. Physical inactivity was defined as self‐reported absence of leisure time physical activity. Factors examined in the multivariable logistic regression model included sociodemographic, behavioral factors, access to health care, health history, current cancer treatment, and pain from cancer or treatment.

Results

Overall, older age (≥65 years: OR = 2.63, 95% CI: 1.25‐5.55) and being underweight (BMI <18.5: OR = 6.11, 95% CI: 1.35‐27.66), were identified as significant factors associated with physical inactivity. In models adjusting for sociodemographics (Model 1), and the prior plus behavioral factors (Model 2), pain from cancer or treatment was significantly associated with physical inactivity (Model 2: OR = 2.23, 95% CI: 1.16‐4.28); however, after fully adjusting for all variables (Model 3), there was no longer evidence of a significant association between pain from cancer and physical activity in female survivors with breast cancer.

Conclusions

We identified demographic (older age) and physical (low BMI and pain) factors to be significantly associated with physical inactivity among breast cancer survivors. Future interventions to promote physical activity in breast cancer survivors could benefit by taking into account these factors to develop tailored recommendations for increasing activity.

The prevalence of overtreatment of osteoporosis: results from the PAADRN trial

Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication.

PURPOSE

There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs.

METHODS

One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables-sex, race/ethnicity, educational attainment, and differences across health systems-and overtreatment using a series of multivariable logistic regression models.

RESULTS

Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers.

CONCLUSION

In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01507662.

Body composition and physical function in the Women's Health Initiative Observational Study

Physical function is critical for mobility and quality of life. We hypothesized that higher total lean mass is associated with higher physical function, and body fat inversely associated, among postmenopausal women. Women's Health Initiative Observational Study participants at Pittsburgh, PA; Birmingham, AL; and Tucson-Phoenix, AZ (1993–1998) completed dual-energy X-ray absorptiometry scans and the Rand SF-36 questionnaire at baseline and 3 y (N = 4526). Associations between quartiles (Q1–4) of lean or fat mass and physical function were tested using linear regression, adjusted for demographics, lifestyle factors, medical history, and scanner serial number. At baseline, participants had a mean ± SD age of 63.4 ± 7.4 y and BMI of 27.4 ± 5.8 kg/m². Higher percent lean mass was positively associated with physical function at baseline (Q4, 83.6 ± 0.6 versus Q1, 74.6 ± 0.7; p < 0.001), while fat mass (kg and %) was inversely associated (e.g., Q4, 73.7 ± 0.7 versus Q1, 84.2 ± 0.7 kg; p_trend < 0.001). Physical function had declined across the cohort at 3 y; the highest relative lean mass quartile at baseline conferred a lesser decline in physical function than the lowest (Q4, −3.3 ± 0.6 versus Q1–7.0 ± 0.6; p_trend < 0.001), while the highest fat mass quartile (% and kg) conferred greater decline (ex. Kg Q4, −6.7 ± 0.7 versus Q1–2.8 ± 0.6; p_trend < 0.001). Increased fat mass (≥5%), but not lean mass, was associated with lower physical function at 3 y (p < 0.001). Adiposity, as well as lean mass, requires consideration in the prediction of physical function among postmenopausal women over time.

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Lean mass (%) is positively associated with physical function in menopause.

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Body fat is negatively associated with physical function in menopause.

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Decline in physical function is more rapid with gains in fat during menopause.

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Body composition influence on functional decline is more evident among women <65 y.

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

The epidemiology of wrist fractures in older men: the Osteoporotic Fractures in Men (MrOS) study

There is limited wrist fracture information on men. Our goal was to calculate frequency and identify risk factors for wrist fracture in the Osteoporotic Fractures in Men (MrOS) study. We confirmed that fracture history and certain medications are predictors, and identified novel predictors including markers of kidney function and physical performance.

INTRODUCTION

To calculate the incidence of wrist fractures and their risk factors in older community-dwelling men from the US Osteoporotic Fractures in Men (MrOS) study.

METHODS

Using triannual postcards, we identified incident wrist fractures (centrally confirmed by radiology) in men aged ≥ 65. Potential risk factors included the following: demographics, lifestyle, bone mineral density (BMD), selected medications, biomarkers, and physical function and performance measures. Both baseline and time-varying models were adjusted for age, race/ethnicity, MrOS geographic location, and competing mortality risks.

RESULTS

We observed 97 incident wrist fractures among 5875 men followed for an average of 10.8 years. The incidence of wrist fracture was 1.6 per 1000 person-years overall and ranged from 1.0 among men aged 65-69 to 2.4 among men age ≥ 80. Significant predictors included the following: fracture history after age 50 [hazard ratio (95% CI): 2.48 (1.65, 3.73)], high serum phosphate [1.25 (1.02, 1.53)], use of selective serotonin receptor inhibitor (SSRI) [3.60 (1.96, 6.63), decreased right arm BMD [0.49 (0.37, 0.65) per SD increase], and inability to perform the grip strength test [3.38 (1.24, 9.25)]. We did not find associations with factors commonly associated with wrist and other osteoporosis fractures like falls, diabetes, calcium and vitamin D intake, and alcohol intake.

CONCLUSIONS

Among these older, community-dwelling men, we confirmed that fracture history is a strong predictor of wrist fractures in men. Medications such as SSRIs and corticosteroids also play a role in wrist fracture risk. We identified novel risk factors including kidney function and the inability to perform the grip strength test.

Prevalence of Osteoporosis and Low Bone Mass Among Puerto Rican Older Adults

Historically, osteoporosis has not been considered a public health priority for the Hispanic population. However, recent data indicate that Mexican Americans are at increased risk for this chronic condition. Although it is well established that there is heterogeneity in social, lifestyle, and health-related factors among Hispanic subgroups, there are currently few studies on bone health among Hispanic subgroups other than Mexican Americans. The current study aimed to determine the prevalence of osteoporosis and low bone mass (LBM) among 953 Puerto Rican adults, aged 47 to 79 years and living on the US mainland, using data from one of the largest cohorts on bone health in this population: The Boston Puerto Rican Osteoporosis Study (BPROS). Participants completed an interview to assess demographic and lifestyle characteristics and bone mineral density measures. To facilitate comparisons with national data, we calculated age-adjusted estimates for osteoporosis and LBM for Mexican American, non-Hispanic white, and non-Hispanic black adults, aged ≥50 years, from the National Health and Nutrition Examination Survey (NHANES). The overall prevalence of osteoporosis and LBM were 10.5% and 43.3% for participants in the BPROS, respectively. For men, the highest prevalence of osteoporosis was among those aged 50 to 59 years (11%) and lowest for men ≥70 years (3.7%). The age-adjusted prevalence of osteoporosis for Puerto Rican men was 8.6%, compared with 2.3% for non-Hispanic white, and 3.9% for Mexican American men. There were no statistically significant differences between age-adjusted estimates for Puerto Rican women (10.7%), non-Hispanic white women (10.1%), or Mexican American women (16%). There is a need to understand specific factors contributing to osteoporosis in Puerto Rican adults, particularly younger men. This will provide important information to guide the development of culturally and linguistically tailored interventions to improve bone health in this understudied and high-risk population. © 2017 American Society for Bone and Mineral Research.

Hip fracture trends in the United States, 2002 to 2015

An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures.

INTRODUCTION

Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates.

METHODS

We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population.

RESULTS

We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015.

CONCLUSIONS

The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.

Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study

Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors.

PURPOSE

The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care.

METHODS

Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models.

RESULTS

In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031).

CONCLUSIONS

Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care.

TRIAL REGISTRATION

The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

The impact of the new National Bone Health Alliance (NBHA) diagnostic criteria on the prevalence of osteoporosis in the United States: supplementary presentation

We evaluated the prevalence of osteoporosis using the osteoporosis diagnostic criteria developed by the National Bone Health Alliance (NBHA), which includes qualified fractures, FRAX score in addition to BMD. The expanded definition increases the prevalence compared to BMD alone definitions; however, it may better identify those at elevated fracture risk. Recently an NBHA working Group published a paper in OI with recommendations for expanding the criteria that would constitute an osteoporosis diagnosis in postmenopausal women and in men over age 50 for use in the US - Siris et al., Osteoporosis International 25(%): 1439-1443, 2014. The recommendations have now been endorsed by NOF, ASBMR and a number of professional medical groups and appear in the NOF Clinician's Guide. The new diagnostic criteria continue to include a T-score by DXA of spine or hip that is less than or equal to -2.5, but alternatively also include a hip fracture with or without BMD testing or a vertebral, pelvis, proximal humerus and in some cases a distal forearm fracture in a person with low bone mass, or a FRAX score that meets or exceeds the NOF Guide osteoporosis treatment cut point.

The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75.

INTRODUCTION

Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention.

METHODS

The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed.

RESULTS

Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41.

CONCLUSION

An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT01507662.

Activating Patients With a Tailored Bone Density Test Results Letter and Educational Brochure: the PAADRN Randomized Controlled Trial

In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk (p < 0.001) and to 77.2 (p = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels.

The effects of a patient activation intervention on smoking and excessive drinking cessations: results from the PAADRN randomized controlled trial

Patients may exhibit risky bone health behaviors. In a large pragmatic clinical trial, we tested whether a tailored patient activation DXA result letter accompanied by a bone health brochure led to smoking and excessive drinking cessations. The intervention did not, however, alter these risky bone health behaviors.

INTRODUCTION

Besides dual-energy x-ray absorptiometry (DXA) screening and pharmacotherapy when indicated, beneficial bone health behaviors including proper calcium and vitamin D intake and weight-bearing and muscle-strengthening exercise should be encouraged. Similarly, risky bone health behaviors like smoking and excessive drinking should be discouraged. We examined whether a direct-to-patient activation intervention led to smoking and excessive drinking cessations.

METHODS

The Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial enrolled 7749 patients between February 2012 and August 2014. Interviews occurred at baseline and 12 and 52 weeks later. Intervention subjects were mailed an individually tailored DXA results letter accompanied by a bone health educational brochure 4 weeks post-DXA. Usual care subjects were not sent these materials. Smoking and excessive drinking were assessed by self-report at each interview. Intention-to-treat linear probability models were used.

RESULTS

Mean age was 66.6 years, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Smoking was reported at baseline by 7.6% of the intervention group vs. 7.7% of the usual care group (p = 0.873). Excessive drinking was reported at baseline by 6.5% of the intervention group vs. 6.5% of the usual care group (p = 0.968). Intention-to-treat analyses indicated no significant differences between the intervention vs. usual care groups at either 12 or 52 weeks post-DXA (all p values ≥ 0.346).

CONCLUSION

An individually tailored DXA result letter accompanied by an educational brochure did not lead to smoking or excessive drinking cessations in patients who received DXA.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT01507662.

Assessing the feasibility of the Effectiveness of Discontinuing Bisphosphonates trial: a pilot study

The Effectiveness of Discontinuing Bisphosphonates (EDGE) study is a planned pragmatic clinical trial to guide "drug holiday" clinical decision making. This pilot study assessed work flow and feasibility of such a study. While participant recruitment and treatment adherence were suboptimal, administrative procedures were generally feasible and minimally disrupted clinic flow.

INTRODUCTION

The comparative effectiveness of continuing or discontinuing long-term alendronate (ALN) on fractures is unknown. A large pragmatic ALN discontinuation study has potential to answer this question.

METHODS

We conducted a 6-month pilot study of the planned the EDGE study among current long-term ALN users (women aged ≥65 with ≥3 years of ALN use) to determine study work flow and feasibility including evaluating the administrative aspects of trial conduct (e.g., time to contract, institutional review board (IRB) approval), assessing rates of site and participant recruitment, and evaluating post-randomization outcomes, including adherence, bisphosphonate-associated adverse events, and participant and site satisfaction. We assessed outcomes 1 and 6 months after randomization.

RESULTS

Nine sites participated, including seven community-based medical practices and two academic medical centers. On average (SD), contract execution took 3.4 (2.3) months and IRB approval took 13.9 (4.1) days. Sites recruited 27 participants (13 to continue ALN and 14 to discontinue ALN). Over follow-up, 22% of participants did not adhere to their randomization assignment: 30.8% in the continuation arm and 14.3% in the discontinuation arm. No fractures or adverse events were reported. Sites reported no issues regarding work flow, and participants were highly satisfied with the study.

CONCLUSIONS

Administrative procedures of the EDGE study were generally feasible, with minimal disruption to clinic flow. In this convenience sample, participant recruitment was suboptimal across most practice sites. Accounting for low treatment arm adherence, a comprehensive recruitment approach will be needed to effectively achieve the scientific goals of the EDGE study.

Large meta-analysis of genome-wide association studies identifies five loci for lean body mass

Lean body mass, consisting mostly of skeletal muscle, is important for healthy aging. We performed a genome-wide association study for whole body (20 cohorts of European ancestry with n = 38,292) and appendicular (arms and legs) lean body mass (n = 28,330) measured using dual energy X-ray absorptiometry or bioelectrical impedance analysis, adjusted for sex, age, height, and fat mass. Twenty-one single-nucleotide polymorphisms were significantly associated with lean body mass either genome wide (p < 5 × 10⁻⁸) or suggestively genome wide (p < 2.3 × 10⁻⁶). Replication in 63,475 (47,227 of European ancestry) individuals from 33 cohorts for whole body lean body mass and in 45,090 (42,360 of European ancestry) subjects from 25 cohorts for appendicular lean body mass was successful for five single-nucleotide polymorphisms in/near HSD17B11, VCAN, ADAMTSL3, IRS1, and FTO for total lean body mass and for three single-nucleotide polymorphisms in/near VCAN, ADAMTSL3, and IRS1 for appendicular lean body mass. Our findings provide new insight into the genetics of lean body mass.

Lean body mass is a highly heritable trait and is associated with various health conditions. Here, Kiel and colleagues perform a meta-analysis of genome-wide association studies for whole body lean body mass and find five novel genetic loci to be significantly associated.

Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy

OBJECTIVES

As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence.

METHODS

Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence.

RESULTS

Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%).

CONCLUSION

One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.

Improving medical record retrieval for validation studies in Medicare data

PURPOSE

The purpose of the study is to describe medical record retrieval for a study validating claims-based algorithms used to identify seven adverse events of special interest (AESI) in a Medicare population.

METHODS

We analyzed 2010-2011 Medicare claims of women with postmenopausal osteoporosis and men ≥65 years of age in the Medicare 5% national sample. The final cohorts included beneficiaries covered continuously for 12+ months by Medicare parts A, B, and D and not enrolled in Medicare Advantage before starting follow-up. We identified beneficiaries using each AESI algorithm and randomly selected 400 women and 100 men with each AESI for medical record retrieval. The Centers for Medicare and Medicaid Services provided beneficiary contact information, and we requested medical records directly from providers, without patient contact.

RESULTS

We selected 3331 beneficiaries (women: 2272; men: 559) for whom we requested 3625 medical records. Overall, we received 1738 [47.9% (95%CI 46.3%, 49.6%)] of the requested medical records. We observed small differences in the characteristics of the total population with AESIs compared with those randomly selected for retrieval; however, no differences were seen between those selected and those retrieved. We retrieved 54.7% of records requested from hospitals compared with 26.3% of records requested from physician offices (p < 0.001). Retrieval did not differ by sex or vital status of the beneficiaries.

CONCLUSIONS

Our national medical record validation study of claims-based algorithms produced a modest retrieval rate. The medical record procedures outlined in this paper could have led to the improved retrieval from our previous medical record retrieval study. Copyright © 2016 John Wiley & Sons, Ltd.

The impact of the new National Bone Health Alliance (NBHA) diagnostic criteria on the prevalence of osteoporosis in the USA

We evaluated the prevalence of osteoporosis using the osteoporosis diagnostic criteria developed by the National Bone Health Alliance (NBHA), which includes qualified fractures, FRAX score in addition to bone mineral density (BMD). The expanded definition increases the prevalence compared to BMD alone definitions; however, it may better identify those at elevated fracture risk.

PURPOSE

The purpose of this paper is to estimate the prevalence of osteoporosis in US adults ≥50 years using the NBHA osteoporosis diagnostic criteria.

METHODS

Utilizing 2005-2008 data of the National Health and Nutrition Examination Survey (NHANES), we identified participants with osteoporosis with any one of the following: (1) femoral neck or lumbar spine T-score ≤ -2.5; (2) low trauma hip fracture irrespective of BMD or clinical vertebral, proximal humerus, pelvis, or distal forearm fracture with a T-score >-2.5 <-1.0; or (3) FRAX score at the National Osteoporosis Foundation intervention thresholds (≥3% for hip fracture or ≥20% for major osteoporotic fracture). We estimated the prevalence overall and by gender and age.

RESULTS

Our sample included 1948 (54.3%) men and 1639 (45.7%) women. Approximately 12% were 80+ years and 21% were from racial/ethnic minority groups. We estimated that 16.0% (0.8) of men and 29.9% (1.0) of women 50+ years have osteoporosis. The prevalence increases with age to 46.3% in men and 77.1% in women 80+ years. The combination of FRAX score and fractures was the largest contributing factor defining osteoporosis in men (70-79, 88.1%; 80+, 80.1%), whereas T-score was the largest contributing factor in women (70-79, 49.2%; 80+, 43.5%).

CONCLUSIONS

We found that 16% of men and 29.9% of women 50+ have osteoporosis based on the NBHA diagnostic criteria. Although the expanded definition increases the prevalence compared to BMD alone-based definitions, it may better identify those at elevated fracture risk in order to reduce the burden of fractures in older adults.

Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial

Patients often do not know or understand their bone density test results, and pharmacological treatment rates are low. In a clinical trial of 7749 patients, we used a tailored patient-activation result letter accompanied by a bone health brochure to improve appropriate pharmacological treatment. Treatment rates, however, did not improve.

INTRODUCTION

Patients often do not know or understand their dual-energy x-ray absorptiometry (DXA) test results, which may lead to suboptimal care. We tested whether usual care augmented by a tailored patient-activation DXA result letter accompanied by an educational brochure would improve guideline-concordant pharmacological treatment compared to usual care only.

METHODS

We conducted a randomized, controlled, double-blinded, pragmatic clinical trial at three health care centers in the USA. We randomized 7749 patients ≥50 years old and presenting for DXA between February 2012 and August 2014. The primary clinical endpoint at 12 and 52 weeks post-DXA was receiving guideline-concordant pharmacological treatment. We also examined four of the steps along the pathway from DXA testing to that clinical endpoint, including (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options.

RESULTS

Mean age was 66.6 years, 83.8 % were women, and 75.3 % were non-Hispanic whites. Intention-to-treat analyses revealed that guideline-concordant pharmacological treatment was not improved at either 12 weeks (65.1 vs. 64.3 %, p = 0.506) or 52 weeks (65.2 vs. 63.8 %, p = 0.250) post-DXA, even though patients in the intervention group were more likely (all p < 0.001) to recall receiving their DXA results letter at 12 weeks, correctly identify their results at 12 and 52 weeks, have contact with their provider at 52 weeks, and have discussed their results with their provider at 12 and 52 weeks.

CONCLUSION

A tailored DXA result letter and educational brochure failed to improve guideline-concordant care in patients who received DXA.

Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure

CONTEXT

Patient education materials can provide important information related to osteoporosis prevention and treatment. However, available osteoporosis education materials fail to follow best-practice guidelines for patient education.

OBJECTIVE

To develop an educational brochure on bone health for adults aged 50 years and older using mixed-method, semistructured interviews.

DESIGN

This project consisted of 3 phases. In Phase 1, we developed written content that included information about osteoporosis. Additionally, we designed 2 graphic-rich brochures, Brochure A (photographs) and Brochure B (illustrations). In Phase 2, interviewers presented the text-only document and both brochure designs to 53 participants from an academic Medical Center in the Midwest and an outpatient clinic in the Southeastern region of the US. Interviewers used open- and closed-ended questions to elicit opinions regarding the brochures. In Phase 3, using feedback from Phase 2, we revised the brochure and presented it to 11 participants at a third site in the Southeastern US.

MAIN OUTCOME MEASURES

Participants' comprehension of brochure text and acceptability of brochure design.

RESULTS

We enrolled 64 participants. Most were women, white, and college-educated, with an average age of 66.1 years. Participants were able to restate the basic content of the brochure and preferred Brochure A's use of photographs.

CONCLUSIONS

Using feedback from older adults, we developed and refined a brochure for communicating bone health information to older adults at risk of osteoporosis and fragility fractures. The methods outlined in this article may serve to guide others in developing health educational brochures for chronic medical conditions.

Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial

Background

Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge.

Methods

The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates.

Results

At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point.

Conclusions

A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care.

Trial registration

Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.

Understanding practice-based research participation: The differing motivations of engaged vs. non-engaged clinicians in pragmatic clinical trials

Background/Aims

Pragmatic clinical trials (PCTs) represent an increasingly used strategy for “real-world” trials. Successful PCTs typically require participation of community-based practices. However, community clinicians often have limited interest or experience in clinical research. Many barriers to practice-based research have been described, but possible motivations to participate among community practices not active in research have not been well explored. The tendency is for researchers to assume similar motivations and priorities across all candidate practices. This is not necessarily the case. A better understanding of the range of reasons clinicians might see for participating in pragmatic trials could be key to promoting this type of practice-based research.

Methods

Semi-structured interviews were conducted with 30 clinicians and staff members. Half of the interviewees had experience doing practice-based clinical trials and half did not. Individuals in these two groups were also diversified in terms of their practice size and location. Participants were asked about motivations and barriers to doing practice-based research in the context of a planned osteoporosis pragmatic clinical trial. Interviews were transcribed, coded, and analyzed.

Results

Barriers identified for both experienced and not-experienced clinicians and staff members included: a lack of time, increased paperwork, disruption to work flows, and concern over practice finances. Similar findings have been reported in the US, UK, Europe, and Australia. However, regarding positive motivations of practices to participate, we found systematic differences in attitude between research-engaged and research-naïve practices that have not been previously reported. The research-experienced group offered a greater number and variety of reasons to take part than the not-experienced group. While both groups expressed motivations related to patient care, clinicians and staff members experienced in practice-based clinical trials were much more likely to cite intellectual, professional, and societal benefits not envisioned by the other group.

Conclusions

We conclude that clinicians not already participating in practice-based trials may have a narrower range of motivations than those already participating. The lack of a broader view of possible benefits to participation may also translate into more obdurate recruiting challenges. These results point to the need for recruitment, engagement, and messaging approaches differentially tailored to the needs and interests of non-participating practices.

Association of Reduced eGFR and Albuminuria with Serious Fall Injuries among Older Adults

BACKGROUND AND OBJECTIVES

Falls are common and associated with adverse outcomes in patients on dialysis. Limited data are available in earlier stages of CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We analyzed data from 8744 Reasons for Geographic and Racial Differences in Stroke Study participants ≥65 years old with Medicare fee for service coverage. Serious fall injuries were defined as a fall-related fracture, brain injury, or joint dislocation using Medicare claims. Hazard ratios (HRs) for serious fall injuries were calculated by eGFR and albumin-to-creatinine ratio (ACR). Among 2590 participants with CKD (eGFR<60 ml/min per 1.73 m(2) or ACR≥30 mg/g), cumulative mortality after a serious fall injury compared with age-matched controls without a fall injury was calculated.

RESULTS

Overall, 1103 (12.6%) participants had a serious fall injury over 9.9 years of follow-up. The incidence rates per 1000 person-years of serious fall injuries were 21.7 (95% confidence interval [95% CI], 20.3 to 23.2), 26.6 (95% CI, 22.6 to 31.3), and 38.3 (95% CI, 31.2 to 47.0) at eGFR levels ≥60, 45-59, and <45 ml/min per 1.73 m(2), respectively, and 21.3 (95% CI, 20.0 to 22.8), 31.7 (95% CI, 27.5 to 36.5), and 42.2 (95% CI, 31.3 to 56.9) at ACR levels <30, 30-299, and ≥300 mg/g, respectively. Multivariable adjusted HRs for serious fall injuries were 0.91 (95% CI, 0.76 to 1.09) and 1.09 (95% CI, 0.86 to 1.37) for eGFR=45-59 and <45 ml/min per 1.73 m(2), respectively, versus eGFR≥60 ml/min per 1.73 m(2) and 1.31 (95% CI, 1.11 to 1.54) and 1.81 (95% CI, 1.30 to 2.50) for ACR=30-299 and ≥300 mg/g, respectively, versus ACR<30 mg/g. Among participants with CKD, cumulative 1-year mortality rates among patients with a serious fall and age-matched controls were 21.0% and 5.5%, respectively.

CONCLUSIONS

Elevated ACR but not lower eGFR was associated with serious fall injuries. Evaluation for fall risk factors and fall prevention strategies should be considered for older adults with elevated ACR.

Bone Mineral Density as a Predictor of Subsequent Wrist Fractures: Findings From the Women's Health Initiative Study

CONTEXT

Wrist fractures are common among postmenopausal women. Associations of bone mineral density (BMD) and 10-year predicted risk of major osteoporotic fracture (MOF) with wrist fractures are poorly characterized.

OBJECTIVE

The objective was to examine associations between the Fracture Risk Assessment Tool (FRAX)-predicted risk of MOF, BMD, BMD change, and wrist fracture.

DESIGN

This was a prospective observational study with a mean follow-up of 8.5 years.

SETTING

This study included 40 US centers.

PARTICIPANTS

A total of 11 392 participants from the Women's Health Initiative BMD Cohort aged 50-79 years at baseline were included in this study.

INTERVENTIONS

None.

MAIN OUTCOME

The goal was to measure incident wrist fracture.

RESULTS

A FRAX-predicted MOF risk ≥9.3% identified 17% of the women aged <65 years who subsequently experienced wrist fracture. Each one standard deviation lower BMD was associated with higher wrist fracture risk, with adjusted hazard ratio (95% confidence interval) of 1.66 (1.42-1.93) for femoral neck (FN) BMD and 1.45 (1.28-1.64) for lumbar spine BMD. Compared with FN BMD T score ≥ -1.0, wrist fracture adjusted hazard ratios (95% confidence interval) were: 1.51 (1.06-2.16) for a T score between -1.01 and -1.49; 1.93 (1.36-2.72) for T score between -1.50 and -1.99; 2.52 (1.77-3.60) for a T score between -2.00 and -2.49; and 2.65 (1.78-3.95) for a T score ≤ -2.5. Decrease in FN BMD between baseline and year 3 was associated with increased risk of subsequent wrist fracture; however, change in lumbar spine BMD was not.

CONCLUSIONS

Lumbar spine and femoral neck BMDs were associated with incident wrist fracture, but the FRAX threshold recommended to identify screening candidates did not identify the majority of women who subsequently experienced wrist fracture. Improved understanding of determinants of wrist fractures is warranted.