Influence of fracture history and bone mineral density testing on the treatment of osteoporosis in two non-academic community centers

Osteoporosis prevention and osteoporosis exercise in community-based public health programs

Osteoporosis is a serious public health concern worldwide, and community-based public health programs that increase osteoporosis preventive behaviors are ideal to combat this major public health issue. A review of community-based public health programs for osteoporosis prevention show that programs vary in numerous ways and have mixed results in increasing osteoporosis preventive behaviors, although most programs have had success in significantly increasing calcium intake, only a few programs have had success in significantly increasing weight-bearing exercise. Regarding calcium intake, all community-based public health programs that implemented: 1) at least one theoretical behavior change model, such as the health belief model, or 2) bone mineral density (BMD) testing for osteoporosis screening, have shown success in significantly increasing calcium intake. As community-based public health programs for osteoporosis prevention have shown limited success in increasing weight-bearing exercise, an additional review of community-based public health programs incorporating osteoporosis exercise showed that they have high compliance rates to increase weight-bearing exercise, but require high-intensity weight-bearing exercise of 80-85% 1-repetition maximum to significantly increase BMD to prevent osteoporosis. In the prevention of osteoporosis, for community-based public health programs to be most effective, they should implement theoretical behavior change models and/or BMD testing for osteoporosis screening, along with high-intensity resistance training. Recommendations for future research to further study effective community-based public health programs are also provided.

Osteoporosis Treatment for Patients with Stroke

PURPOSE

Little is known about the frequency of use of medications to maintain bone health for patients with stroke. This study was undertaken at an urban academic rehabilitation center to determine the prevalence of use of agents that could reduce bone loss in the stroke population.

METHOD

A clinical database was searched for all patients 18 years old and over with stroke. The sample included 1,219 inpatients and 2,776 outpatients. Demographic information (age, gender, and race) and medications were obtained for each patient.

RESULTS

Among inpatients with stroke, 7.1% were taking osteoporosis medications (bisphosphonates, calcitonin, parathyroid hormone, or hormone replacement therapy), 11.3% were taking calcium supplements, 5.9% were taking vitamin D supplements, and 45.1% were taking multivitamin supplements. Among outpatients with stroke, 5.7% were taking osteoporosis medication, 5.8% were taking calcium supplements, 2.2% were taking vitamin D supplements, and 16.0% were taking multivitamin supplements. Patients being treated with specific osteoporosis therapies tended to be older and female by calculated odds ratios. The use of multivitamins was not related to age, gender, or race.

CONCLUSION

Overall, relatively few stroke patients were taking osteoporosis medications or supplements. There is a need to increase the recognition, prevention, and treatment of bone loss in this high-risk population.

Patterns of anti-osteoporosis medication use among women at high risk of fracture: findings from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

Objective

To assess patterns of anti-osteoporosis medication (AOM) use over 3 years among women at high risk of major fracture.

Methods

The GLOW registry follows a cohort of more than 40,000 women aged ≥55 from 615 primary care practices in 10 countries. Self-administered surveys (baseline, 12, 24, and 36 months) collected data on patient characteristics, perception of fracture risk, and AOM use. FRAX scores were calculated from the baseline surveys and women classified as high risk if their FRAX 10-year probability of major fracture was ≥20%.

Results

A total of 5774 women were classified as at high risk and had complete data over 3 years. At baseline, 2271 (39%) reported receiving AOM, 739 (13%) reported prior but not current use, and 2764 (48%) said they had never used AOM. Over 3 years, 85% of baseline non-users continued as non-users and 15% initiated AOM; among baseline users, 49% continued the same medication class, 29% stopped AOM, and 12% switched. Women who stopped AOM were less likely to self-report osteoporosis (HR 0.56, 95% CI 0.42–0.75) than women who continued AOM. Compared with non-users who did not begin treatment, women initiating AOM were more likely to report a diagnosis of osteoporosis (HR 11.3, 95% CI 8.2–15.5) or osteopenia (HR 4.1, 95% CI 2.9–5.7) and be very concerned about osteoporosis (HR 1.9, 95% CI 1.3–2.8).

Conclusions

Less than 40% of women at high risk of fracture reported taking AOM. Women who stopped AOM were less likely to believe they have osteoporosis. Women who initiated treatment appeared motivated primarily by a diagnosis of osteoporosis or osteopenia and concern about the condition.

Characteristics associated with anti-osteoporosis medication use: data from the Global Longitudinal Study of Osteoporosis in Women (GLOW) USA cohort

INTRODUCTION

Many women at risk of fracture do not receive anti-osteoporosis medication (AOM), while others may be receiving unnecessary treatment.

PURPOSE

To examine the characteristics associated with AOM use among women at low and high risks of fracture.

METHODS

The Global Longitudinal Study of Osteoporosis in Women (GLOW) is a prospective cohort study in which data were collected, via self-administered questionnaires, from 60,393 non-institutionalized women aged ≥ 55 years in 10 countries between October 1, 2006 and April 30, 2008. This is a cross-sectional analysis of baseline USA data, in which women were classified as having low fracture risk (<65 years; no FRAX risk factors) or high fracture risk (≥65 years; prior fracture or ≥ 2 other FRAX risk factors).

RESULTS

Of 27,957 women, 3013 were at low risk of fracture and 3699 were at high risk. Only 35.7% of high-risk women reported AOM treatment, rising to 39.5% for those with self-reported osteopenia and 65.4% for those with self-reported osteoporosis. Conversely, 13.4% of low-risk women reported AOM, rising to 28.7% for osteopenia and 62.4% for osteoporosis. Characteristics associated with significantly higher AOM treatment rates among low- and high-risk women were: osteoporosis (odds ratios 75.3 and 18.1, respectively), osteopenia (17.9 and 6.3), concern about osteoporosis (2.0 and 1.8), higher perceived risk of fracture (2.3 and 1.6), and higher vitality score (1.7 and 1.6).

CONCLUSION

Use of AOM is frequently inconsistent with published guidelines in both high- and low-risk women. Characteristics other than FRAX fracture risk appear to influence this use, particularly the presence of self-reported osteoporosis.

Development of an electronic medical record based intervention to improve medical care of osteoporosis

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. An EMR-based intervention (osteoporosis order set) was developed with physician and patient input. There was a trend toward greater calcium supplementation from July 2008 to April 2009 (s = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

INTRODUCTION

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. The study population consisted of patients over 50 years of age.

METHODS

Northwestern Memorial Hospital is a tertiary care academic hospital in Chicago. This study was conducted from September 1, 2007 through June 30, 2009.

RESULTS

Physicians reported that barriers to care comprised nonacute nature of osteoporosis, belief that osteoporosis should be addressed by the PCP, low awareness of recurrent fractures, and radiographs with terms such as "compression deformity", "wedge deformity", or "vertebral height loss" which in their opinion were not clearly indicative of vertebral fractures. An EMR-based intervention was developed with physician and patient input. Over the evaluation period, 295 fracture cases in individuals over the age of 50 years in the medicine floors were analyzed. Mean age was 72 ± 11 years; 74% were female. Sites of fracture included hip n = 78 (27%), vertebral n = 87 (30%), lower extremity n = 61 (21%), upper extremity n = 43 (15%) and pelvis n = 26 (9%). There was no increase in documentation of osteoporosis in the medical record from pre- to post-EMR implementation (p = 0.89). There was a trend toward greater calcium supplementation from July 2008 to April 2009 (p = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

CONCLUSION

An electronic medical record intervention without electronic reminders created with physician input achieves an increase in calcium supplementation but fails to increase diagnosis or treatment for osteoporosis at the time of hospitalization for a fragility fracture.

Addressing secondary prevention of osteoporosis in fracture care: follow-up to "own the bone"

The majority of the 1.8 million individuals who sustain a fracture annually in the United States have osteopenia or osteoporosis, yet <15% of these patients subsequently receive treatment for osteoporosis. A prospective cohort study was conducted to assess the effect of two different interventions on the rate of osteoporosis treatment in patients with a fragility fracture. Patients who were fifty years of age or older and were hospitalized for the treatment of a fragility fracture at either of two academic institutions were eligible for inclusion in the study. The intervention at one hospital involved immediate care for osteoporosis, including initiation of pharmacologic therapy during hospitalization. The intervention at the other hospital involved delayed care, including recommendations for osteoporosis counseling, bone-mineral density testing, and potential treatment for osteoporosis that were communicated to the primary care physician after the patient was discharged from the hospital. Patients were surveyed by telephone six months after the fracture, and their medical and pharmacy records were reviewed to verify the osteoporosis treatment that they had received. The mean age was 73 ± 10 years in the immediate-care group and 74 ± 12 years in the delayed-care group. Eighty percent of the patients were women. Sixty-five percent of the patients in each group completed the telephone interview six months after the fracture, and most had seen their primary care physician and undergone bone-mineral density testing. The rate of bone-mineral density testing was 92% in the immediate-care group compared with 76% in the delayed-care group. Both immediate and delayed care for osteoporosis resulted in a significant increase in the treatment rate compared with the baseline rate of 0% (p < 0.001). However, the primary care physician had initiated osteoporosis therapy by six months after the fracture in only 30% of the patients in the delayed-care group compared with a treatment rate of 67% in the immediate-care group (p < 0.001). Limitations of the study include the possibility that the findings resulted from a difference between the two study centers rather than between the two strategies. In addition, because of the academic and integrated nature of the medical systems at which the study was conducted, the findings cannot necessarily be extrapolated to other types of institutions. In summary, a recommendation for osteoporosis treatment made by an orthopaedic surgeon to the patient's primary care physician resulted in an increase in the rate of bone-mineral density testing and in the rate of therapy compared with baseline. However, immediate initiation of osteoporosis care during hospitalization for the fragility fracture resulted in a higher rate of treatment--with two-thirds of the patients receiving therapy six months after the fracture--compared with delayed initiation.

Increased serum osteopontin is a risk factor for osteoporosis in menopausal women

SUMMARY

Osteopontin (OPN)-deficient mice are resistant to ovariectomy-induced osteoporosis. Therefore, we hypothesized that women with OPN overexpression may show less resistance to postmenopausal osteoporosis. In this study, we first demonstrated that serum OPN levels could be used as a biomarker for the early diagnosis of osteoporosis in postmenopausal women.

INTRODUCTION

Animal studies indicate that OPN-deficient mice are resistant to ovariectomy-induced osteoporosis.

METHODS

From 2004 to 2006, 124 women over the age of 45 were enrolled in a menopausal group, while another 95 women, from 25 to 45 years of age with regular menstruation, were enrolled into a childbearing age group. The serum concentrations of OPN were calculated using the enzyme-link immunosorbent assay method, and bone mineral densities were determined with dual energy X-ray absorptiometry.

RESULTS

Serum OPN levels had a significant positive correlation with age (menopausal group, p < 0.0001) and a negative correlation with body weight, height, hip bone mineral density, and T-scores in the menopausal group. In contrast, there was a positive correlation with the E2 concentration and height, but there was no significant association with the above variables in the childbearing age group. Additionally, high serum OPN levels (>14.7 ng/ml) was a significant risk factor causing menopausal osteoporosis (odds ratio = 2.96, 95% confidence interval, 1.055-8.345).

CONCLUSION

Serum OPN levels could be used as a biomarker for the early diagnosis of osteoporosis in postmenopausal women.

Direct-to-participant feedback and awareness of bone mineral density testing results in a population-based sample of mid-aged Canadians

This population-based study of mid-aged Canadians assessed awareness of diagnosis by bone mineral density (BMD) following dual-energy X-ray absorptiometry (DXA) testing and compared the effects of feedback only to the physician with direct-to-participant feedback. Poor recall of osteoporosis results was observed irrespective of the feedback destination, but direct-to-participant feedback improved recall of borderline or normal results.

INTRODUCTION

BMD testing provides information about fracture risk. This study assessed whether awareness of results, in a random population sample of mid-aged Canadians, differed if results were provided to physicians only or directly to participants.

METHODS

Prospective cohort study of 2,678 women and men aged 40-60 years from the Canadian Multicentre Osteoporosis Study. Participants completed hip and spine DXA and interviewer-administered questionnaires regarding demographics and osteoporosis risk factors. Lateral spine X-rays were conducted on those > or =50 years of age. All test results were reported to the participant, the family physician or both. Associations between BMD results, feedback destination and correct self-report results, 3 years later, were assessed using logistic regression while adjusting for potential confounders.

RESULTS

Only 25% of men and 33% of women correctly reported their osteoporosis diagnoses. Direct-to-participant vs. physician-only reports did not improve recall of osteoporosis diagnosis but improved recall of borderline or normal BMD. Older (vs. younger) men and men with prevalent vertebral fractures demonstrated better recall of their osteoporosis diagnosis.

CONCLUSIONS

Recall of low BMD results was poor, despite direct-to-participant feedback and even in the presence of other osteoporosis risk factors. Direct-to-participant feedback may improve awareness of borderline or normal BMD results.

Closing the osteoporosis care gap: increased osteoporosis awareness among geriatrics and rehabilitation teams

Background

A care gap exists between recommendations and practice regarding the diagnosis and treatment of osteoporosis in fracture patients. The current study was designed to determine rates and predictors of in-hospital diagnosis and treatment of osteoporosis in patients admitted with fragility hip fractures, and to assess differences in these rates since the outset of the multipronged "Fracture? Think Osteoporosis" (FTOP) Program, which includes education of geriatrics and rehabilitation teams.

Methods

This is a retrospective cohort study conducted with data from two Hamilton, Ontario, university-based tertiary-care hospitals, and represents a follow-up to a previous study conducted 8 years earlier. Data pertaining to all 354 patients, age >/= 50, admitted between March 2003 and April 2004, inclusive, with a diagnosis of fragility hip fracture were evaluated. Twelve patients were excluded leaving 342 patients for analysis, with 75% female, mean age 81.

Outcomes included: Primary – In-hospital diagnosis of osteoporosis and/or initiation of anti-resorptive treatment ("new osteoporosis diagnosis/treatment"). Secondary – In-hospital mortality, BMD referrals, pre-admission osteoporosis diagnosis and treatment.

Results

At admission, 27.8% of patients had a pre-existing diagnosis of osteoporosis and/or were taking anti-resorptive treatment. Among patients with no previous osteoporosis diagnosis/treatment: 35.7% received a new diagnosis of osteoporosis, 21% were initiated on anti-resorptive treatment, and 14.3% received a BMD referral. The greatest predictor of new osteoporosis diagnosis/treatment was transfer to a rehabilitation or geriatrics unit: 79.5% of rehabilitation/geriatrics versus 18.5% of patients receiving only orthopedics care met this outcome (p < 0.001).

Conclusion

New diagnosis of osteoporosis among patients admitted with hip fracture has improved from 1.8% in the mid 1990's to 35.7%. Initiation of bisphosphonate therapy has likewise improved from 0% to 21%. Although multiple factors have likely contributed, the differential response between rehabilitation/geriatrics versus orthopedics patients suggests that education of the geriatric and rehabilitation teams, including one-on-one and group-based sessions, implemented as part of the FTOP Program, has played a role in this improvement. A significant care gap still exists for patients discharged directly from orthopedic units. The application of targeted inpatient and post-discharge initiatives, such as those that comprise the entire FTOP Program, may be of particular value in this setting.

Age and drug therapy are key prognostic factors for first clinical fracture in patients with primary osteoporosis

We evaluated the characteristics of 1,142 women and men who attended Canadian osteoporosis clinics and had T-score < or = -2.0 and no prior fractures to determine the predictors of first clinical fracture. Greater age and failure to start osteoporosis drug treatment increased the risk of first clinical fracture.

INTRODUCTION

Although risk factors for osteoporotic fractures are well-known, it is unclear which factors predict poor prognosis in patients with primary osteoporosis. The purpose of this study was to determine prognostic factors for first clinical fracture in patients with T-score < or = -2.0 and no previous clinical fracture.

METHODS

We examined prospectively collected data from 1,142 patients aged 40 and over in the Canadian Database of Osteoporosis and Osteopenia. We used prognosis methodology and performed survival analysis to determine factors that increase the risk of first clinical fracture.

RESULTS

Our inception cohort (mean age = 60.6 years, 91% females) had a cumulative fracture incidence of 5.1% (incidence rate: 2.53/100 person-years). Age and osteoporosis drug use predicted incident clinical fractures in multivariable regression analyses. The risk of first fracture increased by 3% per year. Failing to initiate osteoporosis treatment increased fracture risk by 2.4 times. In addition, low physical activity, high body mass index and low T-scores were found to predict fracture risk in certain patient subgroups using tree-structured survival analysis. These findings were robust and did not change with most sensitivity analyses.

CONCLUSION

Age and osteoporosis drug treatment are the main prognostic predictors of first clinical fracture in patients with T-score < or = -2.0.

Osteoporosis-related kyphosis and impairments in pulmonary function: a systematic review

We conducted a systematic review to examine the relationship between osteoporotic vertebral fractures, kyphosis, and pulmonary function. Findings suggest modest but predictable declines in vital capacity related to the degree of kyphosis. However, there were only four studies, and all had significant methodologic limitations. Further high-quality research is needed.

INTRODUCTION

Our objective was to systematically review the extent to which osteoporosis-related vertebral fractures and kyphosis affect pulmonary function.

MATERIALS AND METHODS

We used a literature search from 1966 to 2006 (using Medline, EMBASE, and hand searches of references) for studies examining pulmonary function in patients without known lung disease who had vertebral fractures or kyphosis secondary to osteoporosis. Two reviewers independently abstracted data. Heterogeneity precluded formal meta-analysis.

RESULTS

Initial searches yielded 453 articles. After applying eligibility criteria, only four case-control studies of limited quality (e.g., only one study was blinded) remained. Since 1966, only 109 patients (6 men) have been studied. All four studies reported reductions in vital capacity (VC), with values ranging from 68% to 94% of predicted values. This was quantified as a 9% reduction in predicted VC per vertebral fracture in one study. The degree of kyphosis clinically (one study) or radiographically (three studies) correlated with declines in VC; impairments were most notable at kyphotic angles>55 degrees. Statistically significant differences in percent predicted VC were obtained only when arm span or recalled height, rather than measured height, was used (two studies).

CONCLUSIONS

Despite conventional teaching, the evidence relating osteoporotic vertebral fractures or kyphosis to pulmonary function is limited. On the basis of available studies, declines in VC secondary to kyphosis seem modest and directly related to the number of vertebral fractures or degree of kyphosis. Future studies need longitudinal follow-up of larger numbers of men and women, appropriate proxies for height, standardized measures for pulmonary function and kyphosis, and efforts to blind outcomes ascertainment.

Antebrachial fractures in four captive polar bears (Ursus maritimus)

OBJECTIVE

To identify common risk factors for antebrachial fractures of captive polar bears and to evaluate outcome after fracture repair.

STUDY DESIGN

Retrospective study.

ANIMALS

Four captive polar bears.

METHODS

United States zoological collections were surveyed to determine the prevalence of fractures in captive polar bears. Medical records of captive polar bears that had antebrachial fractures were reviewed for signalment, history, physical and radiographic findings, fracture management, postoperative care, and outcome. Serum samples from healthy bears and bears with antebrachial fractures were assayed for 25-hydroxyvitamin D (25-OHD) concentrations.

RESULTS

Nineteen fractures (12 polar bears) occurred from 1974 to 2002; 12 fractures involved the antebrachium. Management of 4 antebrachial fractures was reviewed; 3 were repaired by internal fixation and 1 by external coaptation. Fractures healed and bears were returned to exhibit on average 3 months postfracture. Of 11 serum samples assayed for 25-OHD concentrations, 6 were below normal, 1 was low normal and 4 were within normal reference intervals. The 7 bears with subnormal or low normal values were housed in 2 zoos. Subnormal vitamin D concentrations were identified in 2 of 3 bears with fractures.

CONCLUSIONS

Fracture disease is not uncommon in captive polar bears. Additional research is necessary to explore the role of nutrition in polar bear fracture disease.

CLINICAL RELEVANCE

Internal fixation of antebrachial fractures is feasible and reasonably well tolerated in captive polar bears.

The effects of bone therapy on tibial bone loss in young women with anorexia nervosa

OBJECTIVE

Osteoporosis is recognized as a common medical complication of anorexia nervosa (AN). The purpose of the current study was to investigate the recovery mechanism of osteoporosis in AN and the effect of medical treatment on the skeletal system.

METHOD

We conducted a randomized placebo-controlled study of the effects of etidronate and calcium and vitamin D on bone loss in 41 outpatients with the restricting type of AN (AN-R). We measured the tibial speed of sound (SOS) before and after 3 months of treatment.

RESULTS

The bone mineral density (BMD) of the tibial SOS change in both the etidronate group and the calcium and vitamin D Group was significantly greater (p < .001) than in the control group. Urine-N-telopeptide cross-links of type I collagen (NTx) before and after treatment decreased significantly (p < .01) in the etidronate group.

CONCLUSION

These findings suggest that both etidronate and calcium and vitamin D are equally efficacious for reversing the degree of osteoporosis in patients with AN.