The effect of socioeconomic status on bone density testing in a public health-care system

Causal effect of education on bone mineral density: A Mendelian randomization study

Education level may have some association with the incidence of osteoporosis, but it is elusive if this association is causal. This two-sample Mendelian randomization analysis focused on the causal effect of education level on femoral neck bone mineral density (FN-BMD), forearm BMD, lumbar spine BMD, and heel BMD. Twelve single nucleotide polymorphisms were used as instrumental variables. The results suggested that high education level was associated with improved FN-BMD (beta-estimate: 0.406, 95% confidence interval: 0.061 to 0.751, standard error: 0.176, P-value = .021). There were null association between education and other sites of bone mineral density. Our results found the causal effect of high education level on improved FN-BMD, and improved educational attainment may be beneficial to prevent osteoporosis.

Osteoporosis and its associated factors among patients attending Manakamana Hospital, Chitwan, Nepal

BACKGROUND

Osteoporosis is the most common skeletal disorder that weakens bones and increases their susceptibility to fractures. It is becoming an urgent and serious global epidemic. Early diagnosis and treatment are essential to reduce morbidity and mortality associated with it. This study aimed to find out the prevalence of osteoporosis among patients attending at Manakamana Hospital, Bharatpur, Chitwan, Nepal.

METHODS

A cross-sectional study was adopted and 623 patients attending at orthopaedic outpatients department (OPD) of Manakamana Hospital were selected using non-probability consecutive sampling technique. Data were collected from 15th October 2021 to 15th April, 2022, by using interview schedule, chart review and Bone Mineral Density (BMD) measurement through calcaneal ultrasonography. Ethical approval was obtained from Nepal Health Research Council Ethical Review Board prior to study procedures. Obtained data were analysed using descriptive statistics. Association between the variables were measured using chi-square test.

RESULTS

The mean age of the patients was 43.5 (±14.26) years. Nearly half (44%, n = 274) were middle aged adults, 59.7% were female and 56.0% were involved in agriculture and household chores. Nearly half of the patients (45.7%) were overweight/ obese, 7.9% were smokers and 13.5% had habit of alcohol use. Osteopenia or low bone density was detected in 58.9% patients and 19.4% had osteoporosis. The prevalence of osteoporosis was significantly associated with age group (p = <0.001) and educational status (p = 0.013) of the patients.

CONCLUSIONS AND RECOMMENDATIONS

Osteoporosis and osteopenia are prevalent in patients attending in the hospital. Hence, awareness, early screening, and treatment are necessary for the hospital attended patients to enhance their health and, minimize the risk of osteoporosis and the consequences associated with it.

Structural Inequity and Socioeconomic Status Link to Osteoporosis Diagnosis in a Population-Based Cohort of Middle-Older-Age Americans

Socioeconomic status (SES) is an important social determinant of health inequities that has been linked to chronic conditions, including osteoporosis, but research tends to focus on socioeconomic disadvantage rather than how socioeconomic advantage may facilitate these inequities. This study accounts for structural inequities and assesses the relationship between early-life and later-life SES, and risk of osteoporosis diagnosis. Data come from the nationally representative, population-based cohort Health and Retirement Study and include individuals ages 50 to 90. The outcome variable is osteoporosis diagnosis. Logistic regression models of the relationship between SES and osteoporosis diagnosis are estimated, accounting for demographic, health, and childhood variables. Higher levels of childhood and adult SES link to lower odds of osteoporosis diagnosis. Structural inequities in income and underdiagnosis of osteoporosis among persons identifying as Black/African American were detected. Accounting for bone density scan access, inequities in osteoporosis diagnosis appear to stem from barriers to accessing health care due to financial constraints. The important role of SES and evidence of structural inequities leading to underdiagnosis suggest the critical importance of clinicians receiving Diversity, Equity, and Inclusion training to reduce health inequities.

Effects of Gastric Bypass and Sleeve Gastrectomy on Bone Mineral Density and Bone Turnover Markers: A Systematic Review and Meta-Analysis

BACKGROUND

There is a growing interest in the post-operative bone-related effects of bariatric surgery. However, little is known about the comparative effects of the most commonly performed bariatric procedures, namely Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

OBJECTIVES

To systematically assess the differences in areal bone mineral density (aBMD) and biochemical and hormonal markers of bone metabolism among patients undergoing RYGB and SG.

METHODS

We conducted a systematic review and meta-analysis of studies aBMD at different sites, as well as bone-specific alkaline phosphatase (BALP), 25-OH-vitamin D, calcium and parathyroid hormone (PTH) after RYGB and SG.

RESULTS

Fourteen studies were included (717 patients, 50.63% in the RYGB arm). Based on data collected at 1 year, 2 years and > 2 years, there were no significant differences in aBMD measurements at the total hip, lumbar spine, femoral neck, and the whole body with no statistical heterogeneity among different comparisons. Patients in the RYGB group showed significantly higher concentrations of BALP at 1 year (SMD = 0.52, 95%CI, 0.23-0.81, p = 0.0004) and PTH at > 2 years of follow-up (SMD = 0.68, 95%CI, 0.31-1.05, p = 0.0003) compared to the SG group.

CONCLUSION

There were no significant differences in aBMD measurements at the hip, lumbar spine, femoral neck, and the total body following RYGB and SG procedures. However, BALP and PTH concentrations were significantly higher after RYGB surgeries compared to SG. Attention should be paid to patients undergoing RYGB to prevent the expected skeletal fragility over time.

Cancer patients with fractures are rarely assessed or treated for osteoporosis: a population-based study

Among 4238 cancer and 16,418 cancer-free individuals with incident major non-traumatic fractures (hip, clinical vertebral, forearm, humerus), post-fracture osteoporosis care was equally poor for both groups, whether assessed from bone mineral density (BMD) testing, initiation of osteoporosis therapy or either intervention (BMD testing and/or osteoporosis therapy).

INTRODUCTION

Most individuals sustaining a fracture do not undergo evaluation and/or treatment for osteoporosis. Cancer survivors are at increased risk for osteoporosis and fracture. Whether cancer survivors experience a similar post-fracture "care gap" is unclear. Using population-based databases, we assessed whether cancer patients are evaluated and/or treated for osteoporosis after a major fracture.

METHODS

From the Manitoba Cancer Registry, we identified cancer cases (first cancer diagnosis between 1987 and 2013) and cancer-free controls with incident major non-traumatic fractures (from provincial physician billing claims and hospitalization databases). The outcomes were performance of BMD testing (from the BMD Registry), initiation of osteoporosis therapy (from drug dispensation database) or either intervention (BMD testing and/or osteoporosis therapy) in the 12 months post-fracture.

RESULTS

There were 4238 cancer and 16,418 cancer-free individuals who sustained a fracture after the index date (cancer diagnosis) and were followed for at least 1 year post-fracture. Subsequent BMD testing was performed in 11.0% of cancer cases versus 11.5% non-cancer controls (P = 0.43), osteoporosis treatment in 22.9% cancer cases versus 21.8% non-cancer controls (P = 0.15), and either testing or treatment in 28.9% cancer cases versus 28.4% non-cancer controls (P = 0.53). Predictors of BMD testing and/or initiation of therapy were similar for non-cancer and cancer patients. Post-fracture interventions were consistently used more frequently among women, older patients (age 50 years or older), those who sustained fractures in a later calendar period, and (for treatment) after vertebral fracture. Cancer-specific variables (cancer type, years from cancer diagnosis to fracture, specialty of care provider) showed only weak and inconsistent effects.

CONCLUSIONS

A large care gap exists among cancer patients who sustain a fracture, similar to the general population, whereby the evaluation or treatment for osteoporosis is seldom conducted. Care maps may need to be developed for cancer populations to improve post-fracture care.

Factors affecting willingness to get assessed and treated for osteoporosis

Individuals with poor knowledge of osteoporosis and lower socioeconomic status, including being single and having a lower level of annual income, are less likely to be assessed or treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

INTRODUCTION

Despite the negative health consequences of osteoporosis and the availability of effective treatment, a pervasive and persistent prevention care gap for osteoporosis remains present throughout the world. We attempted to identify the factors affecting the willingness of patients to either undergo or avoid assessment and treatment for osteoporosis.

METHODS

A nationwide online survey was conducted in 926 Korean women over age 50. The survey included questions addressing three domains: (1) clinical and socio-demographic characteristics, (2) questions concerning the reasons for undergoing or avoiding osteoporosis assessment or treatment, and (3) knowledge of osteoporosis as measured using the modified Korean version of Facts on Osteoporosis Quiz. The assessed and non-assessed participants were compared in terms of their clinical and socioeconomic statuses, reasons for undergoing or avoiding osteoporosis management, and levels of knowledge of osteoporosis.

RESULTS

The highest-ranked reason for undergoing osteoporosis assessment was fear of osteoporotic fracture, while the highest-ranked reason for avoiding osteoporosis assessment was not feeling a need to get tested for osteoporosis. Participants who sought assessment for osteoporosis were older and more likely to be married, and had greater knowledge of osteoporosis than those who did not seek assessment. The two groups were found to be similar in terms of tobacco use and daily alcohol use. Patients who had been diagnosed with osteoporosis but either did not initiate or discontinued osteoporosis treatment within 1 year were younger and had lower levels of annual income than those who began and continued treatment.

CONCLUSION

Individuals with poor knowledge of osteoporosis and those of lower socioeconomic status, including those who were single and had a lower level of annual income, were less likely to be assessed and treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

The epidemiology of hip fractures across western Victoria, Australia

BACKGROUND

Hip fractures are associated with considerable morbidity and mortality. Hip fracture incidence varies across different levels of accessibility/remoteness and socioeconomic status (SES). As part of the Ageing, Chronic Disease and Injury Study, we aimed to map the pattern of hip fractures across the western region of the Australian state of Victoria, which contains a range of remoteness levels and SES.

METHODS

Data on hip fractures resulting in hospital admission were extracted from the Victorian Admitted Episodes Dataset (VAED) for men and women aged 40+years during 2010-2013 inclusive. An age-adjusted incidence rate (per 10,000population/year) was calculated for the entire region. Crude incidence rates and length of acute care hospital stay (excluding rehabilitation) were calculated for each Local Government Area (LGA). The impact of aggregated age, accessibility/remoteness index of Australia (ARIA) and SES on hip fracture rates aggregated across LGAs was determined using Poisson regression.

RESULTS

For men, the age-standardised rate of hospitalisations for hip fracture across the whole region was 19.2 per 10,000population/year (95%CI 18.0-20.4) and for women, 40.0 (95%CI 38.3-41.7). The highest incidence rates for both sexes occurred in the less accessible LGAs of Yarriambiack and Hindmarsh, as well as the LGA with the lowest SES, Central Goldfields. In both sexes, approximately two thirds of individuals were discharged from acute hospital care within 14days. Increasing age, higher remoteness and lower SES were all associated with higher hip fracture rates.

CONCLUSION

Crude incidence rates varied by location. Given that a high proportion of patients had acute hospital care of ≤14days, and accessibility and SES were associated with hip fracture rates, these results can inform policy and provide a model for other groups to conduct similar research in their local environment.

Non-participation in systematic screening for osteoporosis-the ROSE trial

Population-based screening for osteoporosis is still controversial and has not been implemented. Non-participation in systematic screening was evaluated in 34,229 women age 65-81 years. Although participation rate was high, non-participation was associated with comorbidity, aging other risk factors for fractures, and markers of low social status, e.g., low income, pension, and living alone. A range of strategies is needed to increase participation, including development of targeted information and further research to better understand the barriers and enablers in screening for osteoporosis.

INTRODUCTION

Participation is crucial to the success of a screening program. The objective of this study was to analyze non-participation in Risk-stratified Osteoporosis Strategy Evaluation, a two-step population-based screening program for osteoporosis.

METHODS

Thirty-four thousand two hundred twenty-nine women aged 65 to 81 years were randomly selected from the background population and randomized to either a screening group (intervention) or a control group. All women received a self-administered questionnaire designed to allow calculation of future risk of fracture based on FRAX. In the intervention group, women with an estimated high risk of future fracture were invited to DXA scanning. Information on individual socioeconomic status and comorbidity was obtained from national registers.

RESULTS

A completed questionnaire was returned by 20,905 (61%) women. Non-completion was associated with older age, living alone, lower education, lower income, and higher comorbidity. In the intervention group, ticking "not interested in DXA" in the questionnaire was associated with older age, living alone, and low self-perceived fracture risk. Women with previous fracture or history of parental hip fracture were more likely to accept screening by DXA. Dropping out when offered DXA, was associated with older age, current smoking, higher alcohol consumption, and physical impairment.

CONCLUSIONS

Barriers to population-based screening for osteoporosis appear to be both psychosocial and physical in nature. Women who decline are older, have lower self-perceived fracture risk, and more often live alone compared to women who accept the program. Dropping out after primary acceptance is associated not only with aging and physical impairment but also with current smoking and alcohol consumption. Measures to increase program participation could include targeted information and reducing physical barriers for attending screening procedures.

Utilization of bone mineral density testing among breast cancer survivors in British Columbia, Canada

Breast cancer survivors are at high osteoporosis risk. Bone mineral density testing plays a key role in osteoporosis management. We analyzed a historical utilization of bone mineral density testing in breast cancer survivors. The utilization remained low in the 1995-2008 period. Lower socio-economic status and rural residency were associated with lower utilization.

INTRODUCTION

To evaluate the utilization of bone mineral density (BMD) testing for female breast cancer survivors aged 65+ surviving ≥ 3 years in British Columbia, Canada.

METHODS

A retrospecitve population-based data linkage study. Trends in proportion of survivors with ≥ 1 BMD test for each calendar year from 1995 to 2008 were evaluated with a serial cross-sectional analysis. Associations between factors (socio-demographic and clinical) and BMD testing rates over the period 2006-2008 for 7625 survivors were evaluated with a cross-sectional analysis and estimated as adjusted prevalence ratios (PR_adj) using log-binomial models.

RESULTS

Proportions of survivors with ≥ 1 BMD test increased from 1.0% in 1995 to 10.1% in 2008. The BMD testing rate in 2006-2008 was 26.5%. Socio-economic status (SES) and urban/rural residence were associated with BMD testing rates in a dose-dependent relationship (p for trend< 0.01). Survivors with lower SES (PR_adj = 0.66-0.78) or rural residence (PR_adj = 0.70) were 20-30% less likely to have BMD tests, compared with survivors with the highest SES or urban residence. BMD testing rates were also negatively associated with older age (75+) (PR_adj = 0.47; 95% CI = 0.42, 0.52), nursing home residency (0.05; 0.01, 0.39), recent osteoporotic fractures (0.21; 0.14, 0.32), and no previous BMD tests (0.26; 0.23, 0.29).

CONCLUSION

Utilization of BMD testing was low for breast cancer survivors in BC, Canada. Lower SES and rural residence were associated with lower BMD testing rates.

IMPLICATION FOR CANCER SURVIVORS

Female breast cancer survivors, especially those with lower SES or rural residence, should be encouraged to receive BMD tests as recommended by Canadian guidelines.

Gender differences in the relationship between socioeconomic status and height loss among the elderly in South Korea: Korean National Health and Nutrition Examination Survey 2008-2010

This study aimed to examine average height loss and the relationship between height loss and socioeconomic status (SES) among the elderly in South Korea.Data were obtained from the Korean National Health and Nutrition Examination Survey 2008-2010. A total of 5265 subjects (2818 men and 2447 women) were included. Height loss was calculated as the difference between the subject's self-reported maximum adult height and their measured current height. The height loss values were divided into quartiles (Q1-Q4) for men and women. SES was determined using a self-reported questionnaire for education level, family income, and occupation.Height loss was associated with SES in all age groups, and mean height loss increased with age. In the relationship between education level and maximum height loss (Q4), men with ≤6, 7-9, or 10-12 years of education had higher odds ratios for the prevalence of height loss (Q4) than men with the highest education level (≥13 years). With regard to the relationship between the income level and height loss (Q4), the subjects with the lowest income had an increased prevalence of maximum height loss (Q4) than the subjects with the highest income (odds ratios = 2.03 in men and 1.94 in women). Maximum height loss (Q4) was more prevalent in men and women with a low SES and less prevalent in men with a high SES than in men with a middle SES.Height loss (Q4) was associated with education level in men and with income level (especially low income) in men and women. Height loss was also associated with a low SES in men and women.

FRAX provides robust fracture prediction regardless of socioeconomic status

We investigated the fracture risk assessment tool (FRAX) Canada calibration and discrimination according to income quintile in 51,327 Canadian women, with and without a competing mortality framework. Our data show that, under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of socioeconomic status (SES).

INTRODUCTION

FRAX® predicts 10-year fracture risk. Social factors may independently affect fracture risk. We investigated FRAX calibration and discrimination according to SES.

METHODS

Women aged ≥50 years with baseline femoral neck bone mineral density (BMD) were identified from the Manitoba Bone Density Program, Canada (n = 51,327), 1996-2011. Mean household income, extracted from 2006 census files, was categorized into quintiles. Ten-year fracture probabilities were calculated using FRAX Canada. Incident non-traumatic fractures were studied in relation to income quintile in adjusted Cox proportional hazards models. We compared observed versus predicted fractures with and without a competing mortality framework.

RESULTS

During mean 6.2 ± 3.7 years of follow up, there were 6,392 deaths, 3,723 women with ≥1 major osteoporotic fracture (MOF), and 1,027 with hip fractures. Lower income was associated with higher risk for death, MOF, and hip fracture in adjusted models (all p < 0.005). More women in income quintile 1 (lowest) versus quintile 5 experienced death (19 vs. 8%), MOF (10 vs. 6%), or hip fracture (3.0 vs. 1.3 %) (all p ≤ 0.001). Adjustment for competing mortality mitigated the effect of SES on FRAX calibration, and good calibration was observed. FRAX provided good fracture discrimination for MOF and hip fracture within each income quintile (all p < 0.001). Area under the curve was slightly lower for income quintiles 1 versus 5 for FRAX with BMD to predict MOF (0.68, 95% CI 0.66-0.70 vs. 0.71, 95% CI 0.69-0.74) and hip fracture (0.79, 95% CI 0.76-0.81 vs. 0.87, 95% CI 0.84-0.89).

CONCLUSION

Increased fracture risk in individuals of lower income is offset by increased mortality. Under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of SES.

Is lower income associated with an increased likelihood of qualification for treatment for osteoporosis in Canadian women?

We examined whether low income was associated with an increased likelihood of treatment qualification for osteoporotic fracture probability determined by Canada FRAX in women aged ≥50 years. A significant negative linear association was observed between income and treatment qualification when FRAX included bone mineral density (BMD), which may have implications for clinical practice.

INTRODUCTION

Lower income has been associated with increased fracture risk. We examined whether lower income in women was associated with an increased likelihood of treatment qualification determined by Canada FRAX®.

METHODS

We calculated 10-year FRAX probabilities in 51,327 Canadian women aged ≥50 years undergoing baseline BMD measured by dual energy x-ray absorptiometry 1996-2001. FRAX probabilities for hip fracture ≥3% or major osteoporotic fracture (MOF) ≥20 % were used to define treatment qualification. Mean household income from Canada Census 2006 public use files was used to categorize the population into quintiles. Logistic regression analyses were used to model the association between income and treatment qualification.

RESULTS

Percentages of women who qualified for treatment based upon high hip fracture probability increased linearly with declining income quintile (all p trend <0.001), but this was partially explained by older age among lower income quintiles (p trend <0.001). Compared to the highest income quintile, women in the lowest income quintile had a greater likelihood of treatment qualification based upon high hip fracture probability determined with BMD (age-adjusted odds ratio [OR], 1.34; 95% confidence intervals (CI), 1.23-1.47) or high MOF fracture probability determined with BMD (age-adjusted OR, 1.31; 95% CI, 1.18-1.46). Differences were nonsignificant when FRAX was determined without BMD, implying that BMD differences may be the primary explanatory factor.

CONCLUSIONS

FRAX determined with BMD identifies a larger proportion of lower income women as qualifying for treatment than higher income women.

Low rates of bone mineral density measurement in Medicare beneficiaries with prostate cancer initiating androgen deprivation therapy

BACKGROUND

Men with prostate cancer who undergo androgen deprivation therapy (ADT) are at risk for bone loss and fractures. Our objective was to determine if Medicare beneficiaries with prostate cancer in the state of Texas underwent DXA scans when initiating ADT.

METHODS

We identified men diagnosed with prostate cancer between 2005 and 2007 in the Texas Cancer Registry/Medicare linked database, and who received parenteral ADT or orchiectomy. We identified DXA claims within 1 year before or 6 months after starting ADT. We examined use of bone conservation agents in the subgroup of patients enrolled in Medicare Part D. Multivariate logistic regression models were used to examine determinants of DXA use.

RESULTS

The analysis included 2,290 men (2,262 parenteral ADT, 28 orchiectomy); 197 (8.6 %) underwent DXA within 1 year before and 6 months after starting ADT. Men aged 75 years or older were more likely to undergo DXA than men aged 66-74 years (OR 1.5; 95 % CI 1.1-2.1). Those living in small urban areas were less likely to undergo DXA than those in big areas (OR 0.40; 95 % CI 0.19-0.82). Of the 1,060 men enrolled in Medicare part D, 59 (5.6 %) received bone conservation agents when starting ADT; 134 (12.6 %) either received bone conservation agents or underwent DXA.

CONCLUSIONS

Fewer than one in ten Medicare beneficiaries with prostate cancer initiating ADT underwent a DXA exam. Variation in utilization was also related to residence area size. Further research is needed to identify whether the use of DXA in patients with prostate cancer receiving ADT will result in fracture prevention.

The contributions of First Nations ethnicity, income, and delays in surgery on mortality post-fracture: a population-based analysis

We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture.

INTRODUCTION

First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture.

METHODS

Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996-2004 (population 1, n=63,081), and the hip, 1987-2002(Population 2, n=41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year.

RESULTS

Population 1: First Nations ethnicity was associated with an increased mortality risk of 30-53% for each fracture type. Lower income was associated with an increased mortality risk of 18-26%. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95% confidence interval (CI) 1.07-1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05-1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p≤0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95% CI 1.03-1.27), or surgery delay of 2-3 days (OR 1.34, 95% CI 1.18-1.52) or ≥4 days (OR 2.35, 95% CI 2.07-2.67).

CONCLUSION

A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay>2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.

Disparities in bone density measurement history and osteoporosis medication utilisation in Swiss women: results from the Swiss Health Survey 2007

BACKGROUND

Although factors associated with the utilisation of bone density measurement (BDM) and osteoporosis treatment have been regularly assessed in the US and Canada, they have not been effectively analysed in European countries. This study assessed factors associated with the utilisation of BDM and osteoporosis medication (OM) in Switzerland.

METHODS

The Swiss Health Survey 2007 data included self-reported information on BDM and OM for women aged 40 years and older who were living in private households. Multivariable logistic regression analysis was used to identify sociodemographic, socioeconomic, healthcare-related and osteoporosis risk factors associated with BDM and OM utilisation.

RESULTS

The lifetime prevalence of BDM was 25.6% (95% CI: 24.3-26.9%) for women aged 40 years and older. BDM utilisation was associated with most sociodemographic factors, all the socioeconomic and healthcare-related factors, and with major osteoporosis risk factors analysed. The prevalence of current OM was 7.8% (95% CI: 7.0-8.6%) and it was associated with some sociodemographic and most healthcare-related factors but only with one socioeconomic factor.

CONCLUSIONS

In Swiss women, ever having had a BDM and current OM were low and utilisation disparities exist according to sociodemographic, socioeconomic and healthcare-related factors. This might foster further health inequalities. The reasons for these findings should be addressed in further studies of the elderly women, including those living in institutions.

Clinical review: Ethnic differences in bone mass--clinical implications

CONTEXT

Differences in bone mineral density (BMD) as assessed with dual-energy x-ray absorptiometry are observed between geographic and ethnic groups, with important implications in clinical practice.

EVIDENCE ACQUISITION

PubMed was employed to identify relevant studies. A review of the literature was conducted, and data were summarized and integrated.

EVIDENCE SYNTHESIS

The available data highlight the complex ethnic variations in BMD, which only partially account for observed variations in fracture rates. Factors contributing to ethnic differences include genetics, skeletal size, body size and composition, lifestyle, and social determinants. Despite BMD differences, the gradient of risk for fracture from BMD and other clinical risk factors appears to be similar across ethnic groups. Furthermore, BMD variation is greater within an ethnic population than between ethnic populations. New imaging technologies have identified ethnic differences in bone geometry, volumetric density, microarchitecture, and estimated bone strength that may contribute to a better understanding of ethnic differences in fracture risk.

CONCLUSIONS

Factors associated with ethnicity affect BMD and fracture risk through direct and indirect mechanisms.

Impact of socioeconomic status on ionizing radiation exposure from medical imaging in children

PURPOSE

To characterize cumulative radiation exposure from diagnostic imaging (CEDI) in pediatric patients and to investigate its relationship to patients' socioeconomic status and comorbid medical conditions.

METHODS

A retrospective cohort study of >19,000 pediatric patients seen within the outpatient clinic system of an academic tertiary care urban medical center during the month of January 2006 was conducted to estimate CEDI from all procedures performed within 3 years of the index visit (until January 2009). Socioeconomic status was estimated from census tract geocoding. Comorbid medical conditions were identified from the electronic medical record.

RESULTS

A total of 19,063 patients underwent imaging tests within the index month. The mean age was 8.9 ± 6.3 years. Most had private insurance (56%), with 36% receiving Medicaid and 8% private payers. Our population lived in census tracts in which 27 ± 16% of the population were below the federal poverty level with 62% living in areas in which 20% of residents were living below the poverty level. There were differences in CEDI (P < .0001) by age, insurance type, and percentage poverty in the census tract of residence but not among racial groups (P = .6508). The association between poverty and CEDI was generally explained by the 26 Elixhauser diagnoses, with the exception of rheumatoid arthritis.

CONCLUSION

Patients living in areas of greater poverty were exposed over time to more radiation from diagnostic testing than those living in areas with lower percentages of residents living in poverty. This association was explained almost entirely by the presence of disease burden. No direct association was found between socioeconomic status and CEDI.

A population-based analysis of the post-fracture care gap 1996-2008: the situation is not improving

The post-fracture care gap has not narrowed in recent years. Following an initial improvement, rates of medication initiation have actually declined.

INTRODUCTION

The current study characterizes temporal changes in post-fracture bone mineral density (BMD) testing or osteoporosis treatment initiation from 1996/1997 to 2007/2008.

METHODS

A population-based administrative data repository for Manitoba, Canada was accessed to identify non-traumatic fractures in individuals aged 50 years and older. Outcomes included BMD testing or dispensation of an osteoporosis medication in the 12 months following the fracture.

RESULTS

Thirty thousand nine hundred and twenty (30,920) fracture events met the inclusion criteria; 15,670 affected major osteoporotic fracture sites. Based on either BMD testing or treatment initiation, intervention rates reached a maximum of only 15.5% in 2003/2004, compared with 6.3% in 1996/1997, and 13.2% in 2007/2008 (p-for-trend < 0.001). Post-fracture BMD testing increased from 0.7% in 1996/1997 to 8.9% 2007/2008 (p-for-trend < 0.001). Osteoporosis medication use increased from 6.1% in 1996/1997 to 12.3% in 2001/2002 and then progressively declined to 5.9% by 2007/2008 (p-for-trend = 0.025). Similar trends were observed when only major osteoporotic fractures were included. The initiation of BMD testing or medication varied according to age, gender, geographic region, and income.

CONCLUSION

Despite increased attention to gaps in osteoporosis management post-fracture in the last 10 years, the situation has not improved: in 2007/20008, fewer than 20% of untreated individuals with a low-trauma fracture received intervention. Novel strategies are required to disseminate and implement best practices at the point of care to reduce the risk of recurrent fractures.

Social determinants of bone densitometry uptake for osteoporosis risk in patients aged 50yr and older: a systematic review

The World Health Organization identifies that osteoporosis is one of the leading health problems in the Western world. An increased risk of fragility fracture is observed in more socially disadvantaged individuals in most Western countries. Dual-energy X-ray absorptiometry (DXA) is currently the procedure of choice to diagnose osteoporosis and assess fracture risk. We systematically reviewed the literature regarding social determinants of DXA utilization for osteoporosis detection in patients aged 50yr and older using a computer-aided search of MEDLINE, EMBASE, CINAHL, and PsychINFO from January 1994 to December 2010. Five cross-sectional studies, incorporating 16 separate analyses, were identified for inclusion in this review. The best evidence analysis identified limited evidence for a positive association between either income or education with DXA utilization; furthermore, the best evidence analysis found no evidence for an association between either marital status or working status and DXA utilization. Further research is required to identify whether a relationship exists and elucidate reasons for disparities in DXA utilization between different social groups, such as choice and referral processes, as a necessary precursor in identifying modifiable determinants and appropriate strategies to promote preventive screening to identify fracture risk.

The post-fracture care gap among Canadian First Nations peoples: a retrospective cohort study

Despite targeted attempts to reduce post-fracture care gaps, we hypothesized that a larger care gap would be experienced by First Nations compared to non-First Nations people. First Nations peoples were eight times less likely to receive post-fracture care compared to non-First Nations peoples, representing a clinically significant ethnic difference in post-fracture care.

INTRODUCTION

First Nations peoples are the largest group of aboriginal (indigenous or native) peoples in Canada. Canadian First Nations peoples have a greater risk of fracture compared to non-First Nations peoples. We hypothesized that ethnicity might be associated with a larger gap in post-fracture care.

METHODS

Non-traumatic major osteoporotic fractures for First Nations and non-First Nations peoples aged ≥ 50 years were identified from a population-based data repository for Manitoba, Canada between April 1996 and March 2002. Logistic regression analysis was used to examine the probability of receiving a BMD test, a diagnosis of osteoporosis, or beginning an osteoporosis-related drug in the 6 months post-fracture.

RESULTS

A total of 11,234 major osteoporotic fractures were identified; 502 occurred in First Nations peoples. After adjustment for confounding covariates, First Nations peoples were less likely to receive a BMD test [odds ratio (OR) 0.1, 95% confidence interval (CI), 0.0-0.5], osteoporosis-related drug treatment (OR, 0.5; 95% CI, 0.3-0.7), or a diagnosis of osteoporosis (OR, 0.5; 95% CI, 0.3-0.7) following a fracture compared to non-First Nations peoples. Females were more likely to have a BMD test (OR, 5.0; 95% CI, 2.6-9.3), to be diagnosed with osteoporosis (OR, 1.7; 95% CI, 1.5-2.0), and to begin drug treatment (OR, 4.1; 95% CI, 2.7-6.4) compared to males.

CONCLUSIONS

An ethnicity difference in post-fracture care was observed. Further work is needed to elucidate underlying mechanisms for this difference and to determine whether failure to initiate treatment originates with the medical practitioner, the patient, or a combination of both. It is imperative that all residents of Manitoba receive efficacious and equal care post-fracture, regardless of ethnicity.

Influence of socioeconomic factors on the adherence of alendronate treatment in incident users in Norway

PURPOSE

To examine whether socioeconomic factors influence adherence to alendronate drug treatment among incident users in Norway during 2005-2009.

METHODS

The study included 7610 incident alendronate users in 2005 (40-79 years), followed until 31 December 2009. Mean age was 66.6 years, and 86.7% of the patients were women. Data were drawn from the Norwegian Prescription Database and linked to marital status, education and income. Adherence was measured by the medication possession ratio (MPR). MPR was defined as the number of dispensed defined daily doses divided by the number of days each patient was included in the study. A patient was adherent if MPR ≥ 80%. ORs with 95%CI were estimated using logistic regression.

RESULTS

Among all patients, 45.5% was adherent throughout 4.2 years. A slightly higher proportion of women than men were adherent. Adjusted for all covariates, women aged 70-79 years had an OR of 1.27 (95%CI 1.10-1.45) for adherence compared with those 40-59 years. In women, high household income predicted adherence of alendronate use. In men, a middle educational level compared with a low level, predicted adherence (adjusted OR = 1.47 (95%CI 1.10-1.96)). After adjustments, previous marriage reduced the odds of being adherent compared with present marriage, in both men and women.

CONCLUSIONS

In women, the most important factors for being adherent were high age and high income. In men, a middle educational level predicted adherence. Previous marriage reduced the odds of being adherent in both women and men.

Factors associated with treatment of women with osteoporosis or osteopenia from a national survey

BACKGROUND

Health outcomes could be improved if women at high risk for osteoporotic fracture were matched to effective treatment. This study determined the extent to which treatment for osteoporosis/osteopenia corresponded to the presence of specific risk factors for osteoporotic fracture.

METHODS

This retrospective analysis of the United States 2007 National Health and Wellness Survey included women age ≥ 40 years who reported having a diagnosis of osteoporosis (69% of 3276) or osteopenia (31% of 3276). Patients were stratified by whether they were or were not taking prescription treatment for osteoporosis/osteopenia. Using 34 patient characteristics as covariates, logistic regression was used to determine factors associated with treatment.

RESULTS

Current prescription treatment was reported by 1800 of 3276 (54.9%) women with osteoporosis/osteopenia. The following factors were associated with receiving prescription treatment: patient-reported diagnosis of osteoporosis (versus osteopenia); previous bone mineral density test; ≥ 2 fractures since age 50; older age; lower body mass index; better physical functioning; postmenopausal status; family history of osteoporosis; fewer comorbidities; prescription insurance coverage; higher total prescription count; higher ratio of prescription costs to monthly income; higher income; single status; previous visit to a rheumatologist or gynecologist; and 1 or 2 outpatient visits to healthcare provider (vs. none) in the prior 6 months. Glucocorticoid, tobacco, and daily alcohol use were risk factors for fracture that were not associated with treatment.

CONCLUSIONS

There is a mismatch between those women who could benefit from treatment for osteoporosis and those who are actually treated. For example, self-reported use of glucocorticoids, tobacco, and alcohol were not associated with prescription treatment of osteoporosis. Other clinical and socioeconomic factors were associated with treatment (e.g. prescription drug coverage and higher income) or not (e.g. comorbid osteoarthritis and anxiety) and could be opportunities to improve care.

Pattern of use of DXA scans in men: a cross-sectional, population-based study

Osteoporosis in men is underdiagnosed. The use of dual-emission X-ray absorptiometry (DXA) was evaluated in almost 5,000 men aged 60-74 years. DXA was infrequent, despite the presence of multiple risk factors for osteoporosis and a high FRAX score. There is a need for improved targeting of DXA scans for men at high risk.

INTRODUCTION

Clinical and socioeconomic factors associated with bone mass assessment (DXA) in men have seldom been evaluated. This study aimed to evaluate factors associated with the use of DXA in men.

METHODS

Self-report information on prior DXA and osteoporosis risk factors were obtained from the baseline data of a study investigating the health perspectives of men aged 60-75 years. Socioeconomic and comorbidity data were retrieved from national registers. The FRAX algorithm was used to calculate the absolute fracture risk. Regression analysis was used to identify factors significantly associated with previous DXA scan.

RESULTS

Of the 4,696 men returning questionnaires (50% response rate), 2.7% had prior DXA but 48% had at least one osteoporosis risk factor. Previous DXA was associated with oral glucocorticoid treatment, secondary osteoporosis, rheumatoid arthritis, fracture after age 50, falls within the previous year, smoking, and higher age. Twenty-one percent of men with prior DXA and 10% of men without prior DXA had greater than 20% risk of a major osteoporotic fracture within the next 10 years. One third of those with previous DXA had none of the FRAX osteoporosis risk factors. When family history of osteoporosis and falls were included as risk factors, 18% with previous DXA had no clinical risk factors for osteoporosis.

CONCLUSIONS

DXA was infrequent in this group of elderly men, despite the presence of risk factors for osteoporosis. DXA was also used despite a low fracture risk. There is a need for improved targeting of DXA scans for men at high risk.

Educational difference in the prevalence of osteoporosis in postmenopausal women: a study in northern Iran

Background

Osteoporosis is the most common metabolic bone disease in the world and it is rapidly increasing in Iran. In this study the relationship between educational levels and osteoporosis was investigated among Iranian postmenopausal women.

Method and subjects

Seven hundred and six women aged 50-75 years old were randomly recruited from urban (n = 440) and rural (n = 266) areas in Guilan. Osteoporosis was diagnosed by quantitative ultrasound technique and dual X-ray absorptiometry. Serum 25(OH) D3, body weight and height were measured in all subjects. Other data including age, educational level, menopause age, medications and history of illness were also collected.

Results

We found that the prevalence of osteoporosis was significantly greater among women with low educational level than women with high educational status (18.0% vs 3.8% P < 0.0001). However, women with low educational level had higher mean serum level of vitamin D than women with high educational level. Osteoporosis was significantly more prevalent among women living in rural areas than women living in urban areas (19.1% v.s 13.3%, P < 0.0001).

Conclusion

This study showed that educational level is associated with bone health in this population of postmenopausal women with significantly higher osteoporosis found in lower social groups. Therefore, we suggest that women with low social level should be carefully evaluated for signs of osteoporosis during routine physical examinations.

Association between socioeconomic status and bone mineral density in adults: a systematic review

For most causes of mortality and morbidity, a socioeconomic gradient exists; however, this systematic review identified limited evidence for the role of education on bone mineral density (BMD). Further research is required to build upon the current paucity of data examining influences of socioeconomic status (SES) on BMD, especially in men.

INTRODUCTION

For most causes of mortality and morbidity, a socioeconomic gradient exists, although little is understood of the relationship between BMD and SES. We systematically evaluated evidence of SES as a risk factor for low BMD at the clinically relevant sites of hip and spine in adults.

METHODS

We conducted a computer-aided search of Medline, EMBASE, CINAHL, and PsychINFO from January 1, 1966 until December 31, 2008. Reviewed studies investigated the relationship between SES parameters of income, education, and occupation, and the level of BMD. Studies were rated based on their methodological quality, and a best-evidence synthesis was used to summarise the results.

RESULTS

One case-control and seven cross-sectional studies were identified for inclusion, of which four cross-sectional studies were high-quality. Best-evidence analysis identified consistent, yet limited, evidence for a positive association between educational attainment and BMD in women. No evidence was available regarding an association between income or occupation and BMD in either gender, or education and BMD in men.

CONCLUSIONS

Limited good quality evidence exists for the role that education level may play in BMD levels. Cohort studies are required to examine the relationship between individual SES parameters and BMD in order to identify potential intervention targets.

The association between socioeconomic status and osteoporotic fracture in population-based adults: a systematic review

Although socioeconomic status (SES) is inversely related to most diseases, this systematic review showed a paucity of good quality data examining influences of SES on osteoporotic fracture to confirm this relationship. Further research is required to elucidate the issue and any underlying mechanisms as a necessary precursor to considering intervention implications.

INTRODUCTION

The association between socioeconomic status (SES) and musculoskeletal disease is little understood, despite there being an inverse relationship between SES and most causes of morbidity. We evaluated evidence of SES as a risk factor for osteoporotic fracture in population-based adults.

METHODS

Computer-aided search of Medline, EMBASE, CINAHL, and PsychINFO from January 1966 until November 2007 was conducted. Identified studies investigated the relationship between SES parameters of income, education, occupation, type of residence and marital status, and occurrence of osteoporotic fracture. A best-evidence synthesis was used to summarize the results.

RESULTS

Eleven studies were identified for inclusion, which suggested a lack of literature in the field. Best evidence analysis identified strong evidence for an association between being married/living with someone and reduced risk of osteoporotic fracture. Limited evidence exists of the relationship between occupation type or employment status and fracture, or for type of residence and fracture. Conflicting evidence exists for the relationship between osteoporotic fracture and level of income and education.

CONCLUSION

Limited good quality evidence exists of the role SES might play in osteoporotic fracture. Further research is required to identify whether a relationship exists, and to elucidate underlying mechanisms, as a necessary precursor to considering intervention implications.