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Chen YP, Chan WP, Zhang HW, Tsai ZR, Peng HC, Huang SW, Jang YC, Kuo YJ. Automated osteoporosis classification and T-score prediction using hip radiographs via deep learning algorithm. Ther Adv Musculoskelet Dis 2024; 16:1759720X241237872. [PMID: 38665415 PMCID: PMC11044771 DOI: 10.1177/1759720x241237872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/09/2024] [Indexed: 04/28/2024] Open
Abstract
Background Despite being the gold standard for diagnosing osteoporosis, dual-energy X-ray absorptiometry (DXA) is an underutilized screening tool for osteoporosis. Objectives This study proposed and validated a controllable feature layer of a convolutional neural network (CNN) model with a preprocessing image algorithm to classify osteoporosis and predict T-score on the proximal hip region via simple hip radiographs. Design This was a single-center, retrospective study. Methods An image dataset of 3460 unilateral hip images from 1730 patients (age ⩾50 years) was retrospectively collected with matched DXA assessment for T-score for the targeted proximal hip regions to train (2473 unilateral hip images from 1430 patients) and test (497 unilateral hip images from 300 patients) the proposed CNN model. All images were processed with a fully automated CNN model, X1AI-Osteo. Results The proposed screening tool illustrated a better performance (sensitivity: 97.2%; specificity: 95.6%; positive predictive value: 95.7%; negative predictive value: 97.1%; area under the curve: 0.96) than the open-sourced CNN models in predicting osteoporosis. Moreover, when combining variables, including age, body mass index, and sex as features in the training metric, there was high consistency in the T-score on the targeted hip regions between the proposed CNN model and the DXA (r = 0.996, p < 0.001). Conclusion The proposed CNN model may identify osteoporosis and predict T-scores on the targeted hip regions from simple hip radiographs with high accuracy, highlighting the future application for population-based opportunistic osteoporosis screening with low cost and high adaptability for a broader population at risk. Trial registration TMU-JIRB N201909036.
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Affiliation(s)
- Yu-Pin Chen
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Wing P. Chan
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Han-Wei Zhang
- Biomedica Corporation, New Taipei City, Taiwan
- Program for Aging, China Medical University, Taichung City, Taiwan
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
- Department of Electrical and Computer Engineering, Institute of Electrical Control Engineering, National Yang Ming Chiao Tung University, Hsinchu City, Hsinchu County, Taiwan
| | - Zhi-Ren Tsai
- Department of Computer Science and Information Engineering, Asia University, Taichung City, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung City, Taiwan
- Center for Precision Medicine Research, Asia University, Taichung City, Taiwann
| | | | - Shu-Wei Huang
- Department of Applied Science, National Taitung University, Taitung City, Taitung County, Taiwan
| | - Yeu-Chai Jang
- Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
| | - Yi-Jie Kuo
- Department of Orthopedics, Wan Fang Hospital, Taipei Medical University, No. 111, Sec. 3, Xinglong Road, Wenshan, Taipei 11696, Taiwan (R.O.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Prout T, Pelzl C, Christensen EW, Binkley N, Schousboe J, Krueger D. Dual-energy X-ray Absorptiometry Trends Among US Medicare Beneficiaries: 2005-2019. J Clin Densitom 2024; 27:101456. [PMID: 38128449 DOI: 10.1016/j.jocd.2023.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Bone density measured using dual-energy X-ray absorptiometry (DXA) volume, performance site and interpreters have changed in the US since 2005. The purpose of this report is to provide updated trends in DXA counts, rates, place of service and interpreter specialty for the Medicare fee-for-service population. METHODS The 100 % Medicare Physician/Supplier Procedure Summary Limited Data Set between 2005-2019 was used. DXA counts and annual rates per 10,000 Medicare beneficiaries were calculated. Annual distributions of scan performance location, provider type and interpreter specialty were described. Place of service trends (significance assigned at p < 0.05) of the mean annual share of DXA utilization were identified using linear regression. RESULTS Annual DXA use per 10,000 beneficiaries peaked in 2008 at 832, declined to 656 in 2015 then increased (p < 0.001) by 38 per year to 807 in 2019. From 2005 to 2019 DXA performance in office settings declined from 70.7 % to 47.2 %. Concurrently, outpatient hospital (OH) DXA increased from 28.6 % to 51.7 %. In 2005, 43.5 % of DXAs were interpreted by radiologists. This increased (p < 0.001) in the office and OH, averaging 0.3 and 2.0 percentage points per year respectively, reaching 73.5 % in 2019. Interpretation by most non-radiologist specialties declined (p < 0.001). CONCLUSIONS From 2005-2019, total DXA use among Medicare beneficiaries declined reaching a nadir in 2015 then returned to 2005 levels by 2019. Office DXA declined since 2005 with 51.7 % of all scans now occurring in an OH setting. The proportion of DXAs interpreted by radiologists increased over time, reaching 73.5 % in 2019.
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Affiliation(s)
- Tyler Prout
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Casey Pelzl
- Harvey L. Neiman Health Policy Institute, Reston, VA, USA
| | - Eric W Christensen
- Harvey L. Neiman Health Policy Institute, Reston, VA, USA; University of Minnesota, Health Services Management, St. Paul, MN, USA
| | - Neil Binkley
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | - John Schousboe
- Park Nicollet Clinic & Health Partners Institute, Minneapolis, MN, USA
| | - Diane Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA.
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Furuhata R, Tanji A, Oki S, Kamata Y. Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis. Geriatr Orthop Surg Rehabil 2023; 14:21514593231198645. [PMID: 37645438 PMCID: PMC10460996 DOI: 10.1177/21514593231198645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Osteoporosis can affect the surgical outcomes of proximal humeral fractures in older people. Recently, the cortical bone thickness of the proximal humerus on plain radiograph has been proposed to reflect local osteoporosis of the proximal humerus; however, its effect on the surgical outcome of proximal humeral fractures remains unclear. The purpose of this study is to investigate the influence of cortical bone thickness on postoperative radiographic outcomes after osteosynthesis for proximal humeral fractures. Materials and Methods We retrospectively identified 190 patients (≥50 years) who underwent osteosynthesis with an intramedullary nail or plate for proximal humeral fractures. The patients were categorized into 2 groups according to the cut-off value of an average proximal humerus cortical bone thickness of 6 mm on plain radiographs: patients with and without local osteoporosis. After propensity score matching, we compared the incidence of postoperative radiographic complications between the 2 groups. We also performed subgroup analyses of outcomes in a subgroup of patients who underwent intramedullary nailing and those who underwent plate fixation. Results Propensity score matching yielded 60 patients in each group. No significant difference in complication rates was observed between the 2 groups. However, in the intramedullary nailing subgroup, the incidence of reduction loss was significantly higher in patients with local osteoporosis than in those without local osteoporosis (51.7% vs 14.3%, P = .002). Discussion The proximal humeral cortical bone thickness had no significant effect on the overall radiographic outcome; however, reduction loss after intramedullary nailing was susceptible to local osteoporosis of the proximal humerus. Conclusion Our study suggests that plate fixation is advantageous in preventing postoperative reduction loss in patients with lower cortical bone thickness.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Atsushi Tanji
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Satoshi Oki
- Department of Orthopaedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya-shi, Japan
| | - Yusaku Kamata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Meguro-ku, Japan
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Roblin DW, Goodrich GK, Davis TL, Gander JC, McCracken CE, Weinfield NS, Ritzwoller DP. Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period? Med Care 2023; 61:S39-S46. [PMID: 36893417 PMCID: PMC9994577 DOI: 10.1097/mlr.0000000000001832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND/OBJECTIVE In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits. METHODS Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program. RESULTS For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02). CONCLUSIONS Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.
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Affiliation(s)
- Douglas W. Roblin
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
| | | | | | | | | | - Nancy S. Weinfield
- Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, MD
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Dheeraj D, Chauhan U, Khapre M, Kant R. Comparison of Quantitative Computed Tomography and Dual X-Ray Absorptiometry: Osteoporosis Detection Rates in Diabetic Patients. Cureus 2022; 14:e23131. [PMID: 35433140 PMCID: PMC9007574 DOI: 10.7759/cureus.23131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Diabetes mellitus (DM) adversely affects the skeletal system and is associated with an increased risk of osteoporosis and fragility fractures. This study aimed to assess the diagnostic accuracy of quantitative computed tomography (QCT) in osteoporosis detection in patients with DM. Methods A cross-sectional diagnostic accuracy study was conducted at the diabetic clinic of a tertiary care teaching hospital in North India. A total of 30 individuals with DM were subjected to spinal QCT and lumbar spine and hip dual x-ray absorptiometry (DXA). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios of QCT were measured against DXA and the diagnostic discordance between QCT and DXA was investigated. Results QCT, compared to the gold standard DXA, has a sensitivity/specificity of 92.8% (95% CI 92.4%-93.2%)/81.2% (95% CI 80.6%-81.8%). The PPV/NPV of QCT was 81.2% (95% CI 80.6%-81.8%)/92.8% (95% CI 92.4%-93.2%). The positive likelihood ratio/negative likelihood ratio was 4.95 (95% CI 4.79-5.11)/0.087 (95% CI 0.082-0.093). Area under the curve was 0.871 (95% CI 0.731-1.00). Minor diagnostic discordance was present in 36.6% of patients with diabetes. Conclusion The current study assessed the diagnostic accuracy of QCT in osteoporosis detection in people with diabetes. DXA is the gold standard diagnostic tool; however, its availability is limited. The current study showed that QCT is an excellent diagnostic tool. Based on these results, this study recommends that QCT may serve as a problem-solving investigation tool where DXA is unavailable, or it may be the primary investigation tool for bone mineral density measurement and osteoporosis detection if a dedicated DXA scanner is inaccessible. This study also recommends further investigating the feasibility of opportunistic osteoporosis screening in routine abdominal and chest CT. Finally, considering the silent nature of osteoporosis and the high prevalence of osteoporosis in individuals with diabetes, a proactive approach is required in the screening of osteoporosis.
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Pujia R, Tarsitano MG, Arturi F, De Lorenzo A, Lenzi A, Pujia A, Montalcini T. Advances in Phenotyping Obesity and in Its Dietary and Pharmacological Treatment: A Narrative Review. Front Nutr 2022; 9:804719. [PMID: 35242796 PMCID: PMC8885626 DOI: 10.3389/fnut.2022.804719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/21/2022] [Indexed: 12/20/2022] Open
Abstract
In recent times, it has become evident that there are individuals who, from a metabolic point of view, are affected by obesity but have a normal body mass index. There are also metabolically healthy individuals with a high body mass index who are thus are considered as to be affected by obesity obese. Understanding that individuals with obesity are phenotypically heterogeneous is a relatively novel concept which, although present in the scientific literature, unfortunately has not yet had an impact in clinical practice. However, common dietary approaches are not effective in treating large numbers of obese patients with obesity. This narrative review, based on the material searched via PubMed and the Web of Science up to October 2021, proposes a downsizing of the role of the body mass index in identifying the individual with “true obesity” since it is only partially useful, and suggests a new approach which also integrates the body composition and assessment of metabolic parameters. This approach leads to personalized therapies that work best for each obesity phenotype in reducing the risk of non-communicable diseases.
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Affiliation(s)
- Roberta Pujia
- Department of Medical and Surgical Science Nutrition Unit, University Magna Grecia, Catanzaro, Italy
| | - Maria Grazia Tarsitano
- Department of Medical and Surgical Science Nutrition Unit, University Magna Grecia, Catanzaro, Italy
| | - Franco Arturi
- Department of Medical and Surgical Science Nutrition Unit, University Magna Grecia, Catanzaro, Italy
| | - Antonino De Lorenzo
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, University La Sapienza, Rome, Italy
| | - Arturo Pujia
- Department of Medical and Surgical Science Nutrition Unit, University Magna Grecia, Catanzaro, Italy
| | - Tiziana Montalcini
- Department of Clinical and Experimental Medicine, Nutrition Unit, University Magna Grecia, Catanzaro, Italy
- *Correspondence: Tiziana Montalcini
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Schmidutz F, Schopf C, Yan SG, Ahrend MD, Ihle C, Sprecher C. Cortical bone thickness of the distal radius predicts the local bone mineral density. Bone Joint Res 2021; 10:820-829. [PMID: 34927444 PMCID: PMC8696524 DOI: 10.1302/2046-3758.1012.bjr-2020-0271.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD). METHODS A total of 54 human cadaver forearms (ten singles, 22 pairs) (19 to 90 years) were systematically assessed by clinical radiograph (XR), dual-energy X-ray absorptiometry (DXA), CT, as well as high-resolution peripheral quantitative CT (HR-pQCT). Cortical bone thickness (CBT) of the distal radius was measured on XR and CT scans, and two cortical indices mean average (CBTavg) and gauge (CBTg) were determined. These cortical indices were compared to the BMD of the distal radius determined by DXA (areal BMD (aBMD)) and HR-pQCT (volumetric BMD (vBMD)). Pearson correlation coefficient (r) and intraclass correlation coefficient (ICC) were used to compare the results and degree of reliability. RESULTS The CBT could accurately be determined on XRs and highly correlated to those determined on CT scans (r = 0.87 to 0.93). The CBTavg index of the XRs significantly correlated with the BMD measured by DXA (r = 0.78) and HR-pQCT (r = 0.63), as did the CBTg index with the DXA (r = 0.55) and HR-pQCT (r = 0.64) (all p < 0.001). A high correlation of the BMD and CBT was observed between paired specimens (r = 0.79 to 0.96). The intra- and inter-rater reliability was excellent (ICC 0.79 to 0.92). CONCLUSION The cortical index (CBTavg) at the distal radius shows a close correlation to the local BMD. It thus can serve as an initial screening tool to estimate the local bone quality if quantitative BMD measurements are unavailable, and enhance decision-making in acute settings on fracture management or further osteoporosis screening. Cite this article: Bone Joint Res 2021;10(12):820-829.
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Affiliation(s)
- Florian Schmidutz
- AO Research Institute Davos, Davos, Switzerland.,Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany.,Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Unfallklinik Tübingen, Tübingen, Germany
| | - Christoph Schopf
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
| | - Shuang G Yan
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany.,Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Marc-Daniel Ahrend
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Unfallklinik Tübingen, Tübingen, Germany
| | - Christoph Ihle
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Unfallklinik Tübingen, Tübingen, Germany
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Samuelsson C, Wilczek M, Kälvesten J, Qureshi AR, Brismar TB. Metacarpal bone diameter increases constantly in adult females, but escalated resorption of the inner surface at menopause explains the observed decreased bone mineral density at digital X-ray radiogrammetry. Menopause 2021; 29:42-47. [PMID: 34726194 DOI: 10.1097/gme.0000000000001882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess how bone morphology and mineralization changes with age, in women by digital X-ray radiogrammetry (DXR). DXR has potential as a screening tool for osteoporosis, as it can evaluate bone mineralization similarly to dual-energy X-ray absorptiometry. METHODS The nondominant hand was analyzed with DXR in 13,285 women ages 40-74 years undergoing mammography. 1,556 women attended two consecutive examinations with 18 to 24 months interval. Changes in bone parameters were calculated and compared in 5-year age groups. Regression analysis and ANOVA tests were performed. RESULTS Univariate linear regression showed no significant difference in age or bone size between the groups with single or consecutive measurements. In the group with consecutive measurements, the average inner diameter (DXR-ID) of the metacarpals significantly increased with age from 0.38 cm in the 40-45 years age span to 0.47 cm in the 65+ age group (P < 0.001), whereas DXR bone mineral density (DXR-BMD) decreased from 0.59 g/cm2 to 0.50 g/cm2 in the same age groups (P < 0.001). Intraindividual measurements showed a fourfold increase in yearly DXR-ID increase and concurrent DXR-BMD loss between 50 and 59 years of age (P < 0.001). The outer diameter only increased significantly between the youngest and oldest age group (P < 0.001). CONCLUSIONS The faster decrease in DXR-BMD observed during and after menopause is caused by resorption of the inner cortical surface, not matched by outer diameter increase. We speculate that most bones in the human body grow in the same pattern as observed in the metacarpals, partly explaining decreasing BMD at DXR and dual-energy X-ray absorptiometry.
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Affiliation(s)
- Carl Samuelsson
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Michael Wilczek
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Abdul Rashid Qureshi
- Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Solna, Sweden
| | - Torkel B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Baker BS, Li J, Leary EV. DXA 2: An Automated Program for Extraction of Dual-Energy X-Ray Absorptiometry Data. J Clin Densitom 2021; 24:658-662. [PMID: 33691990 DOI: 10.1016/j.jocd.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION/BACKGROUND Since the 1970s imaging devices have been rapidly advancing to provide researchers, clinicians, radiologists, and practitioners greater capabilities to image bone. Today, dual-energy X-ray absorptiometry (DXA) has emerged as the gold standard for the assessment of bone and body composition. Despite recent improvements in DXA image quality and reduced radiation dosages and scan times, the data extraction process has yet to be streamlined. The objective of this study was to design an application to allow DXA users to quickly and accurately transfer DXA report data directly into a user-friendly format. METHODOLOGY Initial development of the DXA Data Xtraction Assistant (DXA2) included processing 485 DXA reports from a previous study. Using Python script, numeric data from these DXA reports were converted to .csv files and then merged into one file, effectively compiling and organizing all table data from each report, by participant and visit number. A graphical user interface was then developed and beta tested using multiple DXA manufacturers, models, and software versions. To compare the effectiveness of the DXA2 to the current standard of manual extraction, all 485 reports were manually transcribed into Microsoft Excel. The time required per report and the error rates were compared. RESULTS Manual transcription, by an experienced researcher, took over 10 h with an error rate of 0.6% and average error magnitude of 51%. Data extraction from DXA2 took less than 25 min to retrospectively reformat all DXA reports for the DXA2 and transcribe all 485 reports with 100% accuracy. CONCLUSION The DXA2 application automates DXA report data extraction and aggregation for clinical, research, and applied settings and drastically reduces manual data entry time and eliminates transcription errors.
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Affiliation(s)
- Breanne S Baker
- Thompson Laboratory for Regenerative Orthopedics, Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, MO, USA.
| | - Jinpu Li
- Thompson Laboratory for Regenerative Orthopedics, Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, MO, USA
| | - Emily V Leary
- Thompson Laboratory for Regenerative Orthopedics, Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, MO, USA
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Mehta SD, Sebro R. Computer-Aided Detection of Incidental Lumbar Spine Fractures from Routine Dual-Energy X-Ray Absorptiometry (DEXA) Studies Using a Support Vector Machine (SVM) Classifier. J Digit Imaging 2021; 33:204-210. [PMID: 31062114 DOI: 10.1007/s10278-019-00224-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
To assess whether application of a support vector machine learning algorithm to ancillary data obtained from posterior-anterior dual-energy X-ray absorptiometry (DEXA) studies could identify patients with lumbar spine (L1-L4) vertebral body fractures without additional DEXA imaging or radiation. Three hundred seven patients (199 without any fractures of the spine, and 108 patients with at least one fracture of the L1, L2, L3, or L4 vertebral bodies) who had DEXA studies were evaluated. Ancillary data from DEXA output was analyzed. The dataset was split into training (80%) and test (20%) datasets. Support vector machines (SVMs) with 10-fold cross-validation and different kernels were used to identify the best kernel based on the greatest area under the curve (AUC) and the best training vectors in the training dataset. The SVM with the best kernel was then applied to the test dataset to assess the accuracy of the SVM. Receiver operating characteristic (ROC) curves of the SVMs using different kernels in the test dataset were compared using DeLong's test. The SVM classifier with the linear kernel had the greatest AUC in the training dataset (AUC = 0.9258). The AUC of the SVM classifier with the linear kernel in the test dataset was 0.8963. The SVM classifier with the linear kernel had an overall average accuracy of 91.8% in the test dataset. The sensitivity, specificity, positive predictive value, and negative predictive of the SVM classifier with the linear kernel to detect lumbar spine fractures were 81.8%, 97.4%, 94.7%, and 90.5%, respectively. The SVM classifier with the linear kernel ROC curve had a significantly better AUC than the SVM classifier with the cubic polynomial kernel (P = 0.034) for discriminating between patients with lumbar spine fractures and control patients, but not significantly different from the SVM classifier with a radial basis function (RBF) kernel (P = 0.317) or the SVM classifier with a sigmoid kernel (P = 0.729). All fractures identified by the SVM classifiers were not prospectively identified by the radiologist. SVM analysis of ancillary data obtained from routine DEXA studies can identify lumbar spine fractures without the use of vertebral fracture assessment (VFA) DEXA imaging or radiation, and identify fractures missed by radiologists.
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Affiliation(s)
- Samir D Mehta
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Ronnie Sebro
- Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Department of Orthopedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 19104, USA.
- Department of Genetics, University of Pennsylvania, 421 Marie Curie Blvd, Philadelphia, PA, 19104, USA.
- Department of Epidemiology, Biostatistics and Bioinformatics, University of Pennsylvania, 421 Marie Curie Blvd, Philadelphia, PA, 19104, USA.
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Schmidutz F, Yan SG, Schopf C, Ihle C, Ahrend MD, Sprecher CM. Cortical bone thickness predicts the quantitative bone mineral density of the proximal humerus. Arch Osteoporos 2021; 16:33. [PMID: 33594610 DOI: 10.1007/s11657-021-00896-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/12/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Cortical thickness determined at the humerus can serve as an easy and reliable screening tool to predict the local bone status when quantitative bone mineral density (BMD) measurements are not available. It can therefore serve as a rapid screening tool in fragility fractures to identify patients requiring further diagnostic or osteoporosis treatment. INTRODUCTION Quantitative bone mineral density (BMD) of the humerus is difficult to determine but relevant for osteoporosis and fracture treatment. Dual-energy X-ray absorptiometry (DXA) of the femur and lumbar spine overestimates the humeral BMD and is not ubiquitously available. Therefore, this study evaluated whether the cortical bone thickness (CBT) of the humerus or DXA of the forearm is able to predict humeral BMD. METHODS Humeral BMD of 54 upper cadaver extremities (22 pairs, 10 single) (19-90 years) was determined by high-resolution peripheral-quantitative-computed-tomography (HR-pQCT) (volumetric BMD (vBMD)) and DXA (areal BMD (aBMD)) of the proximal humerus and distal forearm. Average and gauge cortical bone thickness (CBTavg/ CBTg) of the humeral diaphysis was determined from standard radiographs (XR) and computed-tomography (CT) and compared to the humeral BMD. Pearson (r) and intraclass-correlation-coefficients (ICC) were used to compare results and rater-reliability. RESULTS CBTavg from XR strongly correlated with the humeral BMD (r = 0.78 aBMD (DXA) and r = 0.64 vBMD (HR-pQCT) (p < 0.0001)). The CBTg revealed a weaker correlation (r = 0.57 aBMD and r = 0.43 vBMD). CBT derived from XR strongly correlated to those from the CT (r = 0.82-0.90) and showed an excellent intra- and inter-rater correlation (ICC 0.79-0.92). Distal forearm aBMD correlated well with the humeral aBMD (DXA) (r = 0.77) and paired specimens highly correlated to the contralateral side (humerus r = 0.89, radius r = 0.97). CONCLUSIONS The CBTavg can reliably be determined from standard radiographs and allows a good prediction of quantitative humeral bone mineral density (aBMD or vBMD) if measurements are not available. Furthermore, the distal forearm or the contralateral humerus can serve as a side to estimate the BMD if the ipsilateral side is impaired.
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Affiliation(s)
- Florian Schmidutz
- AO Research Institute Davos, Davos, Switzerland. .,Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany. .,Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Unfallklinik Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany.
| | - Shuang G Yan
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany.,The First Affiliated Hospital of Anhui Medical University, Anhui Medical University, Anhui, China
| | - Christoph Schopf
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
| | - Christoph Ihle
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Unfallklinik Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
| | - Marc-Daniel Ahrend
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tuebingen, BG Unfallklinik Tuebingen, Schnarrenbergstrasse 95, 72076, Tuebingen, Germany
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12
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Yang J, Cosman F, Stone PW, Li M, Nieves JW. Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective? Osteoporos Int 2020; 31:2321-2335. [PMID: 32778935 DOI: 10.1007/s00198-020-05588-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/04/2020] [Indexed: 01/03/2023]
Abstract
UNLABELLED Vertebral fracture assessment (VFA) is cost-effective when it was incorporated in the routine screening for osteoporosis in community-dwelling women aged ≥ 65 years, which support guidelines, such as the National Osteoporosis Foundation (NOF) for the diagnostic use of VFA as an important addition to fracture risk assessment. INTRODUCTION To evaluate the cost-effectiveness of VFA as a screening tool to reduce future fracture risk in US community-dwelling women aged ≥ 65 years. METHODS An individual-level state-transition cost-effectiveness model from a healthcare perspective was constructed using derived data from published literature. The time horizon was lifetime. Five screening strategies were compared, including no screening at all, central dual-energy X-ray absorptiometry (DXA) only, VFA only, central DXA followed by VFA if the femoral neck T-score (FN-T) ≤ - 1.5, or if the FN-T ≤ - 1.0. Various initiation ages and rescreening intervals were evaluated. Oral bisphosphonate treatment for 5-year periods was assumed. Incremental cost-effectiveness ratios (2017 US dollars per quality-adjusted life-year (QALY) gained) were used as the outcome measure. RESULTS The incorporation of VFA slightly increased life expectancy by 0.1 years and reduced the number of subsequent osteoporotic fractures by 3.7% and 7.7% compared with using DXA alone and no screening, respectively, leading to approximately 30 billion dollars saved. Regardless of initiation ages and rescreening intervals, central DXA followed by VFA if the FN-T ≤ - 1.0 was most cost-effective ($40,792 per QALY when the screening is initiated at age 65 years and with rescreening every 5 years). Results were robust to change in VF incidence and medication costs. CONCLUSION In women aged ≥ 65 years, VFA is cost-effective when it was incorporated in routine screening for osteoporosis. Our findings support the National Osteoporosis Foundation (NOF) guidelines for the diagnostic use of VFA as an important addition to fracture risk assessment.
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Affiliation(s)
- J Yang
- Institute for Social and Economic Research and Policy (ISERP), Columbia University, New York, NY, 10027, USA
| | - F Cosman
- Department of Medicine, Columbia University, New York, NY, 10032, USA
| | - P W Stone
- School of Nursing, Columbia University, New York, NY, USA
| | - M Li
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA
| | - J W Nieves
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA.
- Hospital for Special Surgery, New York, NY, 10021, USA.
- Department of Epidemiology and Institute of Human Nutrition, Columbia University, 630 West 168th Street, IHN PH 1512, New York, NY, 10032, USA.
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13
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Wilczek ML, Bhatta L, Brumpton BM, Freyschuss B, Brismar TB. Screening for women with increased risk of fragility fractures in a general female population using digital X-ray radiogrammetry (DXR). Maturitas 2020; 144:60-67. [PMID: 33358210 DOI: 10.1016/j.maturitas.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/25/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the predictive ability of digital X-ray radiogrammetry (DXR) for fracture in women attending general mammography screening. STUDY DESIGN In a nested case-control study, women aged between 40 and 75 years, who attended the regional mammography screening program, had their bone mass assessed with DXR and provided information regarding clinical risk factors for osteoporosis. Follow-up was done through cross-referencing with National Patient Registers. Associations between DXR, clinical risk factors and fracture risk were examined. Receiver operating characteristics curves for DXR T-score and different fracture types were plotted, and their respective AUC calculated. MAIN OUTCOME MEASURES Fractures (hip, major osteoporotic and any clinical facture). Fracture diagnoses were retrieved from National Patient Registers. RESULTS 14,841 women had their bone mass examined in conjunction with mammography. Of these women, 10,967 returned fully completed questionnaires regarding clinical risk factors. In total 605 fractures (including 355 major osteoporotic fractures and 18 hip fractures) occurred during the follow-up period (median follow-up time was 3.3 years). Women with fractures were older and had lower DXR T-score compared with those without. DXR T-score correlated with fracture risk. HR/SD T-score decrease was 2.15 (CI 1.55-3.00) for hip, 1.47 (CI 1.36-1.59) for major osteoporotic and 1.33 (CI 1.26-1.42) for any clinical fracture. The AUCs for the different fracture types were 0.79 (hip), 0.69 (major osteoporotic) and 0.65 (any clinical). CONCLUSIONS DXR T-score is negatively correlated with risk of fracture in a general female population. This indicates a potential use of DXR in population-based screening for osteoporosis.
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Affiliation(s)
- M L Wilczek
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - L Bhatta
- Norwegian University of Science and Technology, NTNU, Department of Public Health and Nursing, Norway
| | - B M Brumpton
- Norwegian University of Science and Technology, NTNU, Department of Public Health and Nursing, Norway
| | - B Freyschuss
- Department of Medicine H7, Karolinska Institutet, Stockholm, Sweden
| | - T B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Leslie WD, Morin SN, Martineau P, Bryanton M, Lix LM. Factors Associated With Bone Density Monitoring While on Antiosteoporosis Treatment in Routine Clinical Practice: A Registry-Based Cohort Study. J Clin Densitom 2020; 23:568-575. [PMID: 31003744 DOI: 10.1016/j.jocd.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/24/2022]
Abstract
The role for bone mineral density (BMD) monitoring while on antiosteoporosis therapy remains controversial. The current study used population-based registries to identify factors associated with BMD monitoring in women within 5 yr of receiving antiosteoporosis treatment vs treatment without monitoring in routine clinical practice. The analytical dataset consisted of women age 40 yr and older at baseline receiving antiosteoporosis therapy: 6877 with BMD monitoring (mean interval 3.2 yr) and 6747 without BMD monitoring. There was a significant negative secular trend in BMD monitoring during the study period (p < 0.001). Multivariable logistic regression demonstrated that parental hip fracture, glucocorticoid and aromatase inhibitor use, and lower baseline BMD were independently and positively associated with BMD monitoring. Individuals with increasing age, greater body mass index, smoking, rheumatoid arthritis, later calendar year, diabetes, rural residency, lower income, and greater comorbidity score were less likely to undergo monitoring. A shorter monitoring interval (<23 mo) was strongly associated with glucocorticoid and aromatase inhibitor use. In conclusion, our study identifies factors associated with BMD monitoring over 5 yr in patients receiving antiosteoporosis therapy.
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Affiliation(s)
- William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | | | - Patrick Martineau
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Harvard University, Boston, MA, USA
| | - Mark Bryanton
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa M Lix
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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15
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Anupama DS, Norohna JA, Acharya KK, Ravishankar, George A. Effect of exercise on bone mineral density and quality of life among postmenopausal women with osteoporosis without fracture: A systematic review. Int J Orthop Trauma Nurs 2020; 39:100796. [PMID: 33041224 DOI: 10.1016/j.ijotn.2020.100796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 06/04/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Osteoporosis is a progressive disease commonly seen in postmenopausal women which is characterized by decreased bone mass. This is becoming an important public health issue in India. This review aimed to evaluate the effect of exercise on quality of life and bone health status among postmenopausal osteoporotic women. METHODS We searched the following databases: Pubmed-Medline, Proquest, CINAHL, Scopus, Cochrane Central and PEDro. The review included randomized controlled trials that examined the use of exercise aimed at improving bone mineral density and quality of life in postmenopausal osteoporotic women without a history of fracture. Risk of bias was assessed by the Cochrane Risk of Bias tool. RESULTS This review suggests exercise is effective in improving the bone mineral density and quality of life of postmenopausal women with osteoporosis. The exercise interventions included in the studies were heterogeneous and included: Tai Chi, high intensity aerobic exercises, Modified Eight Section Brocade exercises, progressive slow loading low impact exercises, pilates and closed kinetic exercises. Four studies had a small sample size and in three studies, interventions were for a shorter duration. Meta-analysis could not be performed as the studies were not homogenous. CONCLUSION There is a need to conduct more experimental trials with robust research methods so that a high risk of bias can be avoided. The available evidence supports the positive effects of exercises on postmenopausal osteoporosis.
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Affiliation(s)
- D S Anupama
- Manipal College of Nursing, MAHE, Manipal, India
| | - Judith A Norohna
- Department of OBG nursing, Manipal college of Nursing, MAHE, Manipal, India.
| | | | - Ravishankar
- Department of Statistics, Prasanna School of Public Health, MAHE, Manipal, India
| | - Anice George
- Manipal College of Nursing, MAHE, Manipal, India
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16
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Hollick RJ, McKee L, Shim J, Ramsay N, Gerring S, Reid DM, Black AJ. Introducing mobile fracture prevention services with DXA in Northern Scotland: a comparative study of three rural communities. Osteoporos Int 2020; 31:1305-1314. [PMID: 32080756 DOI: 10.1007/s00198-020-05316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 01/23/2020] [Indexed: 11/30/2022]
Abstract
UNLABELLED Mobile fracture prevention services, with DXA, significantly improved access to care for those at high risk of fracture living in rural areas. Introduction of mobile services facilitated access to fracture liaison services and development of integrated of care pathways across community- and secondary-based care. INTRODUCTION The ageing population is growing faster in rural areas, yet most fracture prevention services are located in urban areas. As part of a wider study, evaluating the introduction of mobile fracture prevention services, we focus on whether mobile services improve access to care for those at highest risk of fracture. METHODS Services outcomes were assessed against the Royal Osteoporosis Society clinical standards for fracture liaison services. This included standardised, age-specific referral rates, FRAX 10-year probability of major osteoporotic and hip fracture of referrals, pre- and post-introduction of the mobile service across two island and one rural mainland sites. This was compared with referrals from a similar rural mainland region with local access to a comprehensive service. RESULTS Greatest impact occurred in areas with most limited service provision at baseline. Mean age of patients referred increased from 59 to 68 years (CI 6.8-10.1, p < 0.001). Referral rates increased from 2.8 to 5.4 per 1000 population between 2011 and 2018, with a 5-fold rise in those ≥ 75 years (0.4 to 2.0 per 1000). Mean FRAX 10-year risk of major osteoporotic fracture increased from 12.7 to 17.7% (CI 3.2-5.7, p < 0.001). Mean hip fracture risk probability increased from 3.0 to 5.7% (CI 2.0-3.4, p < 0.001). However, referral rates from the mobile sites remained lower than the comparator site. CONCLUSIONS Mobile fracture prevention services, including DXA, greatly improved uptake amongst high-risk individuals. Mobile services facilitated development of integrated of care pathways, including fracture liaison services, across community- and secondary-based care.
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Affiliation(s)
- R J Hollick
- Aberdeen Centre for Arthritis and Musculoskeletal Health, Epidemiology Group, University of Aberdeen, Aberdeen, UK.
| | - L McKee
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - J Shim
- Aberdeen Centre for Arthritis and Musculoskeletal Health, Epidemiology Group, University of Aberdeen, Aberdeen, UK
| | - N Ramsay
- Department of Rheumatology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - S Gerring
- Department of Rheumatology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - D M Reid
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - A J Black
- Department of Rheumatology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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Abstract
The prevalence of obesity in combination with sarcopenia (the age-related loss of muscle mass and strength or physical function) is increasing in adults aged 65 years and older. A major subset of adults over the age of 65 is now classified as having sarcopenic obesity, a high-risk geriatric syndrome predominantly observed in an ageing population that is at risk of synergistic complications from both sarcopenia and obesity. This Review discusses pathways and mechanisms leading to muscle impairment in older adults with obesity. We explore sex-specific hormonal changes, inflammatory pathways and myocellular mechanisms leading to the development of sarcopenic obesity. We discuss the evolution, controversies and challenges in defining sarcopenic obesity and present current body composition modalities used to assess this condition. Epidemiological surveys form the basis of defining its prevalence and consequences beyond comorbidity and mortality. Current treatment strategies, and the evidence supporting them, are outlined, with a focus on calorie restriction, protein supplementation and aerobic and resistance exercises. We also describe weight loss-induced complications in patients with sarcopenic obesity that are relevant to clinical management. Finally, we review novel and potential future therapies including testosterone, selective androgen receptor modulators, myostatin inhibitors, ghrelin analogues, vitamin K and mesenchymal stem cell therapy.
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Affiliation(s)
- John A Batsis
- Sections of General Internal Medicine and Weight and Wellness, and the Dartmouth Centers for Health and Aging, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, The Health Promotion Research Center and the Norris Cotton Cancer Center, Dartmouth College, Hanover, NH, USA.
| | - Dennis T Villareal
- Division of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX, USA
- Center for Translational Research on Inflammatory Diseases, Michael E DeBakey VA Medical Center, Houston, TX, USA
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18
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Wolinsky FD, Lou Y, Edmonds SW, Saag KG, Roblin DW, Wright NC, Jones MP, Cram P. The effects of a patient activation intervention on smoking and excessive drinking cessations: results from the PAADRN randomized controlled trial. Osteoporos Int 2017; 28:3055-3060. [PMID: 28573377 PMCID: PMC5670005 DOI: 10.1007/s00198-017-4101-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- F D Wolinsky
- Department of Health Management and Policy, University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, Iowa City, IA, 52242, USA.
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
- College of Nursing, University of Iowa, Iowa City, IA, USA.
| | - Y Lou
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - S W Edmonds
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
- CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
| | - K G Saag
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - D W Roblin
- Kaiser Permanente, Atlanta, GA, USA
- Department of Health Management and Policy, Georgia State University, Atlanta, GA, USA
| | - N C Wright
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
- Department of Epidemiology, University of Alabama, Birmingham, AL, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - P Cram
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine and Geriatrics, Mt. Sinai/UHN Hospitals, Toronto, Canada
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Lou Y, Edmonds SW, Jones MP, Ullrich F, Wehby GL, Cram P, Wolinsky FD. Predictors of bone mineral density testing among older women on Medicare. Osteoporos Int 2016; 27:3577-3586. [PMID: 27358177 DOI: 10.1007/s00198-016-3688-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/20/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED Although dual-energy X-ray absorptiometry (DXA) is recommended for all women ≥65 and is covered by Medicare, 40 % of women on Medicare report never having had a DXA. In a longitudinal cohort of 3492 women followed for two decades, we identified several risk factors that should be targeted to improve DXA testing rates. INTRODUCTION DXA is used to measure bone mineral density, screen for osteoporosis, and assess fracture risk. DXA is recommended for all women ≥65 years old. Although Medicare covers DXA every 24 months for women, about 40 % report never having had a DXA test, and little is known from prospective cohort studies about which subgroups of women have low use rates and should be targeted for interventions. Our objective was to identify predictors of DXA use in a nationally representative cohort of women on Medicare. METHODS We used baseline and biennial follow-up survey data (1993-2012) for 3492 women ≥70 years old from the nationally representative closed cohort known as the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The survey data for these women were then linked to their Medicare claims (1991-2012), yielding 17,345 person years of observation. DXA tests were identified from the Medicare claims, and Cox proportional hazard regression models were used with both fixed and time-dependent predictors from the survey interviews including demographic characteristics, socioeconomic factors, health status, health habits, and the living environment. RESULTS DXA use was positively associated with being Hispanic American, better cognition, higher income, having arthritis, using other preventative services, and living in Florida or other southern states. DXA use was negatively associated with age, being African-American, being overweight or obese, having mobility limitations, and smoking. CONCLUSIONS Interventions to increase DXA use should target the characteristics that were observed here to be negatively associated with such screening.
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Affiliation(s)
- Y Lou
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - S W Edmonds
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- University of Iowa College of Nursing, Iowa City, IA, USA
| | - M P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA
| | - F Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - G L Wehby
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - P Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - F D Wolinsky
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- University of Iowa College of Nursing, Iowa City, IA, USA.
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA.
- The University of Iowa, 145 North Riverside Drive, CPHB N211, Iowa City, IA, 52242, USA.
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Kälvesten J, Lui LY, Brismar T, Cummings S. Digital X-ray radiogrammetry in the study of osteoporotic fractures: Comparison to dual energy X-ray absorptiometry and FRAX. Bone 2016; 86:30-5. [PMID: 26921822 PMCID: PMC4833670 DOI: 10.1016/j.bone.2016.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/02/2016] [Accepted: 02/21/2016] [Indexed: 10/22/2022]
Abstract
Osteoporosis is often underdiagnosed and undertreated. Screening of post-menopausal women for clinical risk factors and/or low bone mineral density (BMD) has been proposed to overcome this. Digital X-ray radiogrammetry (DXR) estimates hand BMD from standard hand X-ray images and have shown to predict fractures and osteoporosis. Recently, digital radiology and the internet have opened up the possibility of conducting automated opportunistic screening with DXR in post-fracture care or in combination with mammography. This study compared the performance of DXR with FRAX® and DXA in discriminating major osteoporotic fracture (MOF) (hip, clinical spine, forearm or shoulder), hip fracture and femoral neck osteoporosis. This prospective cohort study was conducted on 5278 women 65years and older in the Study of Osteoporotic Fractures (SOF) cohort. Baseline hand X-ray images were analyzed and fractures were ascertained during 10years of follow up. Age-adjusted area under receiver operating characteristic curve (AUC) for MOF and hip fracture and for femoral neck osteoporosis (DXA FN BMD T-score ≤-2.5) was used to compare the methods. Sensitivity to femoral neck osteoporosis at equal selection rates was tabulated for FRAX and DXR. DXR-BMD, FRAX (no BMD) and lumbar spine DXA BMD were all similar in fracture discriminative performance with an AUC around 0.65 for MOF and 0.70 for hip fractures for all three methods. As expected femoral neck DXA provided fracture discrimination superior both to other BMD measurements and to FRAX. AUC for selection of patients with femoral neck osteoporosis was higher with DXR-BMD, 0.76 (0.74-0.77), than with FRAX, 0.69 (0.67-0.71), (p<0.0001). In conclusion, DXR-BMD discriminates incident fractures to a similar degree as FRAX and predicts femoral neck osteoporosis to a larger degree than FRAX. DXR shows promise as a method to automatically flag individuals who might benefit from an osteoporosis assessment.
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Affiliation(s)
- Johan Kälvesten
- Radiology, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Östergötland County Council, University hospital, Linköping, Sweden; Center for Medical Image Science and Visualization zCMIV), Linköping University, Sweden; Sectra AB, Linköping, Sweden.
| | - Li-Yung Lui
- San Francisco Coordinating Center, California Pacific Medical Center, San Francisco, CA, USA
| | - Torkel Brismar
- Karolinska Institutet, Department for Clinical Science, Intervention and Technology, Division of Radiology, Karolinska University Hospital, Sweden
| | - Steven Cummings
- San Francisco Coordinating Center, California Pacific Medical Center, San Francisco, CA, USA
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21
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Correlation between osteoporotic fracture risk in Brazilian postmenopausal women calculated using the FRAX with and without the inclusion of bone densitometry data. Arch Osteoporos 2016; 11:16. [PMID: 27067597 DOI: 10.1007/s11657-015-0255-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED The risks of fracture were calculated in 402 postmenopausal Brazilian women by FRAX with or without the inclusion of bone densitometry values. The correlation between the risk of major osteoporosis fracture or hip fracture calculated by FRAX with or without BMD was similar in this population, 0.76 and 0.64, respectively. OBJECTIVE The objective of this study is to evaluate the degree of agreement between the 10-year fracture risk in postmenopausal Brazilian women, calculated using the WHO Fracture Risk Assessment Tool (FRAX)-Brazil, with and without the inclusion of bone mineral density (BMD) values. METHODS A cross-sectional study was conducted with 402 postmenopausal women (≥40 years) who had undergone bone densitometry prior to initiating any pharmacological treatment for osteopenia or osteoporosis. The risks of a major osteoporosis fracture or hip fracture were calculated according to FRAX-Brazil either using clinical risk factors alone or with the inclusion of BMD value. The tests used were intraclass correlation coefficient, Mann-Whitney test, and univariate linear regression analysis. RESULTS When the patients were classified according to the cutoff point defined as determining a high risk of a major osteoporosis fracture (≥20 %), 0.75 % were defined as high risk when BMD values were included and 1 % when they were not. With respect to the hip, 5.22 % were defined as having a high risk of fracture (≥3 %) when BMD values were included and 11.44 % when they were not. Intraclass correlation coefficient between the FRAX-Brazil assessed risk with and without the inclusion of BMD values was 0.76 (95 % CI 0.716-0.799) for a major osteoporosis fracture and 0.64 (95 %CI 0.583-0.698) for a hip fracture. CONCLUSION The correlation found for the FRAX-Brazil score obtained with and without the inclusion of BMD values was good for the risk of a major osteoporosis fracture and moderate for the risk of a hip fracture. The fracture risk calculated was similar in this population irrespective of whether or not BMD values were included in the algorithm.
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Klop C, de Vries F, Bijlsma JWJ, Leufkens HGM, Welsing PMJ. Predicting the 10-year risk of hip and major osteoporotic fracture in rheumatoid arthritis and in the general population: an independent validation and update of UK FRAX without bone mineral density. Ann Rheum Dis 2016; 75:2095-2100. [PMID: 26984006 PMCID: PMC5136695 DOI: 10.1136/annrheumdis-2015-208958] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/13/2016] [Accepted: 02/28/2016] [Indexed: 01/11/2023]
Abstract
Objectives FRAX incorporates rheumatoid arthritis (RA) as a dichotomous predictor for predicting the 10-year risk of hip and major osteoporotic fracture (MOF). However, fracture risk may deviate with disease severity, duration or treatment. Aims were to validate, and if needed to update, UK FRAX for patients with RA and to compare predictive performance with the general population (GP). Methods Cohort study within UK Clinical Practice Research Datalink (CPRD) (RA: n=11 582, GP: n=38 755), also linked to hospital admissions for hip fracture (CPRD-Hospital Episode Statistics, HES) (RA: n=7221, GP: n=24 227). Predictive performance of UK FRAX without bone mineral density was assessed by discrimination and calibration. Updating methods included recalibration and extension. Differences in predictive performance were assessed by the C-statistic and Net Reclassification Improvement (NRI) using the UK National Osteoporosis Guideline Group intervention thresholds. Results UK FRAX significantly overestimated fracture risk in patients with RA, both for MOF (mean predicted vs observed 10-year risk: 13.3% vs 8.4%) and hip fracture (CPRD: 5.5% vs 3.1%, CPRD-HES: 5.5% vs 4.1%). Calibration was good for hip fracture in the GP (CPRD-HES: 2.7% vs 2.4%). Discrimination was good for hip fracture (RA: 0.78, GP: 0.83) and moderate for MOF (RA: 0.69, GP: 0.71). Extension of the recalibrated UK FRAX using CPRD-HES with duration of RA disease, glucocorticoids (>7.5 mg/day) and secondary osteoporosis did not improve the NRI (0.01, 95% CI −0.04 to 0.05) or C-statistic (0.78). Conclusions UK FRAX overestimated fracture risk in RA, but performed well for hip fracture in the GP after linkage to hospitalisations. Extension of the recalibrated UK FRAX did not improve predictive performance.
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Affiliation(s)
- Corinne Klop
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK.,Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Epidemiology, Maastricht University/CAPHRI, Maastricht, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center, Utrecht, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center, Utrecht, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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Ito K, Leslie WD. Cost-effectiveness of fracture prevention in rural women with limited access to dual-energy X-ray absorptiometry. Osteoporos Int 2015; 26:2111-9. [PMID: 25807913 DOI: 10.1007/s00198-015-3107-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/10/2015] [Indexed: 01/19/2023]
Abstract
UNLABELLED A reduced reimbursement for office-based dual-energy X-ray absorptiometry (DXA) is likely to exacerbate the burden of fractures in rural areas. Our cost-effective analysis suggests that, in areas where access to DXA is limited, treatment for women at high clinical risk for fractures could both improve health and save money. INTRODUCTION To evaluate the cost-effectiveness of various fracture prevention strategies for rural women with limited access to dual-energy X-ray absorptiometry (DXA). METHODS A Markov model was developed using data from the published literature and the Manitoba Bone Density Program. The participants were a simulated cohort of rural women aged 65 years with travel distance between 10 and 24 mi to the nearest DXA site. The evaluated strategies were (1) watchful waiting, (2) bone mineral density (BMD)-based strategy (i.e., DXA screening followed by pharmacotherapy based on BMD), and (3) clinical risk factor (CRF)-based strategy (i.e., pharmacotherapy for women at high risk for fractures by the World Health Organization Fracture Risk Assessment Tool [FRAX]). The outcome was an incremental cost-effectiveness ratio (ICER) measured by cost per quality-adjusted life-year (QALY) gained. The analysis was preformed from a societal perspective over a lifetime horizon. RESULTS In the base-case analysis, the BMD-based strategy had an ICER of $6000 per QALY gained. For those with travel distance between 25 and 39 mi, the BMD-based strategy would have an ICER of $140,800 per QALY gained. For those with travel distance greater than 40 mi, the CRF-based strategy would be more effective and less costly than other strategies. CONCLUSIONS In areas where DXA is readily available, DXA screening followed by pharmacotherapy guided by BMD would be preferred. In areas with more limited access to DXA, pharmacotherapy for women at high clinical risk for fractures based on FRAX could both improve health and save money from the societal perspective.
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Affiliation(s)
- K Ito
- Division of Geriatric Medicine, Department of Primary Care, University of New England College of Osteopathic Medicine, 11 Hills Beach Road, Biddeford, ME, 04005, USA,
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Kim JW, Koh JM, Park JH, Chang JS. Validation of FRAX without BMD: an age-related analysis of the Fifth Korean National Health and Nutrition Examination Survey (KNHANES V-1, 2010). Bone 2015; 75:27-31. [PMID: 25697083 DOI: 10.1016/j.bone.2015.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Abstract
Although the Fracture Risk Assessment Tool (FRAX) is widely used to evaluate probabilities of fractures, there is no consensus regarding whether it is accurate when bone mineral density (BMD) is not included. This cross-sectional study aimed to compare the 10-year predicted fracture probabilities calculated using FRAX with and without BMD. Data were collected from the 2010 Fifth Korean National Health and Nutrition Examination Survey, and 2706 participants (1260 men and 1446 women) aged 50-90 years were analyzed. Ten-year predicted probabilities for major osteoporotic and hip fractures were calculated using the FRAX model. In men, the 10-year probabilities without BMD were 3.9±1.8% and 1.3±1.4% for major osteoporotic and hip fractures, respectively. In women, the 10-year probabilities without BMD were 7.7±4.4% and 2.6±2.9% for major osteoporotic and hip fractures, respectively. These probabilities were significantly correlated with the probabilities calculated using FRAX with BMD (all, p<0.001). When participants were divided into 10-year age groups and compared with the 10-year predicted fracture probability with BMD, the 10-year predicted fracture probability without BMD was lower in men 50-59 years old, similar to men 60-69 years old, and higher in men ≥70 years old. The FRAX scores without BMD were generally lower for all women. The FRAX model without BMD appears to be a slightly lower fracture probability compared to that calculated with BMD, especially in younger participants. Although these results have important clinical implications for areas with limited ability to evaluate BMD, they must be confirmed by a large prospective study.
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Affiliation(s)
- Ji Wan Kim
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jai Hyung Park
- Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Suk Chang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Wilczek ML, Nielsen C, Kälvesten J, Algulin J, Brismar TB. Mammography and osteoporosis screening--clinical risk factors and their association with digital X-ray radiogrammetry bone mineral density. J Clin Densitom 2015; 18:22-9. [PMID: 25294740 DOI: 10.1016/j.jocd.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 07/23/2014] [Indexed: 11/22/2022]
Abstract
The aim of this study was to study the association between digital X-ray radiogrammetry (DXR) T-score and clinical risk factors for osteoporosis. Women were recruited 2 d per wk at a single mammography screening center between year 2010 and 2012. Included women answered a questionnaire about risk factors for osteoporosis, and a radiograph of the nondominant hand was obtained for DXR analysis. Univariate associations between DXR T-score and risk factors were examined. A generalized linear regression model was fitted to independent variables with univariate associations at p<0.05. The multivariable model was reduced through manual backward elimination, with p>0.1 as the exclusion criterion. Seventy-six percent of the women chose to participate in the study (n=8810). The difference in number of daily mammograms performed on study vs nonstudy days was not significant. All univariate associations between DXR T-score and potential risk factors were highly significant. The multivariable model included height, weight, age, right-handedness, menopause before age 45, alcohol consumption, cortisone treatment, rheumatic disease, and age×smoking status. The coefficient of determination of the model was 0.37. The association between risk factors for osteoporosis and DXR T-score is similar to previously reported associations with dual-energy X-ray absorptiometry.
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Affiliation(s)
- Michael L Wilczek
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | | | - Johan Kälvesten
- Sectra AB, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | | | - Torkel B Brismar
- Division of Radiology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Jandoc R, Jembere N, Khan S, Russell SJ, Allard Y, Cadarette SM. Osteoporosis management and fractures in the Métis of Ontario, Canada. Arch Osteoporos 2015; 10:12. [PMID: 25910866 PMCID: PMC4412654 DOI: 10.1007/s11657-015-0212-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 02/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED Half of Métis citizens, compared to less than 10 % of the general population of Ontario, reside in northern regions, with little access to bone mineral density (BMD) testing. Métis citizens had lower sex-specific and age-standardized rates of BMD testing, yet similar rates of fracture (both sexes) and pharmacotherapy (women only). PURPOSE To examine osteoporosis management and common osteoporosis-related fractures among Métis citizens compared to the general population of older adults residing in Ontario. METHODS We linked healthcare (medical and pharmacy) utilization and administrative (demographic) databases with the Métis Nation of Ontario citizenship registry to estimate osteoporosis management (bone mineral density [BMD] testing, pharmacotherapy) and fractures (hip, humerus, radius/ulna) among adults aged ≥50 years, from April 1, 2006 to March 31, 2011. Pharmacotherapy data were limited to residents aged ≥65 years. Sex-specific and age-standardized rates were compared between the Métis and the general population. Multivariable logistic regression was used to compare rates of BMD testing after controlling for differences in age and region of residence between the Métis and the general population. RESULTS We studied 4219 Métis citizens (55 % men), and 140 (3 %) experienced a fracture. Half of Métis citizens, compared to less than 10 % of the general population of Ontario, resided in northern regions. We identified significantly lower sex-specific and age-standardized rates of BMD testing among Métis compared to the general population, yet found little difference in fracture rates (both sexes) or pharmacotherapy (women only). Differences in BMD testing disappeared after adjusting for region of residence among women yet remained significant among men. CONCLUSIONS Despite finding significantly lower rates of osteoporosis management among men, Métis men and women were found to have similar age-standardized fracture rates to the general population.
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Affiliation(s)
- Racquel Jandoc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | | | - Saba Khan
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | | | | | - Suzanne M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada ,Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,Leslie L. Dan Pharmacy Building, University of Toronto, 144 College Street, Toronto, ON M5S 3M2 Canada
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Warriner AH, Outman RC, Feldstein AC, Roblin DW, Allison JJ, Curtis JR, Redden DT, Rix MM, Robinson BE, Rosales AG, Safford MM, Saag KG. Effect of self-referral on bone mineral density testing and osteoporosis treatment. Med Care 2014; 52:743-50. [PMID: 24984211 PMCID: PMC4101066 DOI: 10.1097/mlr.0000000000000170] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Despite national guidelines recommending bone mineral density screening with dual-energy x-ray absorptiometry (DXA) in women aged 65 years and older, many women do not receive initial screening. OBJECTIVE To determine the effectiveness of health system and patient-level interventions designed to increase appropriate DXA testing and osteoporosis treatment through (1) an invitation to self-refer for DXA (self-referral); (2) self-referral plus patient educational materials; and (3) usual care (UC, physician referral). RESEARCH DESIGN Parallel, group-randomized, controlled trials performed at Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Georgia (KPG). SUBJECTS Women aged 65 years and older without a DXA in past 5 years. MEASURES DXA completion rates 90 days after intervention mailing and osteoporosis medication receipt 180 days after initial intervention mailing. RESULTS From >12,000 eligible women, those randomized to self-referral were significantly more likely to receive a DXA than UC (13.0%-24.1% self-referral vs. 4.9%-5.9% UC, P<0.05). DXA rates did not significantly increase with patient educational materials. Osteoporosis was detected in a greater proportion of self-referral women compared with UC (P<0.001). The number needed to receive an invitation to result in a DXA in KPNW and KPG regions was approximately 5 and 12, respectively. New osteoporosis prescription rates were low (0.8%-3.4%) but significantly greater among self-referral versus UC in KPNW. CONCLUSIONS DXA rates significantly improved with a mailed invitation to schedule a scan without physician referral. Providing women the opportunity to self-refer may be an effective, low-cost strategy to increase access for recommended osteoporosis screening.
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Affiliation(s)
- Amy H. Warriner
- Division of Endocrinology, Diabetes and Metabolism, University of Alabama at Birmingham
| | - Ryan C. Outman
- Division of Preventive Medicine, University of Alabama at Birmingham
| | | | | | - Jeroan J. Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jeffrey R. Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham
| | - David T. Redden
- Department of Biostatistics, University of Alabama at Birmingham
| | - Mary M. Rix
- Kaiser Permanente Center for Health Research/Northwest, Portland, OR
| | | | | | - Monika M. Safford
- Division of Preventive Medicine, University of Alabama at Birmingham
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham
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FitzGerald JD, Battistone M, Brown CR, Cannella AC, Chakravarty E, Gelber AC, Lozada CJ, Punaro M, Slusher B, Abelson A, Elashoff DA, Benford L. Regional distribution of adult rheumatologists. ACTA ACUST UNITED AC 2014; 65:3017-25. [PMID: 24284967 DOI: 10.1002/art.38167] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 08/20/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To analyze the distribution of rheumatology practices in the US and factors associated with that distribution, in order to better understand the supply of the rheumatology workforce. METHODS Using the American College of Rheumatology membership database, all practicing adult rheumatologist office addresses were mapped with ArcView software. The number of rheumatologists per Core Based Statistical Area (CBSA) was calculated. To investigate whether sociodemographic factors correlated with clustering of rheumatologists, covariates from the 2010 US Census for each CBSA, including age, sex, race/ethnicity, and median household income, were modeled. RESULTS Many CBSAs, predominantly smaller micropolitan areas, did not have a practicing rheumatologist. For some of these smaller micropolitan areas (with populations of at least 40,000), the closest practicing rheumatologist was more than 200 miles away. However, we also identified several more-populous areas (populations of 200,000 or more) without a practicing rheumatologist. Greater numbers of rheumatologists were more likely to practice in areas with higher population densities and higher median incomes. More rheumatologists were also found in CBSAs in which there were rheumatology training programs. CONCLUSION These findings demonstrate that many smaller regions of the country have no or few practicing adult rheumatologists. Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care. Policy changes could address potential regional rheumatology workforce shortages, but limitations of the current data would need to be addressed prior to implementation of such changes.
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Friis-Holmberg T, Rubin KH, Brixen K, Tolstrup JS, Bech M. Fracture risk prediction using phalangeal bone mineral density or FRAX(®)?-A Danish cohort study on men and women. J Clin Densitom 2014; 17:7-15. [PMID: 23623379 DOI: 10.1016/j.jocd.2013.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/15/2013] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
Abstract
In this prospective study, we investigated the ability of Fracture Risk Assessment Tool (FRAX), phalangeal bone mineral density (BMD), and age alone to predict fractures using data from a Danish cohort study, Danish Health Examination Survey 2007-2008, including men (n = 5206) and women (n = 7552) aged 40-90 yr. Data were collected using a self-administered questionnaire and by phalangeal BMD measurement. Information on incident and prevalent fractures, rheumatoid arthritis, and secondary osteoporosis was retrieved from the Danish National Patient Registry. Survival analyses were used to examine the association between low, intermediate, and high risk by phalangeal T-score or FRAX and incident fractures, and receiver operating characteristic curves were obtained. Mean follow-up time was 4.3 yr, and a total of 395 persons (3.1%) experienced a fracture during follow-up. The highest rate of major osteoporotic fractures was observed in persons with a high combined risk (FRAX ≥20% and T-score ≤-2.5; women: 32.7 and men: 27.6 per 1000 person-yr). This group also had the highest risk of hip fractures (women: 8.1 and men: 7.2 per 1000 person-yr). FRAX and T-score in combination analyzed as continuous variables performed overall best in the prediction of major osteoporotic fractures. In predicting hip fractures, there was a tendency of T-score performing worse than the other methods.
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Affiliation(s)
- Teresa Friis-Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Katrine Hass Rubin
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kim Brixen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Mickael Bech
- COHERE, Department of Business and Economics, University of Southern Denmark, Odense, Denmark
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Chou SH, Hwang J, Ma SL, Vokes T. Utility of heel dual-energy X-ray absorptiometry in diagnosing osteoporosis. J Clin Densitom 2014; 17:16-24. [PMID: 24144894 PMCID: PMC3946648 DOI: 10.1016/j.jocd.2013.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
Abstract
Although peripheral dual-energy X-ray absorptiometry measurements have been found to predict fractures in population studies of white subjects, little is known about their utility in other races and in patients with greater risk of fracture. In a cross-sectional study of 874 women referred for bone mineral density (BMD) testing, we examined the utility of heel BMD in African-American (AA) compared with Caucasian (CA) women and in women using glucocorticoids. The ability of heel T-score to predict central osteoporosis was similar in AA and CA women (odds ratio [OR] per 1 unit decrease in T-score of 2.79 [95% confidence interval {CI} 2.16-3.60] and 3.15 [95% CI 2.53-3.92], respectively). The association between heel T-score and prevalent vertebral fractures was also similar in the 2 groups (OR 1.46 [95% CI 1.15-1.85] in AA and 1.42 [95% CI 1.16-1.74] in CA). In women using glucocorticoids heel T-score was better than central T-score in predicting vertebral fractures (OR 1.38 [95% CI 1.03-1.85] and 1.22 [95% CI 0.86-1.73], respectively). We conclude that in a multiracial referral population heel BMD predicts central osteoporosis and prevalent vertebral fractures equally well in AA as in CA women and may be better than central BMD in assessing fragility in glucocorticoid users.
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Affiliation(s)
- Sharon H Chou
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago, Chicago, IL, USA
| | - Jessica Hwang
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago, Chicago, IL, USA
| | - Siu-Ling Ma
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago, Chicago, IL, USA; Queens Diabetes and Endocrinology Associates, Flushing, NY, USA
| | - Tamara Vokes
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago, Chicago, IL, USA.
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Low rates of bone mineral density measurement in Medicare beneficiaries with prostate cancer initiating androgen deprivation therapy. Support Care Cancer 2013; 22:537-44. [PMID: 24146343 DOI: 10.1007/s00520-013-2008-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 10/01/2013] [Indexed: 01/05/2023]
Abstract
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.
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Warriner AH, Outman RC, Kitchin E, Chen L, Morgan S, Saag KG, Curtis JR. A randomized trial of a mailed intervention and self-scheduling to improve osteoporosis screening in postmenopausal women. J Bone Miner Res 2012; 27:2603-10. [PMID: 22836812 PMCID: PMC3502704 DOI: 10.1002/jbmr.1720] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 07/11/2012] [Accepted: 07/13/2012] [Indexed: 01/13/2023]
Abstract
Guidelines recommend bone density screening with dual-energy X-ray absorptiometry (DXA) in women 65 years or older, but <30% of eligible women undergo DXA testing. There is a need to identify a systematic, effective, and generalizable way to improve osteoporosis screening. A group randomized, controlled trial of women ≥65 years old with no DXA in the past 4 years, randomized to receive intervention materials (patient osteoporosis brochure and a letter explaining how to self-schedule a DXA scan) versus usual care (control) was undertaken. Outcome of interest was DXA completion. Of 2997 women meeting inclusion criteria, 977 were randomized to the intervention group. A total of 17.3% of women in the intervention group completed a DXA, compared to 5.2% in the control group (12.1% difference, p < 0.0001). When including only those medically appropriate, we found a difference of 19% between the two groups (p < 0.0001). DXA receipt was greater in main clinic patients compared to satellite clinic patients (20.9% main clinic versus 10.1% satellite clinic). The cost to print and mail the intervention was $0.79 per patient, per mailing. The number of women to whom intervention needed to be mailed to yield one extra DXA performed was 9, at a cost of $7.11. DXA scan completion was significantly improved through use of a mailed osteoporosis brochure and the availability for patients to self-schedule. This simple approach may be an effective component of a multifaceted quality improvement program to increase rates of osteoporosis screening.
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Affiliation(s)
- Amy H Warriner
- Division of Endocrinology, Diabetes and Metabolism, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Phalangeal bone mineral density predicts incident fractures: a prospective cohort study on men and women--results from the Danish Health Examination Survey 2007–2008 (DANHES 2007–2008). Arch Osteoporos 2012; 7:291-9. [PMID: 23152065 DOI: 10.1007/s11657-012-0111-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 09/28/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED This prospective study investigates the use of phalangeal bone mineral density (BMD) in predicting fractures in a cohort (15,542) who underwent a BMD scan. In both women and men, a decrease in BMD was associated with an increased risk of fracture when adjusted for age and prevalent fractures. PURPOSE The aim of this study was to evaluate the ability of a compact and portable scanner using radiographic absorptiometry (RA) to predict major osteoporotic fractures. METHODS This prospective study included a cohort of 15,542 men and women aged 18–95 years, who underwent a BMD scan in Danish Health Examination Survey 2007–2008. BMD at the middle phalanges of the second, third and fourth digits of the non-dominant hand was measured using RA (Alara MetriScan®). These data were merged with information on incident fractures retrieved from the Danish National Patient Registry comprising the International Classification of Diseases (ICD-10). Follow-up was 27–45 months. Major osteoporotic fractures (vertebral fractures, humerus fractures, forearm fractures and hip fractures) were used in the analyses. Fracture events were calculated as "persons with fracture" and evaluated using survival analysis. RESULTS A total of 307 (1.98 %) of the participants had experienced a new fracture during follow-up. BMD was significantly lower in subjects with fracture (0.32 vs. 0.34 g/cm(2); p < 0.001 adjusted for age, gender, prevalent fractures, height, weight and smoking). In both women and men, a 1 SD decrease in BMD (T score units) was associated with an increased risk of fracture when adjusted for age and prevalent fractures (women: HR = 1.39, CI 1.24–1.54, p < 0.001; men: HR = 1.47, CI 1.20–1.79, p < 0.001). CONCLUSION Phalangeal BMD as measured using RA predicts the incidence of major osteoporotic fractures.
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Wilczek ML, Kälvesten J, Algulin J, Beiki O, Brismar TB. Digital X-ray radiogrammetry of hand or wrist radiographs can predict hip fracture risk--a study in 5,420 women and 2,837 men. Eur Radiol 2012; 23:1383-91. [PMID: 23229168 PMCID: PMC3622796 DOI: 10.1007/s00330-012-2706-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 09/28/2012] [Accepted: 10/15/2012] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To assess whether digital X-ray radiogrammetry (DXR) analysis of standard clinical hand or wrist radiographs obtained at emergency hospitals can predict hip fracture risk. METHODS A total of 45,538 radiographs depicting the left hand were gathered from three emergency hospitals in Stockholm, Sweden. Radiographs with insufficiently included metacarpal bone, fractures in measurement regions, foreign material or unacceptable positioning were manually excluded. A total of 18,824 radiographs from 15,072 patients were analysed with DXR, yielding a calculated BMD equivalent (DXR-BMD). Patients were matched with the national death and inpatient registers. Inclusion criteria were age ≥ 40 years, no prior hip fracture and observation time > 7 days. Hip fractures were identified via ICD-10 codes. Age-adjusted hazard ratio per standard deviation (HR/SD) was calculated using Cox regression. RESULTS 8,257 patients (65.6 % female, 34.4 % male) met the inclusion criteria. One hundred twenty-two patients suffered a hip fracture after their radiograph. The fracture group had a significantly lower DXR-BMD than the non-fracture group when adjusted for age. The HR/SD for hip fracture was 2.52 and 2.08 in women and men respectively. The area under the curve was 0.89 in women and 0.84 in men. CONCLUSIONS DXR analysis of wrist and hand radiographs obtained at emergency hospitals predicts hip fracture risk in women and men. KEY POINTS • Digital X-ray radiogrammetry of emergency hand/wrist radiographs predicts hip fracture risk. • Digital X-ray radiogrammetry (DXR) predicts hip fracture risk in both women and men. • Osteoporosis can potentially be identified in patients with suspected wrist fractures. • DXR can potentially be used for selective osteoporosis screening.
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Affiliation(s)
- M L Wilczek
- Karolinska Institutet, Department for Clinical Science, Intervention and Technology, Division of Radiology, Karolinska University Hospital, Stockholm, Sweden.
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Lee YS, Jong-Duek B, Yang K, Yoon S. Relationships between physical activity and awareness and treatment status among adults with low femoral bone density in the United States. Am J Health Promot 2012; 27:2-9. [PMID: 22950919 DOI: 10.4278/ajhp.110107-quan-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE To examine relationships between physical activity (PA) and awareness and treatment status of low bone mineral density (BMD) among adults. DESIGN Cross-sectional. SETTING Stratified sample of adults living independently in the community. SUBJECTS A total of 1928 adults aged 50 years and older who participated in the National Health and Nutrition Examination Survey 2005-2006 were included in the analysis. Among those, about 54% were women, 84% were non-Hispanic whites, 65% were married, and 44% were between 50 and 59 years of age. MEASURES Objective measures: femoral neck BMD and duration of PA and step counts measured by accelerometers. Self-report: strength exercise, and awareness and treatment of low bone density. ANALYSIS Multivariate regression analyses using SUDAAN. RESULTS Despite a high prevalence of low BMD, self-reported awareness, treatment, and PA were very low. After controlling socio-demographic and health-related factors, those who were aware of their low bone density status and who received treatment for it were less physically active than those who were unaware of their bone condition or who did not have any treatment. CONCLUSIONS PA levels are below the recommended level for bone health benefits. Health care providers should consider screening individuals at risk of low bone density and encourage them to implement prevention and treatment regimen including increasing daily levels of PA.
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Affiliation(s)
- Young-Shin Lee
- School of Nursing, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA.
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King AB, Fiorentino DM. Medicare payment cuts for osteoporosis testing reduced use despite tests' benefit in reducing fractures. Health Aff (Millwood) 2012; 30:2362-70. [PMID: 22147865 DOI: 10.1377/hlthaff.2011.0233] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bone imaging known as DXA ("dexa")-dual energy x-ray absorptiometry of the central skeleton--is considered the "gold standard" test for osteoporosis, which affects more than fifty million Americans. The tests are associated with improved clinical outcomes through preventing bone fractures. Cuts in Medicare Part B reimbursement for the provision of this preventive imaging in a physician's office began in 2007 and reached 56 percent below the 2006 level in January 2010. To encourage the use of DXA testing, the Affordable Care Act of 2010 provided partial relief from the cuts for two years (2010-11). Our study found that after a decade of growth, DXA testing in all Part B settings plateaued in 2007-09, resulting in 800,000 fewer tests than expected for Medicare beneficiaries--tests that might have prevented approximately 12,000 fractures. Testing declined in 2010, when the start of reimbursement relief under the Affordable Care Act was delayed, and increased outpatient testing failed to offset reduced use in physician offices. Our findings strongly suggest that the payment cuts reduced beneficiary access and that the tests were underused by elderly female Medicare beneficiaries despite strong association with fracture prevention. We recommend that Congress extend the payment relief granted under the Affordable Care Act for at least another two years.
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Abstract
PURPOSE OF REVIEW To summarize recent policy and guideline updates that have significant consequences for the clinical use of dual-energy X-ray absorptiometry (DXA) in the diagnosis and treatment of osteoporosis and, thus, the prevention of fractures and associated morbidity and mortality. RECENT FINDINGS Recent policy trends have sought to reverse reimbursement declines for DXA services, whereas updated guidelines have attempted to restrict the candidates for bone density testing. Recent literature reflects the ongoing controversy of repeat DXA testing. SUMMARY Patient access to DXA scans has been threatened by declining reimbursement and, therefore, access to diagnosis and fracture prevention. There have been successful efforts to reverse this trend, but the future remains uncertain. The complexities and omissions of updated guidelines for obtaining DXA testing may serve again to restrict initial access, and the recent controversy of repeat DXA testing may make monitoring results of therapy more difficult.
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Zhang J, Delzell E, Zhao H, Laster AJ, Saag KG, Kilgore ML, Morrisey MA, Wright NC, Yun H, Curtis JR. Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes. J Bone Miner Res 2012; 27:858-64. [PMID: 22190195 DOI: 10.1002/jbmr.1534] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the United States, Medicare gradually reduced payments for central dual-energy X-ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of $139 in 2006 to about $82 in 2007 and 2008 and $72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office-based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office-based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.
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Affiliation(s)
- Jie Zhang
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Leslie WD, Morin S, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA. Fracture risk assessment without bone density measurement in routine clinical practice. Osteoporos Int 2012; 23:75-85. [PMID: 21850546 DOI: 10.1007/s00198-011-1747-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/24/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED Fracture probability assessed without bone mineral density (BMD) could potentially be sufficient for clinical decision making in many individuals categorized as low or high fracture risk. For individuals falling in a moderate risk range, there is incremental value in using BMD in the probability calculation as this appropriately reclassifies risk in over one third of the individuals. INTRODUCTION A new fracture risk assessment tool from the World Health Organization (FRAX) estimates 10-year major osteoporotic and hip fracture probabilities from multiple clinical risk factors with or without hip BMD. The objective of this study is to determine whether fracture probability derived without BMD can be used to identify individuals who would be designated for treatment. METHODS A historical cohort of 36,730 women and 2,873 men aged 50 years and older drawn from the Manitoba Bone Density Program database, which contains clinical BMD results for the Province of Manitoba, Canada, was included in the study. RESULTS When 10-year probability for major osteoporotic fracture estimated without knowledge of BMD was high (≥ 20%), the vast majority (92.8%) qualified for intervention under the National Osteoporosis Foundation (NOF) guidelines, whereas among those at low risk (<10%), the vast majority (80.5%) did not satisfy any NOF intervention criteria. The benefit of including BMD in the risk assessment was greatest among those initially at moderate risk (10-19%) when fracture probability was derived without BMD, but this represented only 29.4% of the cohort (9.3% of those aged < 65 years and 48.7% of those ≥ 65 years). CONCLUSIONS Fracture probability derived without BMD is able to risk stratify women in terms of future fracture risk and could potentially be sufficient for clinical decision making in many of those designated at low or high fracture risk.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, Canada R2H 2A6.
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Dhainaut A, Rohde G, Hoff M, Syversen U, Haugeberg G. Phalangeal densitometry compared with dual energy X-ray absorptiometry for assessment of bone mineral density in elderly women. J Womens Health (Larchmt) 2011; 20:1789-95. [PMID: 21970521 DOI: 10.1089/jwh.2010.2682] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Reduced bone mineral density (BMD) is identified as a major risk factor for fracture. The World Health Organization criterion for diagnosis of osteoporosis (T-score ≤-2.5 SD) is based on dual energy X-ray absorptiometry (DXA) measurements. However DXA availability may be limited in some regions. In this study the ability of the phalangeal radiographic absorptiometry (RA) device, MetriScan, to identify women with reduced BMD at the femoral neck assessed by DXA was evaluated. METHODS The study population contained women with recent low-energy distal radius fracture and women recruited from the general population, all aged ≥50 years. A triage approach was applied in which two cut-offs for RA T-score were defined at which individuals with 90% sensitivity and 90% specificity could be identified to have or not have reduced BMD at the femoral neck defined as T-score ≤-2.5 SD. RESULTS The correlation between phalangeal RA BMD and femoral neck DXA BMD was r=0.65 (p<0.001). The upper and lower RA T-score cut-off was -1.5 SD and -2.9 SD. With the triage approach being used for the whole cohort, 34% would require a central DXA assessment to determine if the femoral neck T-score is below or above -2.5 SD. CONCLUSION The application of the RA MetriScan device can reduce the number of DXA assessments needed to detect reduced BMD. The device may thus be of clinical value if access to DXA is limited, as well as for screening purposes.
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Affiliation(s)
- Alvilde Dhainaut
- INM Norwegian University of Science and Technology, Trondheim, Norway.
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Rubin KH, Abrahamsen B, Hermann AP, Bech M, Gram J, Brixen K. Prevalence of risk factors for fractures and use of DXA scanning in Danish women. A regional population-based study. Osteoporos Int 2011; 22:1401-9. [PMID: 20683710 DOI: 10.1007/s00198-010-1348-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 06/28/2010] [Indexed: 11/28/2022]
Abstract
SUMMARY To determine the relationship between risk factors and use of DXA scans. Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and socio-economic factors are associated with the use of DXA. INTRODUCTION To determine the relationship between risk factors for fracture and use of DXA scans in Danish women in relation to distance to DXA clinics and socio-economic factors. METHODS From the Danish National Civil Register we randomly selected 5,000 women aged 40-90 years living in the region of Southern Denmark to receive a mailed questionnaire concerning risk factors for fractures. RESULTS The respondents rate was 84% and 77% of the invited population were available for analysis. A total of 10.3% of the women without risk factors and only 36% of the women with three or more risk factors had a history of DXA. The likelihood of a history of DXA was higher with increasing FRAX(™) 10-year risk; i.e., 8.7% and 30.2% in patients with a 10-year fracture risk of 0-14.9% and 25-100%, respectively. In women with less than 10 km to nearest DXA facility, 20.2% had a history of DXA, while 11.5% of those with more than 40 km to the nearest scanner had a history of DXA. Logistic regression analysis showed that distance, fracture risk, oral glucocorticoids, low-energy fracture, conditions associated with secondary osteoporosis, low BMI, history of falls, age 65-79 years, spouse status, and income were significantly associated with having a history of DXA. CONCLUSIONS Our study showed a relatively high use of DXA in low-risk women and the relatively low coverage in women with multiple risk factors. Moreover, distance to DXA clinics, age, and a number of socio-economic factors are associated with the use of DXA.
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Affiliation(s)
- K H Rubin
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Hayes BL, Curtis JR, Laster A, Saag K, Tanner SB, Liu C, Womack C, Johnson KC, Khaliq F, Carbone LD. Osteoporosis care in the United States after declines in reimbursements for DXA. J Clin Densitom 2010; 13:352-60. [PMID: 21029972 PMCID: PMC4420198 DOI: 10.1016/j.jocd.2010.08.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 07/28/2010] [Accepted: 08/04/2010] [Indexed: 11/29/2022]
Abstract
In January 2007, in the United States (US), Medicare initiated a series of cuts to reimbursement for dual-energy X-ray absorptiometry (DXA) services performed in the nonfacility setting that by January 2010 reduced payments for these services by more than 60% compared with 2006 levels. The objectives of this study were to determine if a temporal association exists between Medicare Physician Fee Schedule changes in office-based DXA reimbursement and attendance at educational conferences for osteoporosis, physicians' perceptions of changes in their medical practices, or national trends in retail prescription medications for osteoporosis in those aged 65 and older. Compared with the 2 yr before the decline in Medicare reimbursement for DXA (2005-2006), attendance at educational meetings for osteoporosis in the US declined in the 2 yr after these cuts (2007-2008) by 6%; declines in attendance were only present in meetings selective for bone densitometry. Survey participants reported changes in DXA services with approximately one-third indicating that they had either decreased the number of DXAs they performed or declined service contracts or hardware/software updates compared with 2005-2006. The number of retail prescriptions for Food and Drug Administration-approved osteoporosis drugs (excluding estrogen compounds and raloxifene) in the age 65 and older population increased by 5.5% in the time period 2007-2008 compared with 2005-2006. However, in the last year of the study (2008), total retail prescriptions for these drugs experienced for the first time over the interval of the study, a decline (1.4%) compared with the previous year. This occurred despite a 2.6% increase in the US population age 65 and older. In conclusion, there were temporal associations noted between Medicare cuts in DXA payments in attendance at educational conferences for bone densitometry, self-report of office-based provision of DXA services in the US, and retail prescriptions for osteoporosis therapies.
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Affiliation(s)
- Burton L. Hayes
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeffrey R. Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - Andrew Laster
- Arthritis & Osteoporosis Consultants of the Carolinas, Charlotte, NC, USA
| | - Kenneth Saag
- Arthritis & Osteoporosis Consultants of the Carolinas, Charlotte, NC, USA
| | - S. Bobo Tanner
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Caiqin Liu
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Catherine Womack
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen C. Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fazila Khaliq
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Laura D. Carbone
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Veterans Affairs Medical Center, Memphis, TN, USA
- Address correspondence to: Laura D. Carbone, MD, University of Tennessee Health Science Center, 956 Court Ave., Memphis, TN 38163.
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Dhainaut A, Rohde GE, Syversen U, Johnsen V, Haugeberg G. The ability of hand digital X-ray radiogrammetry to identify middle-aged and elderly women with reduced bone density, as assessed by femoral neck dual-energy X-ray absorptiometry. J Clin Densitom 2010; 13:418-25. [PMID: 21029976 DOI: 10.1016/j.jocd.2010.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/27/2010] [Accepted: 07/14/2010] [Indexed: 01/25/2023]
Abstract
In this study, we evaluate the ability of digitized digital X-ray radiogrammetry (DXR) bone mineral density (BMD) to identify women with reduced BMD at femoral neck, assessed by dual-energy X-ray absorptiometry (DXA). The study population contained women with recent low-energy distal radius fracture and women recruited from the general population, all aged 50 yr or older. The correlation between hand BMD and femoral neck BMD was r=0.65 (p<0.001). We used a triage approach where 2 cutoffs for DXR T-score were defined at which patients with 90% sensitivity and 90% specificity could be identified to have or not have reduced BMD at femoral neck, defined as T-score ≤-2.5 standard deviation (SD). The upper and lower DXR T-score cutoffs were -1.2 and -2.7, respectively. Applying the triage approach in the whole cohort, 32% would require a central DXA assessment to determine the presence or absence of femoral neck T-score ≤-2.5 SD. Our data suggest that DXR can be used to reduce the numbers of patients in need of DXA femoral neck and may, thus, be of clinical value where access to DXA is limited.
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Affiliation(s)
- Alvilde Dhainaut
- Department of Neuroscience, Rheumatology Division, INM Norwegian University of Science and Technology, Trondheim, Norway.
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Leslie WD, Ludwig SM, Morin S. Abdominal fat from spine dual-energy x-ray absorptiometry and risk for subsequent diabetes. J Clin Endocrinol Metab 2010; 95:3272-6. [PMID: 20392865 DOI: 10.1210/jc.2009-2794] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Abdominal obesity is a major risk factor for diabetes. Dual-energy x-ray absorptiometry (DXA) of the lumbar spine provides an index of abdominal fat. OBJECTIVE Our objective was to examine the hypothesis that DXA-derived abdominal fat measurement in women undergoing osteoporosis investigation predicts risk for subsequent diagnosis of diabetes. DESIGN This historical cohort study was derived from the Manitoba Bone Density Program Database for the Province of Manitoba, Canada. SETTING AND PATIENTS 30,252 nondiabetic women aged 40 yr and older were referred for baseline osteoporosis assessment with DXA between January 1990 and March 2007. MAIN OUTCOME MEASURES Each woman's longitudinal provincial health service record was assessed for the presence of diabetes diagnosis codes after DXA testing. RESULTS During 5.2 + or - 2.6 yr of observation, 1252 (4.1%) women met the case definition for diabetes. A greater proportion of abdominal fat from spine DXA was strongly related to subsequent diabetes diagnosis in models adjusted for age, body mass index, and other comorbidities. Those in the highest quintile had 3.56 (95% confidence interval = 2.67-4.75) times the risk for subsequent diabetes diagnosis compared with those in the lowest (reference) quintile. Fat from hip DXA was not predictive of subsequent diabetes after adjustment for the same variables (1.00, 95% confidence interval = 0.79-1.26). CONCLUSIONS Predictive information about diabetes risk can be obtained from spine DXA scans performed for osteoporosis risk assessment. This is consistent with evidence linking abdominal fat with insulin resistance and the metabolic syndrome.
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Lewiecki EM, Bilezikian JP, Laster AJ, Miller PD, Recker RR, Russell RGG, Whyte MP. 2009 Santa Fe Bone symposium. J Clin Densitom 2010; 13:1-9. [PMID: 20171564 DOI: 10.1016/j.jocd.2009.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 12/14/2009] [Accepted: 12/14/2009] [Indexed: 11/24/2022]
Abstract
Osteoporosis is a common skeletal disease with serious clinical consequences because of fractures. Despite the availability of clinical tools to diagnose osteoporosis and assess fracture risk, and drugs proven to reduce fracture risk, it remains a disease that is underdiagnosed and undertreated. When treatment is started, it is commonly not taken correctly or long enough to be effective. Recent advances in understanding of the regulators and mediators of bone remodeling have led to new therapeutic targets and the development of drugs that may offer advantages over current agents in reducing the burden of osteoporotic fractures. Many genetic factors that play a role in the pathogenesis of osteoporosis and metabolic bone disease have now been identified. At the 2009 Santa Fe Bone Symposium, held in Santa Fe, New Mexico, USA, the links between advances in genetics, basic bone science, recent clinical trials, and new and emerging therapeutic agents were presented and explored. Socioeconomic challenges and opportunities in the care of osteoporosis were discussed. This is a collection of medical essays based on key presentations at the 2009 Santa Fe Bone Symposium.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA.
| | - John P Bilezikian
- Columbia University College of Physicians and Surgeons, NYC, NY, USA
| | - Andrew J Laster
- Arthritis and Osteoporosis Consultants of the Carolinas, Charlotte, NC, USA
| | - Paul D Miller
- Colorado Center for Bone Research, Lakewood, CO, USA
| | | | | | - Michael P Whyte
- Washington University School of Medicine, St. Louis, MO, USA
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