Clinical and demographic factors associated with fractures among older Americans

Proximal Hip Fracture: Does Canal Width Matter?

Background/Objectives: Proximal femur fractures are common in the older population and are related to bone quality. Our work evaluates bone parameters from pelvic anteroposterior (AP) radiographs in patients with trochanteric and sub-capital fractures to determine if there are predictive morphology parameters for each fracture type. Methods: Data from 237 medical records were extracted from patients who arrived at our hospital with trochanteric and sub-capital femoral fractures. Descriptive data and radiological evaluation of the calcar-to-canal ratio (CCR), cortical thickness index (CTI), and Dorr classification were measured by two observers and statistically evaluated. Results: A total of 202 patients were found to be eligible for the study. The mean patient age was 81.41 ± 7.27 years old. The mean age of the trochanteric group was significantly higher than that of the sub-capital group (p = 0.005). There were no statistically significant differences in gender and comorbidities. The CCR showed significance, but the CTI and Dorr classification did not show a significant difference (p = 0.001, p = 0.78, and p = 0.98). A high degree of reliability was shown for all measurements. The ICC for CTI and CCR was p = 0.791 and p = 0.770 (p < 0.001), and Cronbach's alpha was 0.815 and 0.796, respectively. Logistic regression was found to be significant in predicting 60.4% of correct forecasts with an odds ratio of 0.011 and 95% confidence interval (p = 0.001). For CTI, the correct forecasting rate was 48%, with an odds ratio of 0.615 (p = 0.78). Conclusions: We found that, out of the measured parameters, the CCR stood out as important, showing that higher CCR levels are linked to an increased likelihood of trochanteric fractures.

Association between dietary acid load and risk of osteoporotic fractures in adults: a systematic review and meta-analysis of observational studies

AIM

We aimed to systematically review and conduct a meta-analysis of the available evidence about the association between dietary acid load (DAL) and fractures in adults.

METHOD

Relevant studies were searched through Web of Science, Scopus, PubMed, and Google Scholar until October 2024. The random-effect model was used to calculate the pooled Odd ratios (OR) and 95% confidence intervals (CIs). Publication bias was evaluated by statistical test of Egger. Subgroup analyses were conducted by study confounders. Moreover, the quality of studies was asessed using the Newcastle Ottawa Scale which is designed for observational studies.

RESULTS

Six studies were included in this review. According to the methodological heterogeneity between studies and their different charactristics, we performed the analysis based on random-effect model that indicated a marginally significant association between DAL and risk of fracture (N event = 5275, Pooled OR: 1.10; 95% CI: 0.99-1.21, P = 0.073) (I2 = 12.9%; P = 0.321). According to subgroup analysis, there was no significant association between DAL and risk of fracture in the cross-sectional effect sizes (N event = 337, OR:0.69; 95%CI:0.47-1.00). There was a significant association between DAL and a greater risk of fracture in cohort studies (N event = 4938, OR:1.12; 95%CI:1.03-1.22, P = 0.006). Also, high-quality studies (OR:1.12; 95%CI:1.03-1.22; P = 0.006) showed a significant association between DAL and fracture risk.

CONCLUSION

DAL was marginally related to a higher risk of fracture. This finding is a trigger for bone health management with a healthy balanced dietary intake.

Epidemiology of fractures in adults of African ancestry with diabetes mellitus: A systematic review and meta-analysis

Diabetes mellitus (DM) is associated with increased fracture risk in White adults. However, the impact of DM on fractures in Black adults is unknown. This systematic review and meta-analysis investigated the association between DM and fractures in adults of African ancestry. MEDLINE, Scopus, CINAHL and Embase databases were searched from their inception up to November 2023 for all studies in the English language investigating the epidemiology of fractures (prevalence, incidence, or risk) in Black men and women (age ≥ 18 years) with type 1 or type 2 DM. Effect sizes for prevalence of previous fractures (%) and incident fracture risk (hazard ratio [HR]) were calculated using a random-effects model on Stata (version 18.0). There were 13 eligible studies, of which 12 were conducted in Black adults from the United States, while one was conducted in adults of West African ancestry from Trinidad and Tobago. We found no fracture data in Black adults with DM living in Africa. Five studies were included in a meta-analysis of incident fracture risk, reporting data from 2926 Black and 6531 White adults with DM. There was increased risk of fractures in Black adults with DM compared to non-DM (HR = 1.65; 95 % confidence interval [CI]: 1.14, 2.39). The risk of fractures was also higher in White adults with DM compared to non-DM (HR = 1.31; 95 % CI: 1.06, 1.61) among these studies. Five studies were included in a meta-analysis of fracture prevalence, of which three also reported fracture prevalence in White adults. There were 175 previous fractures among 993 Black adults with DM and 384 previous fractures among 1467 White adults with DM, with a pooled prevalence of 17.5 % (95 % CI: 15.4, 19.6) and 25.8 % (95 % CI: 4.8, 46.8), respectively. Our results indicate a high burden of fractures in Black adults with DM.

Analysis of Operated Ankle Fractures in Elderly Patients: Are They All Osteoporotic?

Background: Osteoporosis represents a global problem, which involves high risks of disability and death due to the consequences of fragility fractures. The aim of our study is to verify what type of relationship there is between ankle fractures and osteoporosis. Specifically, we aim to understand how the clinical and anamnestic characteristics of patients, along with the radiographic features of these fractures, may contribute to considering them as osteoporotic fractures. Methods: The study group includes 51 consecutive patients aged 60 years or older operated for ankle fracture from May to October 2022. The fractures were divided into uni-, bi-, or trimalleolar based on the plain X-rays. All patients underwent femoral and vertebral bone mineralometry by DXA associated with the FRAX questionnaire. Results: Ankle fractures in the elderly were associated with reduced BMD (76.5% of the total patients examined, 83.8% considering only women) and low-energy traumas (82%). Furthermore, these fractures present features of increased complexity as bone mass decreases. Conclusions: Ankle fractures in the elderly exhibit characteristics that suggest a relationship with bone fragility. For these reasons, it might be advisable to initiate a comprehensive fracture risk assessment in elderly patients who experience an ankle fracture. These fractures should not be underrated, and antiresorptive therapy must always be taken into consideration when selecting patients at risk.

Osteoporosis and Fracture Risk among Older US Asian Adults

PURPOSE OF REVIEW

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults.

RECENT FINDINGS

Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Fracture risk and opioid use in patients aged 17-64 years: An analysis of administrative claims data

STUDY OBJECTIVE

The objective of this work is to describe the risk of fracture in adults aged 17 to 64 years across categories of daily opioid dose.

DESIGN

A retrospective analysis of insurance claims data.

DATA SOURCE

Information from a private health insurance provider for the years 2003-2014 for enrolled individuals living in Iowa.

PATIENTS

Patients who were aged 17 to 64 years and prescribed an opioid were followed for the length of opioid treatment plus 30 days to determine whether a fracture occurred.

MEASUREMENTS

Average daily morphine milligram equivalent (MME) was determined for patients who received a prescription for opioids. The outcome of interest was incident fracture following opioid treatment initiation. Cox proportional hazard models were used to compare the risk of fracture across categorical groups of average daily MME. Inverse probability weighting was used to control for patient-level variables.

MAIN RESULTS

In total, 316,024 individual patients were identified in the administrative claims data as having an opioid prescription from 2003 to 2014, and 3038 fractures occurred during follow-up (9.6 fractures per 1000 opioid-prescribed patients). Relative to the lowest quartile of prescribed opioid (⟨22 MME), patients in each higher prescribed level were more likely to experience a fracture (22-36 MME Hazard Ratio (HR) = 1.35, 95% Confidence Interval (CI): 1.21-1.51; 37-50 MME HR = 1.38, 95% CI: 1.24-1.54; ⟩50 MME HR = 1.35, 95% CI: 1.20-1.52).

CONCLUSIONS

We observed an increased fracture risk in all three higher categories of opioid exposure relative to the lowest category (⟨22 MME). The risk of a fracture should be considered in opioid treatment decisions.

Racial and ethnic difference in the risk of fractures in the United States: a systematic review and meta-analysis

This systematic review and meta-analysis examined the association between race and ethnicity and fracture risk in the United States. We identified relevant studies by searching PubMed and EMBASE for studies published from the databases' inception date to December 23, 2022. Only observational studies conducted in the US population that reported the effect size of racial-ethnic minority groups versus white people were included. Two investigators independently conducted literature searches, study selection, risk of bias assessment, and data abstraction; discrepancies were resolved by consensus or consultation of a third investigator. Twenty-five studies met the inclusion criteria, and the random-effects model was used to calculate the pooled effect size due to heterogeneity between the studies. Using white people as the reference group, we found that people of other races and ethnic groups had a significantly lower fracture risk. In Black people, the pooled relative risk (RR) was 0.46 (95% confidence interval (CI), 0.43-0.48, p < 0.0001). In Hispanics, the pooled RR was 0.66 (95% CI, 0.55-0.79, p < 0.0001). In Asian Americans, the pooled RR was 0.55 (95% CI, 0.45-0.66, p < 0.0001). In American Indians, the pooled RR was 0.80 (95% CI, 0.41-1.58, p = 0.3436). Subgroup analysis by sex in Black people revealed the strength of association was greater in men (RR = 0.57, 95% CI = 0.51-0.63, p < 0.0001) than in women (RR = 0.43, 95% CI = 0.39-0.47, p < 0.0001). Our findings suggest that people of other races and ethnic groups have a lower fracture risk than white people.

Aging and Bone Metabolism

Changes in bone architecture and metabolism with aging increase the likelihood of osteoporosis and fracture. Age-onset osteoporosis is multifactorial, with contributory extrinsic and intrinsic factors including certain medical problems, specific prescription drugs, estrogen loss, secondary hyperparathyroidism, microenvironmental and cellular alterations in bone tissue, and mechanical unloading or immobilization. At the histological level, there are changes in trabecular and cortical bone as well as marrow cellularity, lineage switching of mesenchymal stem cells to an adipogenic fate, inadequate transduction of signals during skeletal loading, and predisposition toward senescent cell accumulation with production of a senescence-associated secretory phenotype. Cumulatively, these changes result in bone remodeling abnormalities that over time cause net bone loss typically seen in older adults. Age-related osteoporosis is a geriatric syndrome due to the multiple etiologies that converge upon the skeleton to produce the ultimate phenotypic changes that manifest as bone fragility. Bone tissue is dynamic but with tendencies toward poor osteoblastic bone formation and relative osteoclastic bone resorption with aging. Interactions with other aging physiologic systems, such as muscle, may also confer detrimental effects on the aging skeleton. Conversely, individuals who maintain their BMD experience a lower risk of fractures, disability, and mortality, suggesting that this phenotype may be a marker of successful aging. © 2023 American Physiological Society. Compr Physiol 13:4355-4386, 2023.

Fracture risk and impact of osteoporosis in patients with Parkinson's disease: a nationwide database study

INTRODUCTION

Patients with Parkinson's disease (PD) showed an increased risk of fractures in previous studies and a high prevalence of osteoporosis is reportedly a potential contributor. We conducted a nationwide database study on the risk of fractures and the impact of osteoporosis on patients with PD compared to controls.

MATERIALS AND METHODS

Using a nationwide database in South Korea, we identified incident patients with PD in 2004-2006 and selected four age- and sex-matched controls. We checked the occurrence rates of overall and hip fractures and plotted Kaplan-Meier curves and a Cox proportional hazards model to determine risk. We also conducted stratified analyses according to the presence or absence of osteoporosis.

RESULTS

We identified 9126 patients with PD and 35,601 controls. Patients with PD had a greater probability of fractures throughout the study period in Kaplan-Meier curves, and an increased risk of overall (aHR 1.35, 95% CI 1.297-1.405) and hip (aHR 1.814, 95% CI 1.66-1.983) fractures in a Cox proportional hazards model. In the stratified analysis, the increased risk of overall fracture (aHR 1.333, 95% CI 1.273-1.396 and aHR 1.412, 95% CI 1.301-1.532, respectively) and hip fracture (aHR 1.773, 95% CI 1.604-1.96 and aHR 2.008, 95% CI 1.657-2.434, respectively) due to PD was similar between patients with and without osteoporosis.

DISCUSSION

Patients with PD, with or without osteoporosis, are more likely to experience fractures, especially hip fractures. There seems to be no interaction between PD and osteoporosis in regard to the occurrence of fractures, and therefore no effect modification by osteoporosis.

Severity of underweight and risk of fracture: a Korean nationwide population-based cohort study

Underweight is an important modifiable risk factor for fractures. However, there have been few large cohort studies regarding the relationship between underweight and fracture in the general population. We investigated the risk of fracture development according to underweight severity in a large population cohort. This nationwide cohort study included 2,896,320 people aged ≥ 40 years who underwent national health checkups in 2009 and were followed up to identify the incidence of fracture until December 31, 2018. After applying the exclusion criteria that included overweight and obese individuals, the study population was divided according to body mass index (BMI) into normal weight (18.5 ≤ BMI < 23.0), mild underweight (17.5 ≤ BMI < 18.5), moderate underweight (16.5 ≤ BMI < 17.5), and severe underweight (BMI < 16.5) groups. Cox proportional hazards regression analyses were performed to calculate the hazard ratios for risk of fracture according to underweight severity. Severely underweight participants had a 28% increased fracture risk (adjusted hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.20-1.37) compared with those of normal weight. In addition, fracture risk was increased by 14% in individuals with moderate underweight (adjusted HR 1.14, 95% CI 1.08-1.19) and 9% in those with mild underweight (adjusted HR 1.09, 95% CI 1.06-1.13). The severity of underweight was significantly associated with risk of fracture.

Bisphosphonates and the risk of atypical femur fractures

Bisphosphonates are effective in reducing hip and other fractures. However, concerns about atypical femur fractures (AFFs) have contributed to substantially decreased bisphosphonate use, and hip fracture rates may be increasing. Despite this impact, important uncertainties remain regarding AFF risks including the association between bisphosphonate use and other risk factors such as BMD, age, weight, and race. To address this evidence gap, a cohort study of 196,129 women ≥50 years of age in the Southern California Kaiser Permanente HMO women (with ≥1 bisphosphonate prescription) were studied; the primary outcome was radiographically-adjudicated AFF between 2007 and 2017. Risk factors including bisphosphonate use and race were obtained from electronic health records. Multivariable Cox models were used for analysis. Benefit-risk was modeled for 1-10 years of bisphosphonates to compare fractures prevented vs. AFFs associated. Among 196,129 women, 277 (0.1%) sustained AFFs. After multivariable adjustment, AFF risk increased with longer bisphosphonate duration: hazard ratio (HR) increased from HR = 8.9 (95%CI: 2.8,28) for 3-5 years to HR = 43.5 (13.7138.1) for >8 years. Hip BMD, surprisingly, was not associated with AFF risk. Other risk factors included Asian ancestry (HR = 4.8 (3.6, 6.6)), short stature, overweight, and glucocorticoid use. Bisphosphonate discontinuation was associated with rapid decrease in AFF risk. Decreases in osteoporotic and hip fractures risk during 1-10 years of bisphosphonates far outweighed the increase AFF risk in Caucasians, but less so in Asians. In Caucasians, after 3 years 149 hip fractures were prevented with 2 AFFs associated compared to 91 and 8 in Asians. The evidence for several potential mechanisms is summarized with femoral geometry being the most likely to explain AFF risk differences between Asians and Caucasians. The results from this new study add to the evidence base for AFF risk factors and will help inform clinical decision-making for individual patients about initiation and duration of bisphosphonate therapy and drug holidays.

Age-Related Changes in Bone Density, Microarchitecture, and Strength in Postmenopausal Black and White Women: The SWAN Longitudinal HR-pQCT Study

Higher fracture risk in White versus Black women is partly explained by lower BMD and worse bone microarchitecture in White women. However, whether rates of decline in bone density, microarchitecture and strength differ between postmenopausal Black and White women is unknown. Further, factors that influence rates of age-related bone microarchitecture deterioration remain ill-defined. Thus, over 6.7 years, longitudinal changes were measured in peripheral volumetric bone mineral density (vBMD), microarchitecture, and strength at the distal radius and tibia using HR-pQCT in postmenopausal Black (n = 80) and White (n = 137) women participating in the Study of Women's Health Across the Nation. It was assessed whether age-related changes in vBMD and microarchitecture were influenced by body weight, body composition, and/or weight change. It was found that at the radius, where White women appeared to have slightly greater rates of loss in total vBMD, cortical bone volume, and porosity than Black women, those differences were attenuated after adjusting for clinical covariates. At the tibia, Black and White women had similar rates of bone loss. Independent of race and other clinical covariates, women with the lowest baseline body weight experienced the greatest decline in total and trabecular vBMD at the radius. Furthermore, women who lost weight over the follow-up period had higher rates of bone loss, particularly at the tibia, compared with those who maintained or gained weight. Higher baseline total body fat mass was also protective of bone loss at both the radius and tibia. In conclusion, these findings indicate that lower fracture risk among postmenopausal Black women is not caused by slower rates of bone deterioration, and highlight the importance for postmenopausal women to avoid lower body weight and excessive weight loss to avert rapid bone loss and subsequent fractures. © 2021 American Society for Bone and Mineral Research (ASBMR).

Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies

Individuals with low socio-economic status (SES) have a more than 25% higher risk of fragility fractures than individuals with high SES. Body mass index and lifestyle appear to mediate the effect of SES on fracture risk. Strategies to prevent fractures should aim to reduce unhealthy behaviours through tackling structural inequalities.

INTRODUCTION

This systematic review and meta-analysis aimed to evaluate the impact of socio-economic status (SES) on fragility fracture risk.

METHODS

Medline, Embase, and CINAHL databases were searched from inception to 28 April 2021 for studies reporting an association between SES and fragility fracture risk among individuals aged ≥50 years. Risk ratios (RR) were combined in meta-analyses using random restricted maximum likelihood models, for individual-based (education, income, occupation, cohabitation) and area-based (Index of Multiple Deprivation, area income) SES measures.

RESULTS

A total of 61 studies from 26 different countries including more than 19 million individuals were included. Individual-based low SES was associated with an increased risk of fragility fracture (RR 1.27 [95% CI 1.12, 1.44]), whilst no clear association was seen when area-based measures were used (RR 1.08 [0.91, 1.30]). The strength of associations was influenced by the type and number of covariates included in statistical models: RR 2.69 [1.60, 4.53] for individual-based studies adjusting for age, sex and BMI, compared with RR 1.06 [0.92, 1.22] when also adjusted for health behaviours (smoking, alcohol, and physical activity). Overall, the quality of the evidence was moderate.

CONCLUSION

Our results show that low SES, measured at the individual level, is a risk factor for fragility fracture. Low BMI and unhealthy behaviours are important mediators of the effect of SES on fracture risk. Strategies to prevent fractures and reduce unhealthy behaviours should aim to tackle structural inequalities in society thereby reducing health inequalities in fragility fracture incidence.

Duration of Bisphosphonate Drug Holidays in Osteoporosis Patients: A Narrative Review of the Evidence and Considerations for Decision-Making

Bisphosphonates are first-line therapy for osteoporosis, with alendronate, risedronate, and zoledronate as the main treatments used globally. After one year of therapy, bisphosphonates are retained in bone for extended periods with extended anti-fracture effects after discontinuation. Due to this continued fracture protection and the potential for rare adverse events associated with long-term use (atypical femoral fractures and osteonecrosis of the jaw), a drug holiday of two to three years is recommended for most patients after long-term bisphosphonate therapy. The recommendation for a drug holiday up to three years is derived primarily from extensions of pivotal trials with alendronate and zoledronate and select surrogate marker studies. However, certain factors may modify the duration of bisphosphonate effects on a drug holiday and warrant consideration when determining an appropriate time off-therapy. In this narrative review, we recall what is currently known about drug holidays and discuss what we believe to be the primary considerations and areas for future research regarding drug holiday duration: total bisphosphonate exposure, type of bisphosphonate used, bone mineral density and falls risk, and patient sex and body weight.

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

Is ankle fracture related to low bone mineral density and subsequent fracture? A systematic review

OBJECTIVES

Ankle fractures are common in the elderly. However, their association with osteoporosis remains controversial. This systematic review aims to determine the relationship between ankle fracture and bone mineral density (BMD), and to investigate the risk of subsequent fractures after ankle fracture.

METHODS

MEDLINE and Scopus publications were searched from inception to March and April 2019, respectively. Articles were selected by 2 independent reviewers for cross-sectional, cohort, or case-control studies comparing BMD or subsequent fracture risk in low-energy ankle fractures patients with that of the normal population. Data extraction was performed by 2 investigators. Discrepancies were resolved with the third reviewer. Quality assessment was conducted using the modified Newcastle-Ottawa Scale.

RESULTS

Overall, 19 articles were included. The quality assessment showed a generally low-to-moderate risk of bias among studies, mainly due to potential confounders and inadequate follow-up. Of 13 studies exploring BMD in ankle fractured-patients, lower central and peripheral BMD was found in 3 and 2 studies, respectively. The risk of subsequent fracture was examined in 11 studies with relative risks ranging from 0.7 to 4.59. An increased risk of any subsequent fractures in women, both genders, and men was found in 5, 2, and 1 articles, respectively.

CONCLUSIONS

Despite the lack of clear association with BMD, the contribution of ankle fracture to increased subsequent fracture risk and its associated microarchitectural changes cannot be overlooked. Moreover, its potential role as an early predictor of future fracture may promote secondary prevention. Further studies with longer follow-up and stricter confounder control are recommended.

The risk of hip and non-vertebral fractures in type 1 and type 2 diabetes: A systematic review and meta-analysis update

BACKGROUND

Diabetes is associated with increased fracture risk but we do not know what affects this risk. We investigated the risk of hip and non-vertebral fractures in diabetes and whether this risk was affected by age, gender, body mass index, diabetes type and duration, insulin use and diabetic complications.

METHODS

We selected a previously published review to be updated. MEDLINE, Embase and Cochrane databases were searched up to March 2020. We included observational studies with age and gender-adjusted risk of fractures in adults with diabetes compared to adults without diabetes. We extracted data from published reports that we summarised using random effects model.

FINDINGS

From the 3140 records identified, 49 were included, 42 in the hip fracture analysis, reporting data from 17,571,738 participants with 319,652 fractures and 17 in the non-vertebral fracture review, reporting data from 2,978,487 participants with 181,228 fractures. We found an increase in the risk of fracture in diabetes both for hip (RR 4.93, 3.06-7.95, in type 1 diabetes and RR1.33, 1.19-1.49, in type 2 diabetes) and for non-vertebral fractures (RR 1.92, 0.92-3.99, in type 1 and RR 1.19, 1,11-1.28 in type 2). At the hip, the risk was higher in the younger population in both type 1 and type 2 diabetes. In those with type 2 diabetes, longer diabetes duration and insulin use was associated with an increased risk. We did not investigate the effect of bone density, falls, anti-diabetic drugs and hypoglycemia.

CONCLUSION

Diabetes is associated with an increase in both hip and non-vertebral fracture risk.

Use of bone-modifying agents and clinical outcomes in older adults with multiple myeloma

Background

Guidelines recommend bone‐modifying agents (BMAs) for all patients initiating treatment for myeloma. We examined adherence to this recommendation, and BMA effectiveness in the era of bortezomib/lenalidomide‐based therapy among Medicare beneficiaries.

Methods

From the linked Surveillance, Epidemiology, and End Results‐Medicare registry, we selected beneficiaries receiving anti‐myeloma chemotherapy in 2007‐2013. We matched BMA recipients (within 90 days of first chemotherapy) to nonrecipients using a propensity score, balancing patient‐, disease‐, and therapy‐related confounders. Cumulative incidence of skeletal‐related events (SREs) and overall survival (OS) was compared in proportional hazard models accounting for competing risks and immortal‐time bias.

Results

Among 4611 patients with median age of 76 years, 51% received BMA. Bone‐modifying agents use remained steady over time (P = .87) and was significantly less frequent for patients who were older, with comorbidities, without prior SRE, and those treated without bortezomib or lenalidomide. In a propensity score‐matched cohort, BMA recipients experienced a lower incidence of SRE (11.0% vs 14.6% at 3 years; subhazard ratio, 0.73; 95% CI, 0.60‐0.89) and better OS (53.3% vs 47.8% at 3 years; hazard ratio, 0.86; 95% CI, 0.77‐0.95). The results were consistent in the subgroup (76%) treated with bortezomib and/or immunomodulatory drugs (IMiDs). The incidence of osteonecrosis of the jaw (ONJ) was 3.2% at 3 years.

Conclusions

In this observational study, the observed benefits of early BMA administration among patients treated with contemporary anti‐myeloma regimens were similar to historical clinical trials. Frequent omission of BMA highlights a remediable deficiency in the quality of supportive care, and suggests that timely administration may be a useful indicator of quality care in myeloma.

Discordant pattern of peripheral fractures in diabetes: a meta-analysis on the risk of wrist and ankle fractures

To clarify if the peripheral microarchitectural abnormalities described in diabetics have clinical consequences, we evaluated the risk of wrist and ankle fractures. The meta-analysis resulted in an increase in the risk of ankle fractures and a decrease in wrist fractures risk, suggesting that microarchitecture may not be the major fracture determinant.

INTRODUCTION

There is evidence for an increase in the risk of hip fractures in diabetes (both in type 1 and 2), but the risk is not established for other skeletal sites. Microarchitecture evaluations have reported a decrease in volumetric bone mineral density and an increase in cortical porosity at the radius and tibia. To investigate if there is a clinical consequence for these microarchitectural abnormalities, we performed a systematic review and meta-analysis on the risk of ankle and wrist fractures in diabetes.

METHODS

Medline and Embase were searched using the terms 'diabetes mellitus', 'fracture', 'ankle', 'radius' and 'wrist'. Relative risks and 95% confidence intervals were calculated using random effects model.

RESULTS

For ankle fractures, six studies were selected including 2,137,223 participants and 15,395 fractures. For wrist fractures, 10 studies were eligible with 2,773,222 subjects and 39,738 fractures. The studies included men and women, ages 20 to 109 years for the wrist and 27 to 109 years for the ankle. The vast majority of subjects had type 2 diabetes. Diabetes was associated with an increase in the risk of ankle fractures (RR 1.30 95%CI 1.15-1.48) and a decrease in wrist fractures (RR 0.85 95%CI 0.77-0.95). In the studies that reported body mass index (BMI), the mean values were 10% higher in the diabetic groups than controls.

CONCLUSION

The risk of fractures is increased in diabetes at the ankle and decreased at the wrist. The same pattern is observed in obesity. Although bone microarchitectural features are different in obesity and diabetes, the epidemiology of peripheral fractures is similar in both diseases suggesting that microarchitecture may not be the major determinant of peripheral fractures in these populations.

Risk of Subsequent Fragility Fractures Observed After Low-Trauma Ankle Fractures

While fragility fractures (FFs) are one of the strongest predictors of subsequent osteoporotic fractures, it remains unclear whether low-trauma ankle fractures have this ability. The aim of the study was to identify the characteristics of patients with low-trauma ankle FFs who develop subsequent FFs. The OPTIMUS initiative is a strategy to improve osteoporosis treatment post-FF in orthopedic clinics. FRAX scores without BMD (FRAX-BMI) were calculated at time of inclusion. Recurrent FFs were recorded over a 48-month follow-up. All FFs were X-ray-confirmed. A total of 265 patients with initial ankle FF were included (190 women; mean age 62.8 ± 9.6 years), of whom 15 developed new FFs. Patients with ankle FFs had longer time until recurrence and lower 2-year incidence of recurrent FFs (3.2%) compared with those having wrist FFs (9.0%) or other initial FFs (9.6%), and 4-year incidence rates of 6.2, 13.4, and 15.3%, respectively (log-rank test, p = 0.001). With an ankle FF at inclusion, recurrent FFs were more frequent in patients with previous FF (6.2 per 100 patient-years; p < 0.01) or high-risk FRAX-BMI scores pre- or post-FF (2.4 or 2.0 per 100 patient-years, respectively; ns), compared to patients without any of these conditions (0.7 per 100 patient-years). Ankle FFs represent a clinical opportunity for identifying at-risk patients who should be targeted for treatment (previous FFs and/or high-risk FRAX). Because of mechanical factors and other contributors involved, ankle FFs themselves do not predict subsequent FFs overall, and their inclusion in FRAX-BMI risk calculation may thus not be warranted.

Real-world effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women

Studies examining real-world effectiveness of osteoporosis therapies are beset by limitations due to confounding by indication. By evaluating longitudinal changes in fracture incidence, we demonstrated that osteoporosis therapies are effective in reducing fracture risk in real-world practice settings.

INTRODUCTION

Osteoporosis therapies have been shown to reduce incidence of vertebral and non-vertebral fractures in placebo-controlled randomized clinical trials. However, information on the real-world effectiveness of these therapies is limited.

METHODS

We examined fracture risk reduction in older, post-menopausal women treated with osteoporosis therapies. Using Medicare claims, we identified 1,278,296 women age ≥ 65 years treated with zoledronic acid, oral bisphosphonates, denosumab, teriparatide, or raloxifene. Fracture incidence rates before and after treatment initiation were described to understand patients' fracture risk profile, and fracture reduction effectiveness of each therapy was evaluated as a longitudinal change in incidence rates.

RESULTS

Fracture incidence rates increased during the period leading up to treatment initiation and were highest in the 3-month period most proximal to treatment initiation. Fracture incidence rates following treatment initiation were significantly lower than before treatment initiation. Compared with the 12-month pre-index period, there were reductions in clinical vertebral fractures for denosumab (45%; 95% confidence interval [CI] 39-51%), zoledronic acid (50%; 95% CI 47-52%), oral bisphosphonates (24%; 95% CI 22-26%), and teriparatide (72%; 95% CI 69-75%) during the subsequent 12 months. Relative to the first 3 months after initiation, clinical vertebral fractures were reduced for denosumab (51%; 95% CI 42-59%), zoledronic acid (25%; 95% CI 17-32%), oral bisphosphonates (23%; 95% CI 20-26%), and teriparatide (64%; 95% CI 58-69%) during the subsequent 12 months.

CONCLUSION

In summary, reductions in fracture incidence over time were observed in cohorts of patients treated with osteoporosis therapies.

A systematic review of socioeconomic status measurement in 13 years of U.S. injury research

OBJECTIVE

The purpose of this review was to assess the impact of socioeconomic status (SES) on injury and to evaluate how U.S. injury researchers have measured SES over the past 13years in observational research studies.

DESIGN & METHODS

This systematic review included 119 US injury studies indexed in PubMed between January 1, 2002 and August 31, 2015 that used one or more individual and/or area-level measures of SES as independent variables. Study findings were compared to the results of a previous review published in 2002.

RESULTS

Findings indicate SES remains an important predictor of injury. SES was inversely related to injury in 78 (66%) of the studies; inverse relationships were more consistently found in studies of fatal injury (77.4%) than in studies of non-fatal injury (58%). Approximately two-thirds of the studies (n=73, 61%) measured SES along a gradient and 59% used more than one measure of SES (n=70). Studies that used a gradient measure of SES and/or more than one measure of SES identified significant relationships more often. These findings were essentially equivalent to those of a similar 2002 review (Cubbin & Smith, 2002).

CONCLUSIONS

There remains a need to improve measurement of SES in injury research. Public health training programs should include best practices for measurement of SES, which include: measuring SES along a gradient, selecting SES indicators based on the injury mechanism, using the smallest geographic region possible for area-level measures, using multiple indicators when possible, and using both individual and area-level measures as both contribute independently to injury risk. Area-level indicators of SES are not accurate estimates of individual-level SES.

PRACTICAL APPLICATIONS

Injury researchers should measure SES along a gradient and incorporate individual and area-level SES measures that are appropriate to the injury outcome under study.

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003-2010

Introduction

One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography.

Methods

We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region.

Results

Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9–68.8]) to 68.8 (95% CI [57.8–79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75–84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03).

Conclusion

ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting.

Cortical microstructure compensates for smaller bone size in young Caribbean Hispanic versus non-Hispanic white men

Hispanic men have smaller bone size but thicker and denser cortices compared to white men, leading to similar mechanical competence.

INTRODUCTION

The purpose of this study was to assess differences in vBMD and microarchitecture in young Caribbean Hispanic (n = 30) and non-Hispanic Caucasian (n = 30) men.

METHODS

We measured areal bone mineral density (aBMD) at the spine, total hip (TH), femoral neck (FN), and forearm by dual-energy X-ray absorptiometry (DXA) and bone geometry, mass, microarchitecture, and mechanical competence by high-resolution peripheral quantitative computed tomography (HRpQCT), individual trabecula segmentation (ITS), and finite element analysis (FEA).

RESULTS

Hispanic men were slightly older, shorter, and heavier and had higher BMI compared with white men. aBMD, measured by DXA, did not differ at the spine, TH, or forearm before or after adjustment for age, height, weight, and the interaction of height and weight. At the FN, marginally significant higher BMD in Hispanics prior to adjustment was attenuated and no longer differed after adjustment for covariates. Adjusted HRpQCT indices indicated smaller total and trabecular area at the radius but greater total volumetric density and cortical thickness in Hispanic versus white men. The adjusted difference in cortical density at the radius was of borderline significance. Trabecular and ITS microstructure tended not to differ at the radius. At the tibia, results were similar. Bone size tended to be smaller and covariate-adjusted cortical density and cortical thickness were greater in Hispanic versus white men. Additionally, cortical porosity was lower at the tibia in Hispanic compared to white men. Stiffness and failure load did not differ at either skeletal site by ethnicity.

CONCLUSION

In conclusion, greater cortical thickness and density as well as lower cortical porosity tend to compensate for smaller bone size in Hispanic men, leading to similar mechanical competence compared with white men.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Total flavonoids from Rhizoma Drynariae (Gusuibu) for treating osteoporotic fractures: implication in clinical practice

This systematic review was performed to determine the clinical efficacy and safety of total flavonoids from Rhizoma Drynariae (TFRD) for osteoporotic fractures and to provide clear evidence for clinical practice. Eight databases were searched to identify relevant randomized controlled trials (RCTs) until December 2016. Six RCTs involving 846 patients were included. The primary outcomes included fracture recurrence and death. Meta-analysis showed that both the combination therapy and TFRD alone were better than conventional treatments in improving bone mineral density (BMD) value (weighted mean difference [WMD] =3.68, 95% confidence interval [CI]: 0.01 to 0.04, P=0.0002), (WMD =0.14; 95% CI: 0.11 to 0.16; P<0.00001), respectively, and enhancing therapeutic effect (OR =0.25; 95% CI: 0.12 to 0.51; P=0.0002). Thirty-three patients experienced adverse drug reactions (ADRs), none of the ADRs were severe and all were resolved after symptomatic treatments. Gastrointestinal symptoms were the most common ADRs in the usage of TFRD. Overall, the effect of TFRD on osteoporotic fractures was supported by improving BMD and therapeutic effect. Due to the methodological drawbacks of the included studies, the conclusions should be treated with caution for future research. Registration number: CRD42017052797.

Risk of Vertebral Fracture in Patients Diagnosed with a Depressive Disorder: A Nationwide Population-Based Cohort Study

OBJECTIVE:

Previous studies have reported that depression may play a crucial role in the occurrence of vertebral fractures. However, a clear correlation between depressive disorders and osteoporotic fractures has not been established. We explored the association between depressive disorders and subsequent new-onset vertebral fractures. Additionally, we aimed to identify the potential risk factors for vertebral fracture in patients with a depressive disorder.

METHODS:

We studied patients listed in the Taiwan National Health Insurance Research Database who were diagnosed with a depressive disorder by a psychiatrist. The comparison cohort consisted of age- and sex-matched patients without a depressive disorder. The incidence rate and hazard ratios of subsequent vertebral fracture were evaluated. We used Cox regression analysis to evaluate the risk of vertebral fracture among patients with a depressive disorder.

RESULTS:

The total number of patients with and without a depressive disorder was 44,812. The incidence risk ratio (IRR) between these 2 cohorts indicated that depressive disorder patients had a higher risk of developing a subsequent vertebral fracture (IRR=1.41, 95% confidence interval [CI]=1.26-1.57, p<0.001). In the multivariate analysis, the depressive disorder cohort showed a higher risk of vertebral fracture than the comparison cohort (adjusted hazard ratio=1.24, 95% CI=1.11-1.38, p<0.001). Being older than 50 years, having a lower monthly income, and having hypertension, diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease, autoimmune disease, or osteoporosis were considered predictive factors for vertebral fracture in patients with depressive disorders.

CONCLUSIONS:

Depressive disorders may increase the risk of a subsequent new-onset vertebral fracture.

Trabecular bone scores and lumbar spine bone mineral density of US adults: comparison of relationships with demographic and body size variables

This study examines demographic patterns and body size relationships in trabecular bone score and lumbar spine BMD of US adults from NHANES 2005-2008.

INTRODUCTION

Limited data exist on demographic and body size relationships for trabecular bone score (TBS), a new variable derived from bone texture analysis of lumbar spine dual-energy X-ray absorptiometry (DXA) scans. This study compares demographic patterns and correlations with body size (body mass index (BMI), weight, waist circumference, total body fat, trunk fat, trunk lean) between TBS and lumbar spine bone mineral density (LSBMD) for adults age ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 2005-2008 with BMI in the optimal range for TBS (15-37 kg/m(2)).

METHODS

LSBMD, TBS, body fat, and lean were obtained by DXA. Weight, height, and waist circumference were measured. BMI was calculated from height and weight.

RESULTS

Sex differences in TBS varied by age and race/ethnicity (p sex X age interaction and p sex X race/ethnicity interaction < 0.001). In most of the nine demographic subgroups examined, TBS did not differ by sex (four subgroups) or was significantly higher in women (three subgroups). TBS differences by race/ethnicity were inconsistent in men; in women, non-Hispanic whites (NHWs) had higher TBS than non-Hispanic blacks (NHBs) or Mexican Americans (MAs) in all age groups. In contrast, LSBMD was either significantly higher in men (five subgroups) or did not differ by sex (four subgroups). Race/ethnic differences in LSBMD were consistent across age and sex (NHB > NHW > MA). All body size variables were negatively related to TBS but positively related to LSBMD.

CONCLUSIONS

Demographic patterns and body size relationships differed between TBS and LSBMD.

Geographic variations in orthopedic trauma billing and reimbursements for hip and pelvis fractures in the Medicare population

We investigated geographic variations in Medicare spending for DRG 536 (hip and pelvis fracture). We identified 22,728 patients. The median number of charges, discharges, and payments were recorded. Hospitals were aggregated into core based statistical (CBS) areas and the coefficient of variation (CV) was calculated for each area. On average, hospitals charged 3.75 times more than they were reimbursed. Medicare charges and reimbursements demonstrated variability within each area. Geographic variation in Medicare spending for hip fractures is currently unexplained. It is imperative for orthopedists to understand drivers behind such high variability in hospital charges for management of hip and pelvis fractures.

Global Forum: Fractures in the Elderly

Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.

[Femoral fractures in elderly Brazilians: a spatial and temporal analysis from 2008 to 2012]

Fractures in the elderly (≥ 60 years) have a major public health impact and take a heavy social and economic toll. This article aimed to describe spatial and time trends in femoral fractures among elderly men and women in all regions of Brazil. Bayesian descriptive analyses of spatial and time series were performed on data obtained from the Hospital Information System of the Brazilian Unified National Health System, using Poisson regression for femoral fractures in individuals 60 years of age or older from 2008 to 2012. There were more than 181,000 femoral fractures during this period, predominantly in women, without important spatial correlations or temporal differences. Despite the lack of temporal and spatial correlations, the number of femoral fractures in elderly Brazilians was high, with heavy financial and social costs. Public health policies are urgently needed to control predisposing factors for femoral fractures in elderly Brazilians.

The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture

SUMMARY

This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound.

INTRODUCTION

This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture.

METHODS

This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics.

RESULTS

States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056).

CONCLUSIONS

Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.

Forearm fractures in Central Norway, 1999-2012: incidence, time trends, and seasonal variation

The incidence of forearm fractures for men and women ≥40 years in Central Norway was high during the period 1999-2012. A decline in fractures was observed only among women over 50 years. A seasonal variation with highest incidence in the winter months was found among women.

PURPOSE

The aim of this study was to examine the incidence of forearm fractures in Central Norway in men and women 40 years and older from 1999 to 2012 and assess time trends as well as seasonal variations.

METHODS

Data is from the fracture registry in Nord-Trøndelag, including all forearm fractures in persons ≥40 sustained from 1999 to 2012. Annual incidence of forearm fractures were calculated and tested for trends. Variations in the occurrence of fractures were explored by comparing proportion of fractures by month and seasons.

RESULTS

The study population consisted of 4003 subjects (77.1% women). The total number of fractures were 4240. There was an increase in fractures for women with increasing age, steepest, a three-fold increase between age group 40-50 and the age group 50-60. Among men, this pattern was not observed as incidences did not change with increasing age. The age-standardized incidence rate for all fractures among women ≥50 ranged from 82 fractures per 1000 (95% CI 71-94) to 100 (88-114) and among men from 19 (14-27) to 31 (24-39). Restricting the analysis to the first fracture sustained during the observed period, women ≥50 years showed a reduction in fractures of 1.30% per year (95% CI 0.01%: 2.56%,) and 12.18% per 10 years (3.61%: 19.98%). For all women, there was a trend towards a decline of 0.73% per year (-2.29%: 0.85%), although not significant. For men, there was a trend towards an increase in fractures of 1.66% per year (-0.11%: 3.45%). The occurrence of fractures among women varied by season of the year, with higher fracture rates in the winter months.

CONCLUSIONS

The incidence rate of forearm fractures in Central Norway was high. However, a small decline in the incidence of the first fracture among women older than 50 years was observed. Fractures were more often sustained during winter months among women.

Development of an algorithm to identify fall-related injuries and costs in Medicare data

BACKGROUND

Identifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.

METHODS

First, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.

RESULTS

To illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.

CONCLUSIONS

This algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.

Diabetes and fracture risk in older U.S. adults

OBJECTIVE

We examined the diabetes-fracture relationship by race/ethnicity, including the link between pre-diabetes and fracture.

RESEARCH DESIGN AND METHODS

We used Medicare- and mortality-linked data for respondents aged 65years and older from the third National Health and Nutrition Examination Survey (NHANES III) and NHANES 1999-2004 for three race/ethnic groups: non-Hispanic whites (NHW), non-Hispanic blacks (NHB), and Mexican Americans (MA). Diabetes was defined as diagnosed diabetes (self-reported) and diabetes status: diagnosed and undiagnosed diabetes (positive diagnosis or hemoglobin A1c (A1C)≥6.5%); pre-diabetes (no diagnosis and A1C between 5.7% and 6.4%); and no diabetes (no diagnosis and A1C<5.7%). Non-skull fractures (n=750) were defined using published algorithms. Hazards ratios (HRs) were calculated using Cox proportional hazards models.

RESULTS

The diabetes-fracture relationship differed significantly by race/ethnicity (pinteraction<0.05). Compared to those without diagnosed diabetes, the HRs for those with diagnosed diabetes were 2.37 (95% CI 1.49-3.75), 1.87 (95% CI 1.02-3.40), and 1.22 (95% CI 0.93-1.61) for MA, NHB, and NHW, respectively, after adjusting for significant confounders. HRs for diagnosed and undiagnosed diabetes were similar to those for diagnosed diabetes alone. Pre-diabetes was not significantly related to fracture risk, however. Compared to those without diabetes, adjusted HRs for those with pre-diabetes were 1.42 (95% CI 0.72-2.81), and 1.20 (95% CI 0.96-1.51) for MA and NHW, respectively. There were insufficient fracture cases to examine detailed diabetes status in NHB.

CONCLUSIONS

The diabetes-fracture relationship was stronger in MA and NHB. Pre-diabetes was not significantly associated with higher fracture risk, however.

Targeting a high-risk group for fall prevention: strategies for health plans

OBJECTIVES

Although Medicare has implemented incentives for health plans to reduce fall risk, the best way to identify older people at high risk of falling and to use screening results to target fall prevention services remains unknown. We evaluated 4 different strategies using a combination of administrative data and patient-reported information that health plans could easily obtain.

STUDY DESIGN

Observational study.

METHODS

We used data from 1776 patients 75 years or older in 4 community-based primary care practices who screened positive for a fear of falling and/or a history of falls. For these patients, we predicted fall-related injuries in the 24 months after the date of screening using claims/encounter data. After controlling for age and gender, we predicted the number of fall-related injuries by adding Elixhauser comorbidity count, any claim for a fall-related injury during the 12 months prior to screening, and falls screening question responses in a sequential fashion using negative binomial regression models.

RESULTS

Basic patient characteristics, including age and Elixhauser comorbidity count, were strong predictors of fall-related injury. Among falls screening questions, a positive response to, "Have you fallen 2 or more times in the past year?" was the most predictive of a fall-related injury (incidence rate ratio [IRR], 1.56; 95% CI, 1.25-1.94). Prior claim for a fall-related injury also independently predicted this type of injury (IRR, 1.41; 95% CI, 1.05-1.89). The best model for predicting fall-related injuries combined all of these approaches.

CONCLUSIONS

The combination of administrative data and a simple screening item can be used by health plans to target patients at high risk for future fall-related injuries.

Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations

In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility.

INTRODUCTION

Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin.

METHODS

In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography.

RESULTS

Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude.

CONCLUSION

Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.

Functional Restriction for the Fear of Falling In Family Caregivers

Hip fractures often result from falls, and most family caregivers fear another fall. This study aimed to assess this fear in family caregivers and analyze its influence on functional recovery.This study was retrospectively performed by interview at the clinic or through telephone contact. The Falls Efficacy Scale International (FES-I) was used to assess fall-related feelings of patients and their family caregivers.Of the 539 patients studied, hip fracture was caused by a fall in 467 (86.6%). The mean FES-I value of the family caregivers was significantly lower than that of the patients (85.39 versus 99.02, P < 0.001). The mean patient functional recovery score (FRS) was 68.41. A fracture caused by a fall and recurrent fall-related fractures both reduced caregiver FES-I scores. The difference between patient and caregiver FES-I scores showed a significant positive correlation with the FRS (P < 0.001).Family caregivers were more concerned about falls than were patients. Furthermore, a greater difference in the fall-related reaction between caregivers and patients was associated with greater adverse effects on rehabilitation.

Effect of a falls quality improvement program on serious fall-related injuries

OBJECTIVES

To determine whether a program that improves the quality of care for falls reduces the number of episodes of care for serious fall-related injuries.

DESIGN

Nonrandomized controlled trial.

SETTING

Four community-based primary care practices.

PARTICIPANTS

Individuals aged 75 and older who screened positive for fall risk.

INTERVENTION

A multicomponent quality improvement program (Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders) involving face-to-face clinician education about falls and decision support to prompt primary care providers to implement appropriate care, including referral to appropriate community resources, in response to individuals screening positive for fall risk.

MEASUREMENTS

Episodes of care for selected fall-related injuries, based on healthcare claims.

RESULTS

Of 1,791 individuals with data available for analysis, 1,187 were in the intervention group, and 604 were in the control group. Mean age was 83, and more than two-thirds of the sample were women. After adjusting for potential confounders, there were no statistically significant differences between intervention and control groups in episodes of care for fall-related injuries during the 12-month (incidence rate ratio (IRR) 1.27, 95% confidence interval (CI) = 0.93-1.73) or 24-month (IRR 1.18, 95% CI = 0.93-1.49) period after initiation of the intervention.

CONCLUSION

Despite improving the care of falls, this quality improvement initiative did not result in a change in the number of episodes of care for serious fall-related injuries. Future work in community-based settings should test higher-intensity interventions to reduce fall-related injuries.

The degenerative state of the intervertebral disk independently predicts the failure of human lumbar spine to high rate loading: an experimental study

BACKGROUND

In the elderly, 30%-50% of patients report a fall event to precede the onset of vertebral fractures. The dynamic characteristics of the spine determine the peak forces on the vertebrae in a fall. However, we know little about the effect of intervertebral disk degeneration on the failure of human spines under the high loading rates associated with such falls. We hypothesized that MR estimates of disk hydration and viscoelastic properties will provide better estimates of failure strength than bone density alone.

METHODS

Seventeen L1-L3 human spine segments were imaged (magnetic resonance imaging, dual-energy X-ray absorptiometry), their dynamic responses quantified using pendulum based impact, and the spines tested to failure under high rate loading simulating a fall event. The spines' stiffness and damping constants were computed (Kelvin-Voigt model) with disk hydration and geometry assessed from T2 and proton density images.

FINDINGS

Under impact, the spines exhibited a second-order underdamped response with stiffness and damping ranging (17.9-754.5) kN/m and (133.6-905.3) Ns/m respectively. Damping, but not stiffness, was negatively correlated with higher ultimate strength (P<0.05). Higher bone mineral density and MR-estimated disk hydration correlated with higher ultimate strength (P<0.01 for both). No such correlations were observed for the T2 values. Adding disk hydration yielded a 20% increase in the model's association with failure load compared to bone density alone (MANOVA, P<0.001).

INTERPRETATION

The strong correlation between disk viscoelastic properties and MR-estimated hydration with the spine segments' ultimate strength clearly demonstrates the need to include disk degeneration as part of fracture risk assessment in the elderly spine.

Sex- and age-specific associations between income and incident major osteoporotic fractures in Canadian men and women: a population-based analysis

We investigated sex- and age-specific associations between income and fractures at the hip, humerus, spine, and forearm in adults aged ≥50 years. Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women.

INTRODUCTION

Associations between income and hip fractures are contested, even less is known about other fracture sites. We investigated sex- and age-specific associations between income and major osteoporotic fractures (MOF) at the hip, humerus, spine, and forearm.

METHODS

Incident fractures were identified from administrative health data for adults aged ≥50 years in Manitoba, Canada, 2000-2007. Mean neighborhood (postal code area) annual household incomes were extracted from 2006 census files and categorized into quintiles. We calculated age-adjusted and age-specific sex-stratified fracture incidence across income quintiles. We estimated relative risks (RR) and 95% CI for income quintile 1 (Q1, lowest income) vs. income quintile 5 (Q5) and tested the linear trend across quintiles.

RESULTS

We identified 15,094 incident fractures (4736 hip, 3012 humerus, 1979 spine, and 5367 forearm) in 2718 men and 6786 women. For males, the RR of fracture for the lowest vs. highest income quintile was 1.63 (95% CI 1.42-1.87) and the negative trend was statistically significant (p < 0.0001); individual skeletal sites showed similar associations. For females, the RR of fracture for the lowest vs. highest income quintile was 1.14 (95% CI 1.01-1.28), with a statistically significant negative trend (p = 0.0291); however, the only skeletal site associated with income in women was the forearm (Q1 vs. Q5 RR 1.09, 95% CI 1.01-1.28).

CONCLUSIONS

Compared to men with the highest income, men with the lowest income had an increased fracture risk at all skeletal sites. These associations were attenuated in women. For men, these effect sizes seem large enough to warrant public health concern.

Epidemiology of forearm fractures in adults in Denmark: national age- and gender-specific incidence rates, ratio of forearm to hip fractures, and extent of surgical fracture repair in inpatients and outpatients

National epidemiological studies of forearm fractures are scarce. We examined in- and outpatient rates in Denmark, including anatomical location, surgery, hospitalization ratio, recurrent fractures, and ratio of forearm to hip fractures. This may be useful for triangulation in countries with less detailed information. Rates were higher than previously estimated.

INTRODUCTION

Despite a significant contribution to the overall burden of osteoporotic, nonvertebral fractures, relatively little information is available about age- and gender-specific incidence rates for many countries including Denmark.

METHODS

We used national individual patient data on inpatient and outpatient treatment to calculate rates of forearm fractures, taking readmissions into account, with subtables for distal and proximal fractures. We also calculated ratios of forearm to hip fractures that may be useful when imputing forearm fracture rates from other administrative sources. In addition, we report the rates of hospital admission and the rates of surgical treatment, allowing readers to extrapolate from the number of admissions or surgical procedures to incidence rates, should their data sources be less comprehensive.

RESULTS

Forearm fracture rates were 278 per 100,000 patient years in men aged 50+ and 1,110 per 100,000 in women aged 50+. The female to male incidence rate ratio was 4.0 for the age group 50+ but close to unity in persons aged 40 or under. Two thirds of patients were treated on an outpatient basis with little difference across age and gender strata. Four out of five fractures were treated conservatively. The rate of forearm fractures in Denmark was somewhat higher in both genders than recently imputed from hip fracture rates and were close to the rates previously reported in studies from Norway and Sweden.

CONCLUSION

The rates of forearm fracture in Denmark are higher than previously estimated and very similar to the high risk reported from studies in Norway and Sweden.

Hemoglobin and hip fracture risk in older non-Hispanic white adults

SUMMARY

The relationship between hemoglobin and hip fracture was examined in older non-Hispanic white adults from the third National Health and Nutrition Examination Survey (NHANES III). Both low and high hemoglobin values were associated with increased hip fracture risk before and after adjusting for selected risk factors.

INTRODUCTION

The few studies to date that have examined the relationship between hemoglobin and fracture risk have focused on low hemoglobin values. The present study examined hip fracture risk across the hemoglobin distribution in older non-Hispanic white adults from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994).

METHODS

Hemoglobin was measured using a Coulter S-plus Jr.® (Coulter Electronics, Hialeah, FL) in 2,122 non-Hispanic whites age 65 years and older. Hip fracture cases were identified using linked Medicare and mortality records obtained through 2007. Cox proportional hazards models were used to assess the best-fitting model and to estimate the hazards ratio (HR) for hip fracture by hemoglobin decile before and after adjusting for selected confounders.

RESULTS

There were 239 hip fracture cases in the analytic sample. The best fitting model was quadratic. When compared to values in the middle of the distribution, those with hemoglobin in the lowest and highest deciles had increased hip fracture risk (HRlowest decile = 2.96, 95 % confidence interval (CI) 1.44-6.08; HRhighest decile = 2.06, 95 % CI 1.09-3.92) after adjusting for age and sex. Both HRs remained significant after adjusting for additional confounders (HRlowest decile = 2.24, 95 % CI 1.09-3.92; HRhighest decile = 2.37, 95 % CI 1.35-4.16).

CONCLUSIONS

Both low and high hemoglobin values were associated with increased hip fracture risk. The mechanism underlying the relationship is not clear, but there were some suggestions that it may differ for low versus high hemoglobin.

Multimorbidity in women with and without osteoporosis: results from a large US retrospective cohort study 2004-2009

To determine the incidence of comorbidities in women with and without osteoporosis, incidence rates per 1,000 person-years were calculated using electronic health records from an integrated healthcare system. The overall comorbidity burden and health service utilization were greater in women with osteoporosis than in the controls.

INTRODUCTION

This retrospective cohort study describes the incidence of an array of comorbidities in women with and without osteoporosis (OP).

METHODS

Using electronic health records from an integrated healthcare system, we identified 22,414 women aged 55-89 years with OP and 22,414 age-matched controls without OP. Incidence rates (IRs) per 1,000 person-years (P-Y) were calculated and 95% confidence intervals (CI) were estimated.

RESULTS

Women with OP had significantly more comorbidities, medications, hospitalizations, and outpatient visits than the controls. Most cardiac comorbidity rates were 20-25% lower in the OP cohort than in the control cohort. Hypertension had the largest rate difference; the IR was 42.0 per 1,000 P-Y (95% CI 40.2-44.0) in the OP cohort compared to 94.0 (95% CI 90.7-97.4) in the control cohort. Rates for cerebrovascular disease were similar for both cohorts at 26 per 1,000 P-Y. Bronchitis, sinusitis, and cystitis were each 55 per 1,000 P-Y in the OP cohort, whereas they ranged from 28 to 34 per 1,000 P-Y in the controls. The OP cohort had decreased incidence of ovarian, uterine, colorectal, and liver cancers and increased incidence of lung cancer, breast cancer, and multiple myeloma, compared to the non-OP cohort. Falls, depression, vision, and musculoskeletal issues were higher for the OP cohort than the controls.

CONCLUSIONS

This study demonstrates the high disease burden in women with OP. This knowledge may help guide the clinical management of this population and may aid in the interpretation of adverse events in randomized clinical trials of OP therapies.

Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009

BACKGROUND

Clinical practice recommendations state that patients with fragility fractures should be evaluated for osteoporosis and treated for the disease if it is present. The purpose of this study was to assess osteoporosis evaluation and treatment patterns for patients with fragility fractures and assess whether anti-osteoporosis pharmacotherapy initiated immediately following a fragility fracture is associated with improved adherence to the treatment protocol.

METHODS

This retrospective cohort study involved data from a large commercially insured population seen in the period from 2001 through 2009. Patients were community-dwelling individuals aged fifty years or older who had a new low-energy fracture at the hip, vertebra, wrist, or humerus with no evidence of a fragility fracture, osteoporosis treatment, malignant disease, or Paget disease for twelve months preceding the fracture. Rates of diagnostic testing and pharmacotherapy for osteoporosis within twelve months post-fracture were evaluated. Patients treated with oral bisphosphonates were evaluated to determine whether twelve-month adherence to the treatment protocol differed between those who had initiated therapy sooner (at zero to ninety days) and those who initiated it later (at ninety-one to 365 days) following the fracture.

RESULTS

The 88,571 women and 41,984 men had an average age of 72.3 years and 70.5 years, respectively. Nineteen percent (16,464) of the women and 10% (4014) of the men initiated osteoporosis pharmacotherapy, and 30% (26,481) of the women and 15% (6427) of the men underwent diagnostic testing and/or pharmacotherapy following fracture. Treatment rates were highest following vertebral fracture and lowest following wrist or humeral fracture. Treatment rates significantly decreased over time (from 2001 through 2009). The average twelve-month adherence (medication possession ratio) was 56% and 61% among women and men, respectively. Adherence was similar between patients who had initiated treatment sooner after the fracture and those who had initiated it later after the fracture.

CONCLUSIONS

Clinical guidelines for evaluation and treatment following fragility fracture were met for less than one-third of women and less than one-sixth of men. While primary fracture prevention remains the ideal, secondary prevention is critical and there is a need to reverse the downward trend in adherence to post-fracture guidelines.

Patterns and predictors of osteoporosis medication discontinuation and switching among Medicare beneficiaries

BACKGROUND

Low adherence to bisphosphonate therapy is associated with increased fracture risk. Factors associated with discontinuation of osteoporosis medications have not been studied in-depth. This study assessed medication discontinuation and switching patterns among Medicare beneficiaries who were new users of bisphosphonates and evaluated factors possibly associated with discontinuation.

METHODS

We identified patients initiating bisphosphonate treatment using a 5% random sample of Medicare beneficiaries with at least 24 months of traditional fee-for-service and part D drug coverage from 2006 through 2009. We classified medication status at the end of follow-up as: continued original bisphosphonate, discontinued without switching or restarting, restarted the same drug after a treatment gap (≥ 90 days), or switched to another anti-osteoporosis medication. We conducted logistic regression analyses to identify baseline characteristics associated with discontinuation and a case-crossover analysis to identify factors that precipitate discontinuation.

RESULTS

Of 21,452 new users followed respectively for 12 months, 44% continued their original therapy, 36% discontinued without switching or restarting, 8% restarted the same drug after a gap greater than 90 days, and 11% switched to another anti-osteoporosis medication. Factors assessed during the 12-month period before initiation were weakly associated with discontinuation. Several Factors measured during follow-up were associated with discontinuation, including more physician visits, hospitalization, having a dual-energy X-ray absorptiometry test, higher Charlson comorbidity index scores, higher out-of-pocket drug payments, and upper gastrointestinal problems. Patterns were similar for 4,738 new users followed for 30 months.

CONCLUSIONS

Among new bisphosphonates users, switching within and across drug classes and extended treatment gaps are common. Robust definitions and time-varying considerations should be considered to characterize medication discontinuation more accurately.

Association of polypharmacy with fall-related fractures in older Taiwanese people: age- and gender-specific analyses

OBJECTIVE

To elucidate the associations between polypharmacy and age- and gender-specific risks of admission for fall-related fractures.

DESIGN

Nested case-control study.

SETTING

This analysis was randomly selected from all elderly beneficiaries in 2007-2008, and represents some 30% of the whole older insurers using Taiwan's National Health Insurance Research Database.

PARTICIPANTS

We identified 5933 cases newly admitted for fall-related fractures during 2007-2008, and 29 665 random controls free from fracture.

PRIMARY AND SECONDARY OUTCOME MEASURES

Polypharmacy was defined as the use of fall-related drugs of four or more categories of medications and prescribed related to fall within a 1-year period. Logistic regression models were employed to estimate the ORs and related 95% CIs. The interaction of polypharmacy with age and sex was assessed separately.

RESULTS

Compared with those who consumed no category of medication, older people who consumed 1, 2, 3 and ≥4 categories of medications were all at significantly increased odds of developing fall-related fractures, with a significant dose-gradient pattern (β=0.7953; p for trend <0.0001). There were significant interactions between polypharmacy and age, but no significant interactions between polypharmacy and gender. The dose-gradient relationship between number of medications category and risk of fall-related fractures was more obvious in women than in men (β=0.1962 vs β=0.1873). Additionally, it was most evident in older people aged 75-84 years (β=0.2338).

CONCLUSIONS

This population-based study in Taiwan confirms the link between polypharmacy and increased risk of fall-related fractures in older people; and highlights that elderly women and older people aged 75-84 years will be the targeted participants for further prevention from fall-related fractures caused by polypharmacy.