Utilization of osteoporosis medication after a fragility fracture among elderly Medicare beneficiaries

Strength and strain distributions obtained from digital wrist tomosynthesis discriminate patients with and without a history of fragility fracture

Bone fractures due to osteoporosis are a significant problem. Limited accuracy of standard bone mineral density (BMD) for fracture risk assessment, combined with low adherence to bone health screening precludes identification of those at risk of fracture. Because of the wide availability of digital breast tomosynthesis (DBT) imaging, bone screening using a DBT scanner at the time of breast screening has been proposed. Earlier studies have shown that BMD, microstructure, and stiffness of the distal radius can be calculated using digital tomosynthesis imaging of the wrist (DWT). However, strength and stress/strain parameters, which are more relevant to structural failure, and have the potential to enhance the utility of DWT, were not examined previously. Therefore, this study aimed to examine the ability of DWT to discriminate patients with and without fragility fracture using DWT based finite element (DWT-FE) derived strength and stress/strain distribution properties, and to determine in vivo repeatability of these biomechanical properties. Twenty-two postmenopausal women with any fragility fracture (included spine, hip, distal radius, humerus and tibia fractures) and 68 without were recruited. Each participant's nondominant arm (dominant arm if history of fracture in the nondominant arm) was scanned with DWT and compressive loading was simulated using FE modeling. Six additional patients were DWT-scanned thrice, with repositioning, to determine the repeatability of the study variables. Age and T-score were not different between fracture and nonfracture groups (p > 0.1), but strength and stress/strain parameters were significant predictors of fracture status (AUC = 0.64-0.74). Standard deviation of tensile strain was the most discriminatory variable for fracture status (AUC = 0.74) and was independent from stiffness. Repeatability error of DWT biomechanical properties was 0.7 % to 5.8 %. This study demonstrated that DWT-FE based strength and standard deviation of tensile strain were reproducible and predict fracture status independent from BMD and stiffness. The results suggest that the accuracy of fracture risk screening can be improved in the highly accessible environment of mammographic imaging.

Frequency of Osteoporosis-Related Fractures in the Kingdom of Bahrain

BACKGROUND

Osteoporosis-related fragility fractures are increasing worldwide. An assessment of the prevalence of fragility fractures in Bahrain is needed to determine proper action and preventive strategies. The main objective of this study was to conduct a retrospective cross-sectional study to investigate the prevalence of fragility fractures in adult Bahraini patients. Another objective was to explore the relationship of fragility fracture risk with BMD, age, sex, BMI, vitamin D status, and therapy.

METHODS

To investigate the fragility fractures, we retrospectively reviewed the dual-energy X-ray absorptiometry (DEXA) data of patients who underwent scans for the diagnosis of osteoporosis between 2016 and 2018. The data were collected from four large centers in Bahrain. The patients' medical records were reviewed for the fragility fracture data, BMD, sex, age, BMI, vitamin D status, and therapy.

RESULTS

Among a total of 4572 patients who visited the radiology departments during the 3-year study period, only 412 patients with fragility fractures were considered for the current study. The mean age of the patients in this cohort was 63.9 ± 12.2 years. There were 393 females (95.6%). Among the 431 fragility fractures, there were 175 (40.6%) belonging to three common fracture sites: vertebral (86, 20.9%), femur (60, 14.6%), and distal radius (Colles) fractures (29, 7%). Other fragility fractures were hand (7%), radius and ulna (3.7%), humerus (6.5%), tibia and fibula (5.6%), foot/ankle (27.9%), ribs (3.0%), and pelvis (1.6%). Our results revealed a significant association between the fragility fractures and BMD (χ2 = 6.7, p = 0.035). We reported a significant association of fragility fracture with sex (p = 0.006) and with denosumab therapy (p < 0.001).

CONCLUSIONS

This study reported a reduced BMD and an increased prevalence of fragility fractures among Bahraini subjects. The highest frequencies of fragility fractures among our cohort were foot/ankle, vertebral, and hip fractures, respectively. We showed a statistically significant association between fragility fractures and BMD. The current study indicated that not only patients with low BMD but also patients with fragility fractures were undertreated. Thus, the immediate initiation of treatment and the synthesis of local osteoporosis treatment guidelines are warranted.

Physician-dentist dual referral model concept for coordinated bone anabolic therapy

BACKGROUND

Bone anabolic drugs used for the pharmacologic treatment of osteoporosis have the potential to enhance alveolar bone regeneration to improve implant success. There are no US Food and Drug Administration-approved drugs indicated to improve oral bone density around teeth or implants.

METHODS

The authors summarized expert opinions on a novel coordinated treatment approach leveraging the effects of systemic bone anabolic drugs to enhance dental implant therapy in patients with osteoporosis and a dual referral model for physicians and dentists to address the clinical needs of patients with osteoporosis from a comprehensive perspective of oral-systemic health. Interviews of key opinion leaders were conducted with a bone health specialist group consisting of specialists in orthopedic surgery, internal medicine, geriatrics, endocrinology, and clinical densitometry and a surgical dental specialist group consisting of periodontists and oral surgeons.

RESULTS

Overall, both groups shared positive feedback on the idea of strategically timing administration of anabolic osteoporosis drugs with dental treatment. Both groups expressed interest in the dual referral model.

CONCLUSIONS

The feedback of key opinion leaders supported the coordinated bone anabolic therapy concept and identified a need for improved interdisciplinary collaboration, education, and communication to realize the synergies of physician-dentist clinical cooperation.

PRACTICAL IMPLICATIONS

Strategic timing of osteoporosis therapy could improve skeletal bone health and reduce fracture risk while offering adjunctive dental benefits.

Geographic Variation in Osteoporosis Treatment in Postmenopausal Women: A 15-Year Longitudinal Analysis

Context

Osteoporosis affects more than half of older women, but many are not treated. Whether treatment differs between rural and urban areas is unknown.

Objective

To examine differences in osteoporosis treatment among postmenopausal women living in urban and rural areas of Australia.

Methods

Women participating in the Australian Longitudinal Study on Women's Health, a prospective longitudinal cohort study, born between 1946-1951, and with osteoporosis or fractures, were included. Surveys from 2004 to 2019 were linked to the Pharmaceutical Benefits Scheme (government-subsidized medications) to assess osteoporosis treatment and adherence, comparing geographical areas.

Results

Of the 4259 women included (mean age, 55.6 years), 1703 lived in major cities, 1629 inner regional, 794 outer regional, and 133 remote areas. Over the 15-year follow-up, 1401 (32.9%) women received treatment, including 47.4% of women with osteoporosis and 29.9% with fractures. Women in outer regional and remote areas were less likely to use antiosteoporosis treatment than those in major cities on univariable analysis (outer regional odds ratio, 0.83; 95% CI, 0.72-0.95; remote, 0.65; 0.49-0.86), but this did not remain significant on multivariable analysis. Median duration of use was 10 to 36 months, adherence varied by treatment type (34%-100%) but was not related to incident fractures, and of the women who stopped denosumab, 85% did not receive another consolidating treatment.

Conclusions

One-third of women with osteoporosis/fractures received treatment, and adherence was low. There was no difference in treatment use between urban and rural areas after adjusting for risk factors, although the specific treatment used, and adherence, differed.

The estimated prevalence of osteoporosis in Bahrain: a multi-centered-based study

OBJECTIVES

the primary aim of this study was to examine the prevalence and risk factors of low bone mineral density in Bahrain.

METHODS

this was a retrospective study, which targeted a cohort of 4822 Bahraini subjects (mean age 59.36 years: 93% females). Demographic data and results of lumbar and femur DEXA scan for the targeted sample, over the period 2016-2018, were retrieved from four hospitals.

RESULTS

The prevalence of low BMD was 62.3% (46.4% had osteopenia and 15.9% had osteoporosis). The highest rate of osteopenia was detected at the age group younger than 44 years. However, with increasing age, the rate of osteopenia declined, whereas osteoporosis increased (P < 0.001). Females were found to be at higher risk of developing both osteopenia (45.8%) and osteoporosis (18.1%) compared to males (39% and 12.4%, respectively) (P < 0.001). Postmenopausal women exhibited higher rates of low BMD (42.4% osteopenia, 22.3% osteoporosis) compared to elderly men (30.9% osteopenia, 9% osteoporosis).

CONCLUSIONS

We reported high prevalence of osteopenia and osteoporosis in Bahrain. Low BMD was more common in females, especially in postmenopausal women. Highest prevalence of osteopenia happened at young age. Therefore, we advocate screening at younger age than previously recommended.

Digital wrist tomosynthesis (DWT)-based finite element analysis of ultra-distal radius differentiates patients with and without a history of osteoporotic fracture

Despite effective therapies for those at risk of osteoporotic fracture, low adherence to screening guidelines and limited accuracy of bone mineral density (BMD) in predicting fracture risk preclude identification of those at risk. Because of high adherence to routine mammography, bone health screening at the time of mammography using a digital breast tomosynthesis (DBT) scanner has been suggested as a potential solution. BMD and bone microstructure can be measured from the wrist using a DBT scanner. However, the extent to which biomechanical variables can be derived from digital wrist tomosynthesis (DWT) has not been explored. Accordingly, we measured stiffness from a DWT based finite element (DWT-FE) model of the ultra-distal (UD) radius and ulna, and correlate these to reference microcomputed tomography image based FE (μCT-FE) from five cadaveric forearms. Further, this method is implemented to determine in vivo reproducibility of FE derived stiffness of UD radius and demonstrate the in vivo utility of DWT-FE in bone quality assessment by comparing two groups of postmenopausal women with and without a history of an osteoporotic fracture (Fx; n = 15, NFx; n = 51). Stiffness obtained from DWT and μCT had a strong correlation (R2 = 0.87, p < 0.001). In vivo repeatability error was <5 %. The NFx and Fx groups were not significantly different in DXA derived minimum T-scores (p > 0.3), but stiffness of the UD radius was lower for the Fx group (p < 0.007). Logistic regression models of fracture status with stiffness of the nondominant arm as the predictor were significant (p < 0.01). In conclusion this study demonstrates the feasibility of fracture risk assessment in mammography settings using DWT imaging and FE modeling in vivo. Using this approach, bone and breast screening can be performed in a single visit, with the potential to improve both the prevalence of bone health screening and the accuracy of fracture risk assessment.

Age-dependent gender differences in the diagnosis and treatment of osteoporosis during hospitalization in patients with fragility fractures

BACKGROUND

There is a gender difference in the acceptance of osteoporosis diagnosis and treatment in patients after fragility fractures, but this difference is rarely assessed during hospitalization, and it is unclear whether these differences are age-dependent. This study aimed to evaluate the differences between male and female fragility fracture patients of different age groups who received the diagnosis and treatment of osteoporosis during hospitalization.

METHODS

31,265 fragility fracture patients aged ≥ 50 years from the Fragility Fracture Management Database in a high-volume orthopedic hospital from December 2019 to February 2023 were included in this study. We compared the differences in the rates of men and women with fragility fracture who received the measurement of bone mineral density (BMD) and bone metabolism biochemical markers (BMBMs) and treatment with anti-osteoporosis medications (AOMs), and follow-up to the internal medicine clinic within 3 months after discharge, across all age groups and across different age stages (50-59, 60-69, 70-79, and ≥ 80 years).

RESULTS

The detection rates of female patients receiving BMD and BMBMs during hospitalization were 31.88% and 5.30%, respectively, compared with 22.23% and 2.69% for men. The rate of receiving any AOMs treatment was 44.63% for women and 31.60% for men. The follow-up rate of returning to the internal medicine clinic within 3 months after discharge was 9.79% for women compared to 3.00% for men. There was a significant difference between males compared to females (P < 0.0001). Analysis of patients by different age group revealed that differences in the diagnosis and treatment of osteoporosis were found only in patients under 80 years of age, while gender differences in the return to the internal medicine clinic for follow-up after discharge were present in all age groups.

CONCLUSIONS

Gender differences present in osteoporosis management in patients with fragility fracture during hospitalization, especially for patients under 80 years of age. This finding suggests that orthopedic surgeons neglect to manage osteoporosis in male patients with fragility fracture during hospitalization.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Osteoporosis care through an Integrated, People-Centred Health Services framework lens: a hybrid qualitative analysis of international patient experiences

OBJECTIVES

Globally, patients with osteoporosis have unmet needs in terms of care accessibility, patient-centredness and care comprehensiveness. The WHO developed the Integrated, People-Centred Health Services (IPCHS) framework to reorient and integrate healthcare systems using 5 interdependent strategies and 20 substrategies. Patients' perspectives with regard to these strategies are poorly understood. We sought to relate patient-experienced gaps in osteoporosis care to the IPCHS strategies and identify key strategies to guide osteoporosis care reforms.

DESIGN, SETTING AND PARTICIPANTS

Qualitative online study of the experiences of international patients with osteoporosis.

PROCEDURE

Two researchers conducted semi-structured interviews in English, Dutch, Spanish and French that were recorded and transcribed verbatim. Patients were categorised according to their countries' healthcare systems (universal, public/private and private) and fracture status. A hybrid (sequential theory-driven and data-driven) analysis was performed, with the IPCHS framework used for the theory-driven analysis.

RESULTS

Thirty-five patients (33 women) from 14 countries participated. Twenty-two patients had universal healthcare and 18 had experienced fragility fractures. Prioritised substrategies overlapped among healthcare systems, with reported shortcomings related primarily to 'empowering and engaging individuals and families' and 'coordinating care' (at varying levels). Patients with all healthcare types prioritised 'reorienting care', with different substrategies prioritised. Patients with private healthcare called for 'improving funding and reforming payment systems'. Substrategy prioritisation did not differ between those receiving primary and secondary fracture prevention.

CONCLUSION

Patients' experiences with osteoporosis care are universal. Given the current care gaps and associated patient burdens, policymakers should make osteoporosis a(n) (inter)national health priority. Integrated osteoporosis care reforms should focus on patient-reported experiences with and be guided by priorities in IPCHS strategies, taking into account the healthcare system context.

Closing the gap in osteoporosis management: the critical role of primary care in bone health

OBJECTIVE

The World Health Organization issued a call to action for primary care to lead efforts in managing noncommunicable diseases, including osteoporosis. Although common, osteoporosis remains underdiagnosed and undertreated. Primary care practitioners (PCPs) are critical in identifying individuals at risk for osteoporosis and osteoporotic fractures; however, recent advances in assessment, diagnosis, and treatment of osteoporosis have not been incorporated into clinical practice in primary care due to numerous reasons including time constraints and insufficient knowledge. To close this gap in clinical practice, we believe PCPs need a practical strategy to facilitate osteoporosis assessment and management that is easy to implement.

METHODS

In this article, we consolidate information from various global guidelines and highlight areas of agreement to create a streamlined osteoporosis management strategy for a global audience of PCPs.

RESULTS

We present a systematic approach to facilitate osteoporosis assessment and management that includes four steps: (1) identifying patients at risk through proactive screening strategies, (2) investigating and diagnosing patients, (3) intervening with personalized treatment plans, and (4) implementing patient-centered strategies for long-term management and monitoring of patients.

CONCLUSION

Primary care has a central role in ensuring the incorporation of key elements of holistic care as outlined by the World Health Organization in managing noncommunicable diseases including osteoporosis; namely, a people-centered approach, incorporation of specialist services, and multidisciplinary care. This approach is designed to strengthen the health system's response to the growing osteoporosis epidemic.

Trends in anti-osteoporotic medication utilization following fragility fracture in the USA from 2011 to 2019

The purpose of this study was to determine whether there has been any change in osteoporosis treatment following primary fragility fractures and what agents were being given. The study found an overall low utilization rate with no difference in treatment utilization from 2011 to 2019.

PURPOSE

The aim of this study is to describe trends in the utilization of anti-osteoporotic medication after fragility fracture, including changes in the specific types of medications prescribed.

METHODS

Patients older than 65 with fragility fractures sustained from 2011 to 2019 were identified in the PearlDiver Patient Records Database. Osteoporosis treatment rate was defined as the rate at which patients were prescribed any of the fourteen most used anti-osteoporotic medications within 1 year of fragility fracture. Fragility fractures were subcategorized by type. Treatment of fragility fractures was further stratified by patient demographics (age and gender) and medication type.

RESULTS

This study showed an overall osteoporosis treatment rate of 8.01%, with treatment rates of 6.87% following hip fractures, 6.71% following upper extremity fractures, and 14.38% following vertebral compression fractures (VCF). From 2011 to 2018, there was no change in the overall fragility fracture treatment rate (p = 0.32). Of the three fracture categories analyzed, only the treatment rate for VCFs increased (p = 0.048). Osteoporosis treatment in patients with VCF increased among patients 65-74 years old (p < 0.05) and male patients (p = 0.013). Treatment in patients with upper extremity fractures increased among patients 70-74 years old (p = 0.038). Bisphosphonates were the most frequently prescribed class of medications. Bisphosphonates and denosumab increased in utilization (p = 0.049 and p < 0.001 respectively) while calcitonin utilization decreased (p < 0.001).

CONCLUSION

Besides the overall low utilization rate of osteoporosis treatment in patients following fragility fractures, there has been no change in the treatment utilization rate within the past decade. More resources and interventions need to be enforced for all providers managing these patients if we are ever to address the osteoporosis epidemic.

Medical management patterns in a US commercial claims database following a nontraumatic fracture in postmenopausal women

Among women ≥ 50 years with fracture, 76% had not received osteoporosis diagnosis or treatment at 6 months and only 14% underwent a DXA scan. Nearly half of all and 90% of hip fracture patients required surgery. Fractures cause substantial clinical burden and are not linked to osteoporosis diagnosis or treatment.

PURPOSE

Osteoporosis (OP) and OP-related fractures are a major public health concern, associated with significant economic burden. This study describes management patterns following a nontraumatic fracture for commercially insured patients.

METHODS

This retrospective cohort study identified women aged ≥ 50 years having their first nontraumatic index fracture (IF) between January 1, 2015 and June 30, 2019, from IQVIA's PharMetrics® Plus claims database. Medical management patterns at month 6 and medication use patterns at months 6, 12, and 24 following the IF were described.

RESULTS

Among 48,939 women (mean (SD) age: 62.7 (9.5) years), the most common fracture types were vertebral (30.6%), radius/ulna (24.9%), and hip (HF; 12.1%). By month 6, 76% of patients had not received an OP diagnosis or treatment, 13.6% underwent a DXA scan, and 11.2% received any OP treatment. Surgery was required in 43.1% of all patients and 90.0% of HF patients on or within 6 months of the fracture date. Among HF patients, 41.4% were admitted to a skilled nursing facility, 96.7% were hospitalized an average of 5.5 days, and 38.1% required durable medical equipment use. The 30-day all-cause readmission rate was 14.3% among those hospitalized for the IF. Overall, 7.4%, 9.9%, and 13.2% had a subsequent fracture at months 6, 12, and 24, respectively.

CONCLUSION

Our findings provide an overview of post-fracture management patterns using real-world data. OP was remarkably underdiagnosed and undertreated following the initial fracture. Nontraumatic fracture, particularly HF, resulted in substantial ongoing clinical burden.

Osteoporosis management in the United States

There are numerous organizational osteoporosis initiatives in the United States offering a variety of recommendations and guidelines. A common method of implementing these goals is centered around multidisciplinary provider teams with the broad task of diagnosis, treatment, and prevention of current and future osteoporosis related fractures. These teams have generally proved to be successful even though it remains debated, which specific provider specialty is ultimately responsible for osteoporosis care. The current United States healthcare infrastructure represents the significant obstacle in widespread adoption of successful treatment programs. The development of further quality standards and incorporation of fracture liaison services into reimbursement and funding models will allow for continued improvement in osteoporosis care.

[Effect of bone anabolic therapy on bone remodeling and bone density in geriatric patients with osteoporosis and falling syndrome]

BACKGROUND

Older adults with severe osteoporosis are the most vulnerable group of geriatric patients. They are shown the purpose of anti-osteoporotic therapy, which should be effective and safe. Teriparatide showed a decrease in the risk of fractures, an increase in BMD. In Russia, the use of teriparatide in the geriatric population is extremely scarce.

AIM

assess clinical course, bone metabolism parameters and efficacy of bone-anabolic therapy in elderly and senile patients with severe osteoporosis and falls.

MATERIALS AND METHODS

The longitudinal prospective study included 100 patients 60 years and older with severe osteoporosis who had one or more falls within the last year. All patients were prescribed calcium and vitamin D preparations and bone-anabolic therapy (teriparatide 20 mg daily subcutaneously). The duration of follow-up was 24 months and included 3 visits: screening, at 12 and 24 months. The effectiveness of bone-anabolic therapy was carried out on the basis of assessing the frequency of new fractures, reduction of pain, changes in BMD according to X-ray densitometry, dynamics of bone metabolism markers.

RESULTS

All patients had severe osteoporosis and aggravated comorbidity status, suffered a fall within the last year, and also low-energy fractures in the past. One in three patients had a vertebral fracture, one in five had a proximal femoral fracture. Prior to the start of the study, 61 patients received antiosteoporotic therapy. During the follow-up, 4 patients died, 96 patients completed the study. Against the background of teriparatide therapy, a decrease in the number of new cases of low-energy fractures and the number of patients with chronic pain was obtained. An increase in BMD was noted in the lumbar spine after 24 months and in the femoral neck after 12 months. There was no negative dynamics of the BMD. Also after 12 months, an increase in P1NP and C-terminal telopeptide of collagen type 1 was noted, after 24 months - osteocalcin and C-terminal telopeptide.

CONCLUSION

The use of teriparatide can be recommended as an effective intervention to treat severe osteoporosis in geriatric patients with falls.

Protocol for the models of primary osteoporosis screening in men (MOPS) cluster randomized trial

Current guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, analyses in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this study is to determine whether a new model of primary osteoporosis screening reduces fracture risk compared to usual care. We are conducting a pragmatic group randomized trial of 38 primary care teams assigned to usual care or a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. The study will: 1) compare the impact of the BHS model on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, medication adherence, and femoral neck bone mineral density); 2) quantify the impact on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) estimate the impact on health system and policy outcomes using Markov models of screening program cost per quality adjusted life year based from health system and societal perspectives.

A Structural Equation Modelling Approach to Determine Factors of Bone Mineral Density in Korean Women

BACKGROUND

no studies have assessed the associations of nutrient intake, physical activity, age, and body mass index (BMI) with bone mineral density (BMD) using structural equation modelling (SEM) in Korean women. The aim of this study was to examine the effects of nutrient intakes, physical activity, and body mass index (BMI) on BMD in Korean premenopausal and postmenopausal women, with the SEM approach, based on the fourth and fifth Korea National Health and Nutrition Examination Surveys (KNHANES) 2008-2011.

METHODS

SEM analysis was performed with 4160 women (2863 premenopausal women and 1297 postmenopausal women) aged 30-75 years in order to investigate total, direct, or mediating effects of nutrient intake, physical activity, age, and BMI on BMD. Model sensitivity to external misspecification and statistical significance of SEM was determined by phantom variables and bootstrapping. Reliability assessment of the SEM was done by Cronbach's alpha.

RESULTS

a direct effect of minerals (potassium, calcium, and phosphorus) on BMD (total femur, femoral neck, lumbar spine, and whole body) was observed in premenopausal and postmenopausal women (p = 0.045 and p = 0.048, respectively). Age and BMI showed a total effect on BMD in premenopausal and postmenopausal women (p = 0.002, respectively).

CONCLUSIONS

our study suggests that mineral intake (potassium, calcium, and phosphorus), age, and BMI are major contributors to BMD in Korean premenopausal and postmenopausal women aged 30-75 years.

Phase 1b Evaluation of Abaloparatide Solid Microstructured Transdermal System (Abaloparatide-sMTS) in Postmenopausal Women with Low Bone Mineral Density

BACKGROUND AND OBJECTIVE

Abaloparatide, an anabolic osteoporosis treatment administered by subcutaneous (SC) injection, increases bone mineral density (BMD) and reduces fracture risk in postmenopausal women with osteoporosis. The abaloparatide-solid Microstructured Transdermal System [abaloparatide-sMTS (Kindeva, St Paul, MN, USA)], which delivers abaloparatide intradermally, is in development to provide an alternative method for abaloparatide delivery. The objective of this study was to evaluate the ability of subjects to self-administer abaloparatide-sMTS, based on pharmacokinetic and pharmacodynamic markers.

METHODS

In this single-arm, open-label, Phase 1b study, 22 healthy postmenopausal women aged 50-85 years with low BMD were trained to self-administer abaloparatide-sMTS 300 μg once daily to the thigh for 5 min for 29 days. The primary endpoint was systemic exposure to abaloparatide. Secondary endpoints included percent change from baseline in serum procollagen type I N-terminal propeptide (s-PINP), patient experience, and safety.

RESULTS

All 22 subjects completed the study. At baseline, mean age was 65.2 years, mean total hip T-score was - 1.32, and mean lumbar spine T-score was - 1.98. On Day 1, the median time to reach maximum concentration (Tmax) for abaloparatide-sMTS was 0.33 h and geometric mean (CV %) maximum concentration (Cmax) and area under the concentration-time curve from time 0 to the time of the last quantifiable concentration (AUC0-t) were 447 (38.0) pg/mL and 678 (45.3) pg·h/mL, respectively; the pharmacokinetic profile was similar on Days 15 and 29. Median percentage change in s-PINP was 45.4% and 64.4% at Days 15 and 29, respectively. The most common adverse events (AEs) were application site erythema, pain, and swelling, which were mostly of mild or moderate severity. No AEs led to study drug withdrawal and no serious AEs were reported. The success rate for self-administration at first application was 99.7%, and subject acceptability was high (~ 4.5 on a 5-point Likert Scale).

CONCLUSIONS

Subjects successfully self-administered abaloparatide-sMTS, which provided a consistent pharmacokinetic profile over 29 days and produced s-PINP increases from baseline similar to that observed in the pivotal trial with abaloparatide-SC. Observed patient experience along with the clinical data support continued clinical development of abaloparatide-sMTS.

TRIAL REGISTRATION NUMBER

NCT04366726, Date of registration 04/29/2020, retrospectively registered.

Evaluation of a Clinical Platform to Promote Chronic Disease Management

Self-reported data suggest American adults with multiple chronic conditions account for 25.7% to 60% of the population. Despite emphasis on information technology to improve quality in health care, data addressing outcomes of clinically focused, provider-oriented dashboards are limited. To explore integrating performance platforms into clinical care, the authors designed a platform-based intervention to address 2 prevalent chronic conditions with significant long-term burden. This study used a performance platform to enhance clinicians' management of patients with diabetes and osteoporosis. Descriptive statistics were used to summarize patients' surveys and quality metrics, and to analyze clinicians' knowledge, attitudes, and beliefs in the pre and post time frames. The frequency of screening for osteoporosis in women improved post intervention (40% vs. 44%, P < 0.0001), whereas other quality metrics did not. Clinician respondents were primarily physicians (82%), white (73%), internal medicine specialists (58%), with an average of 18 years' experience, and nearly equally male and female. Their percent of correctly answered knowledge questions increased slightly in the postintervention phase for osteoporosis and hypoglycemia (0.53 and 1.74, respectively); however, results were not statistically significant (P > 0.4). Post intervention, clinicians reported that their attitudes and beliefs regarding disease management had changed in the past 6 months in a positive direction. Although few outcomes studied changed over time, results suggest that performance platforms may have a role to play in managing chronic conditions. However, their efficacy must continue to be evaluated in order to improve understanding of optimal approaches to integrating technology into patient care.

Vertebral fracture assessment (VFA) for osteoporosis screening in US postmenopausal women: is it cost-effective?

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.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Anti-osteoporosis medication treatment pattern after osteoporotic fracture during 2010-2016 in Fujian, China

This study demonstrates a low anti-osteoporosis drug treatment rate (22.1% in women, 9.5% in men) after osteoporotic fracture in the real-world setting of Fujian, China. The primary medication was calcitonin. The suboptimal treatment was particularly critical among men, low-level hospitals, wrist/vertebral fracture, and the younger elderly patients.

INTRODUCTION

The objective of this study was to investigate the prescription patterns and related influencing factors of anti-osteoporosis drug prescribing after osteoporotic fracture in Fujian, China, between 2010 and 2016.

METHODS

This is a retrospective cohort study based on an existing electronic health record database (National Healthcare Big Data in Fuzhou, China, 37 hospitals included). Patients over 50 years old with newly diagnosed osteoporotic fractures between 2010 and 2016 were included. Postfracture osteoporosis therapies were summarized by overall and fracture site. Multivariate logistic regression was performed to identify influencing factors of anti-osteoporosis medication (AOM) prescription.

RESULTS

Overall, 22.1% of women and 9.5% of men over 50 years old received AOM treatment after osteoporotic fracture within 1 year during 2010-2016, with particular low use of bisphosphonates, 5.3% in women and 1.5% in men. The highest rate of AOM treatment was found in patients with hip fracture (24.5%), followed by vertebral fracture (14.2%) and wrist fracture (2.3%). Of the AOM-treated patients, 90.5% received calcitonin therapy. The treatment rate of AOM showed a slight decline during 2010-2016, but steady rise trends were observed in Ca/vitamin D (VD) prescription. Hospital level, age, sex, previous osteoporosis, previous AOM prescription, and previous oral glucocorticoid prescription were strong predicting factors of AOM prescription.

CONCLUSION

In a real-world setting, AOM treatment was suboptimal and the treatment rate even decreased over time among osteoporosis fracture patients in Fujian, China. The suboptimal treatment was particularly critical among men, low-level hospitals, wrist/vertebral fracture, and the younger elderly patients.

High rates of undiagnosed and untreated osteoporosis in postmenopausal women receiving medical services in the area of Upper Silesia

INTRODUCTION

High social cost and high risk of disability make postmenopausal osteoporosis one of major public health problem in the 21st century. The aim of this study was to assess frequency of undiagnosed and untreated osteoporosis in postmenopausal women in the Upper Silesia Region of Poland. Additionally, we compare estimation of the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF) based on fracture risk assessment tool (FRAX) with and without bone mineral density (BMD).

MATERIAL AND METHODS

The survey included 450 postmenopausal women (age 65 ±11 years). A detailed questionnaire included demographic and anthropometric data, comorbidity, history of previous low-energy fractures, family medical history, and treatment for osteoporosis. The FRAX calculator was used to estimate the risk of MOF and HF.

RESULTS

Osteoporosis was previously diagnosed in 23.7% women. Of those 70.2% were receiving vitamin D, 27% calcium preparations, 33% bisphosphonates, and 22% were untreated. Only 42.2% women with previous fractures had been diagnosed with osteoporosis and 42.8% received any treatment. 12.5% women with FRAX-BMD ≥ 10% had no risk factors of osteoporosis and < 10% risk of MOF and HF in FRAX without BMD.

CONCLUSIONS

Osteoporosis often remains undiagnosed and untreated in postmenopausal women. There is a great need to popularize FRAX without BMD calculator among physicians, especially GPs, as the risk calculation justify the implementation of antiosteoporotic therapy. Women with burden of risk factors of fractures and borderline FRAX without BMD values, should be referred to a densitometry examination, as having greater risk of fracture than shown by FRAX without BMD.

Testing a theoretical model of imminent fracture risk in elderly women: an observational cohort analysis of the Canadian Multicentre Osteoporosis Study

We examined the underlying relationship between fracture risk factors and their imminent risk. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher imminent fracture risk. Past year falls indirectly predicted imminent risk through physical functioning and general health.

INTRODUCTION

This study aimed to examine direct and indirect effects of several factors on imminent (1 year) fracture risk.

METHODS

Data from women age 65 and older from population-based Canadian Multicentre Osteoporosis Study were used. Predictors were identified from study years 5 and 10, and imminent fracture data (1-year fracture) came from years 6 and 11 (year 5 predicts year 6, year 10 predicts year 11). A structural equation model (SEM) was used to test the theoretical construct. General health and physical functioning were measured as latent variables using items from the 36-Item Short Form Health Survey (SF-36) and bone mineral density (BMD) T-score was a latent variable based on observed site-specific BMD data (spine L1-L4, femoral neck, total hip). Observed variables were fractures and falls. Model fit was evaluated using root mean square error of approximation (RMSEA), Tucker Lewis index (TLI), and comparative fit index (CFI).

RESULTS

The analysis included 3298 women. Model fit tests showed that the SEM fit the data well; χ²(172) = 1122.10 < .001, RMSEA = .03, TLI = .99, CFI = .99. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher risk of fracture in the subsequent year (p < .001). Past year falls had a statistically significant but indirect effect on imminent fracture risk through physical functioning and general health (p < .001).

CONCLUSIONS

We found several direct and indirect pathways that predicted imminent fracture risk in elderly women. Future studies should extend this work by developing risk scoring methods and defining imminent risk thresholds.

Unknown osteoporosis in older patients admitted to post-acute rehabilitation

BACKGROUND

Osteoporotic fractures are associated with increased morbidity, mortality, and increased health care use. As the number of older adults increases, identifying those at increased risk for osteoporotic fractures has become of utmost importance to providing them with preventive and therapeutic interventions.

AIMS

To determine the prevalence of unknown clinical and densitometric osteoporosis and to investigate the performance of different diagnostic strategies for osteoporosis in elderly patients admitted to rehabilitation.

METHOD

This is an observational study. Eligible participants were older adults admitted to rehabilitation in an academic hospital in Switzerland over an 11-month period. Patients with previously unknown osteoporosis underwent dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA), and history review for past fractures.

RESULTS

Complete assessment was available for 252 patients. Previously undiagnosed osteoporosis was identified in 62.3% of these patients, a proportion that was higher among women (71.5%) than men (44.8%). DXA proved most sensitive, followed by VFA and history review. Results differed across gender: DXA remained the most sensitive single test among women, but VFA proved most sensitive in men. The best test to combine with history review was DXA in women (detection increasing from 47.5 to 93.2%) and VFA in men (detection increasing from 35.9 to 84.6%).

CONCLUSIONS

Prevalence of previously unknown osteoporosis appears very high in elderly patients admitted to post-acute rehabilitation. The combination of history review of previous fractures with DXA in women and with VFA in men appears the best two-step strategy to improving detection of osteoporosis in this population.

Impact of Bone Mineral Density on the Incidence of Age-Related Vertebral Fragility Fracture

BACKGROUND

Vertebral fragility fracture (VFF) is a common fracture related to osteoporosis. However, VFF might be asymptomatic and often occurs in patients without osteoporosis. Therefore, we investigated the characteristics of age-related VFF and their correlation with bone mineral density (BMD). Furthermore, we analyzed other factors affecting VFF.

METHODS

Medical records from a single center were retrospectively reviewed for 2,216 patients over 50 years old with vertebral fractures conservatively treated from 2005 to 2016. Patients' age, gender, body mass index (BMI), BMD, fracture level, previous vertebral fractures, and anti-osteoporosis medications were obtained. Patients were divided into fragility/non-fragility groups and age sub-groups. The odds ratio for VFF in relation to BMD was evaluated. We also identified other predictive factors for VFF by age groups.

RESULTS

The fragility group had a higher women ratio, older age, lower BMI, lower BMD, and greater incidence of previous vertebral fractures than the non-fragility group. VFFs were seen in 41.18% of normal BMD patients aged 50-59 and 67.82% of those aged 60-69. The proportion of VFFs increased with age in all WHO osteoporosis classifications. Patients with osteopenia and osteoporosis were 1.57 and 2.62 fold more likely to develop VFFs than normal BMD. In the younger group (under 70), age, women, BMD, and previous vertebral fracture were significant factors affecting VFF, and in the older group (70 and over), age, women, and BMD were factors. In the fragility group, anti-osteoporosis medication rates were 25.08% before and 45.96% after fracture.

CONCLUSION

Considerable VFFs occurred in the younger age groups without osteoporosis and age itself was another important predictor of VFF especially in older age groups. The discrepancy between the incidence of VFF and BMD suggests the necessity of supplemental screening factors and anti-osteoporosis treatment guidelines using only BMD should be reconsidered.

Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk

We reviewed the experimental and clinical evidence that hip bone strength estimated by BMD and/or finite element analysis (FEA) reflects the actual strength of the proximal femur and is associated with hip fracture risk and its changes upon treatment.

INTRODUCTION

The risk of hip fractures increases exponentially with age due to a progressive loss of bone mass, deterioration of bone structure, and increased incidence of falls. Areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), is the most used surrogate marker of bone strength. However, age-related declines in bone strength exceed those of aBMD, and the majority of fractures occur in those who are not identified as osteoporotic by BMD testing. With hip fracture incidence increasing worldwide, the development of accurate methods to estimate bone strength in vivo would be very useful to predict the risk of hip fracture and to monitor the effects of osteoporosis therapies.

METHODS

We reviewed experimental and clinical evidence regarding the association between aBMD and/orCT-finite element analysis (FEA) estimated femoral strength and hip fracture risk as well as their changes with treatment.

RESULTS

Femoral aBMD and bone strength estimates by CT-FEA explain a large proportion of femoral strength ex vivo and predict hip fracture risk in vivo. Changes in femoral aBMD are strongly associated with anti-fracture efficacy of osteoporosis treatments, though comparable data for FEA are currently not available.

CONCLUSIONS

Hip aBMD and estimated femoral strength are good predictors of fracture risk and could potentially be used as surrogate endpoints for fracture in clinical trials. Further improvements of FEA may be achieved by incorporating trabecular orientations, enhanced cortical modeling, effects of aging on bone tissue ductility, and multiple sideway fall loading conditions.

Predictors of imminent risk of fracture in Medicare-enrolled men and women

Advancing age, female sex, recent prior fracture and falls, and specific comorbidities and medications contribute to imminent (within 1-2 years) risk of fracture in Medicare enrollees. Clinician awareness of these risk factors and their dynamic nature may lead to improved osteoporosis care for elderly patients.

PURPOSE

The burden of osteoporotic fracture disproportionately affects the elderly. Growing awareness that fracture risk can change substantially over time underscores the need to understand risk factors for imminent (within 1-2 years) fracture. This study assessed predictors of imminent risk of fracture in the US Medicare population.

METHODS

Administrative claims data from a random sample of Medicare beneficiaries were analyzed for patients aged ≥ 67 years on January 1, 2011 (index date), with continuous coverage between January 1, 2009 and March 31, 2011, excluding patients with non-melanoma cancer or Paget's disease. Incident osteoporotic fractures were identified during 12 and 24 months post-index. Potential predictors were age, sex, race, history of fracture, history of falls, presence of osteoporosis, cardiovascular diseases, chronic obstructive pulmonary disorder (COPD), mood/anxiety disorders, polyinflammatory conditions, difficulty walking, use of durable medical equipment, ambulance/life support, and pre-index use of osteoporosis medications, steroids, or central nervous system medications. Cox proportional hazards models were used to evaluate predictors of fracture risk in the two follow-up intervals.

RESULTS

Among 1,780,451 individuals included (mean age 77.7 years, 66% female), 8.3% had prior fracture and 6.1% had a history of falls. During the 12- and 24-month follow-up periods, 3.0% and 5.4% of patients had an incident osteoporotic fracture, respectively. Imminent risk of fracture increased with older age (double/triple), female sex (> 80%), recent prior fracture (> double) and falls, and specific comorbidities and medications.

CONCLUSIONS

Demographics and factors including fall/fracture history, comorbidities, and medications contribute to imminent risk of fracture in elderly patients.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures.

RECENT FINDINGS

Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Comparison of Teriparatide and Denosumab in Patients Switching From Long-Term Bisphosphonate Use

CONTEXT

Teriparatide and denosumab are effective treatments for osteoporosis and typically reserved as second-line options after patients have used bisphosphonates. However, limited head-to-head comparative effectiveness data exist between teriparatide and denosumab.

OBJECTIVE

We compared changes in bone mineral density (BMD) between groups treated with teriparatide or denosumab after using bisphosphonates, focusing on the change in BMD while on either drug over 2 years.

DESIGN

Observational cohort study using electronic medical records from two academic medical centers in the United States.

PARTICIPANTS

The study population included osteoporotic patients >45 years who received bisphosphonates >1 year before switching to teriparatide or denosumab.

OUTCOME MEASURES

Annualized BMD change from baseline at the lumbar spine, total hip, and femoral neck.

RESULTS

Patients treated with teriparatide (n = 110) were compared with those treated with denosumab (n = 105); the mean (SD) age was 70 (10) years and median duration (interquartile range) of bisphosphonate use was 7.0 (5.6 to 9.7) years. Compared with denosumab users, teriparatide users had higher annualized BMD change at the spine by 1.3% (95% CI 0.02, 2.7%) but lower at the total hip by -2.2% (95% CI -2.9 to -1.5%) and the femoral neck by -1.1% (95% CI -2.1 to -0.1%). Those who switched to teriparatide had a transient loss of hip BMD for the first year, with no overall increase in the total hip BMD over 2 years.

CONCLUSIONS

Among patients who use long-term bisphosphonates, the decision of switching to teriparatide should be made with caution, especially for patients at high risk of hip fracture.

Low rate of densitometric diagnosis and treatment in patients with severe osteoporosis in Colombia

Our study describes the clinical characteristics of patients with fragility fractures. It also shows there is a low knowledge about osteoporosis and its relation to fractures, in addition to the very poor adherence to medical advice and treatment.

INTRODUCTION

Osteoporosis is a systemic skeletal disease associated with an increased risk of fragility fractures and is a public health problem worldwide due to population aging. Early osteoporosis diagnosis and treatment is very important for reducing the incidence of fragility fractures and the resulting complications. Our study describes the clinical characteristics of patients with fragility fractures and their risk factors, evaluates the level of knowledge that patients have about osteoporosis, and follows-up on each case to establish if, after the fracture, a densitometric diagnosis was made and the patient received specific treatment in his outpatient follow-up through his health insurance plan.

METHODS

A descriptive cross-sectional study was carried out in a university hospital in Bogotá, Colombia. The data was collected by means of a questionnaire, administered to all patients admitted by the orthopedic emergency department with a diagnosis of fragility fracture. After discharge, a telephone follow-up was done every 3 months for 1 year, and patients were asked if they had already had the dual X-ray absorptiometry (DXA) scan and if they had begun osteoporosis treatment.

RESULTS

A total of 111 patients with an average age of 74.4 years (± 11.3 years), of which 84 (75.6%) were women, all consulted for osteoporotic fracture at the orthopedic emergency department of the hospital. Hip fracture was the most frequent (51.4%), followed by vertebral (23.4%), wrist (22.5%), and humerus (4.5%) fracture. A total of 49.5% (n = 55) of the patients did not know what osteoporosis is; 58.6% (n = 65) did not know that fracture is the main complication of this disease, and 62.2% (n = 69) did not associate fractures with osteoporosis. All patients were educated about osteoporosis and the importance of diagnosing and treating it. Patients were given a medical order to have a DXA scan upon discharge; however, only 24.3% (n = 27) had the DXA scan in the first year of the fracture. A total of 33.3% (n = 37) received calcium plus vitamin D, and only 9.9% (n = 11) received osteoporosis treatment (7 bisphosphonate patients and 4 denosumab). No patient received osteoformative therapy.

CONCLUSIONS

Our study shows that Colombian patients have little knowledge about osteoporosis and its relationship with fragility fractures. It also shows that densitometries are not done and, what is worse, patients with a diagnosis of fracture have limited access to treatment after discharge.

Higher rates of osteoporosis treatment initiation and persistence in patients with newly diagnosed vertebral fracture when introduced in inpatients than later in outpatients

Whether in-hospital management of patients with newly identified vertebral fractures leads to a higher rate of osteoporosis medication than delayed outpatient management remains unknown. Our study showed that early osteoporosis therapy initiation in a fracture liaison service during hospital stay was a more efficacious strategy for secondary fracture prevention.

INTRODUCTION

Fracture liaison services are standard care for secondary fracture prevention. A higher rate of osteoporosis treatment initiation may be considered when introduced in the hospital rather than an outpatient recommendation to a primary care physician (PCP). Whether this applies to patients with newly detected vertebral fractures in a general internal medicine ward remains unknown. We prospectively investigated whether in-hospital management of newly identified vertebral fractures led to a higher rate of osteoporosis medication initiation and persistence at 3 and 6 months than delayed outpatient management by a PCP.

METHODS

We conducted a prospective study including hospitalized patients > 60 years systematically searched for asymptomatic vertebral fractures on lateral chest and/or abdominal radiographs. Patients were included either in phase 1 (outpatient care recommendations on osteoporosis management to a PCP) or in phase 2 (inpatient care management initiated during hospitalization). The percentage of patients under osteoporosis treatment was evaluated by telephone interview at 3 and 6 months.

RESULTS

Outpatients' (84 with fracture/407 assessed (21%); 75.7 ± 7.7 years) and inpatients' (100/524 (19%); 77.8 ± 9.4 years) characteristics were similar. Osteoporosis medication was more often prescribed in inpatients at 3 (67% vs. 19%, respectively; p < 0.001) and 6 months (69 vs. 27%, respectively; p < 0.001). The percentage under treatment was also higher in inpatients than in outpatients at 3 (52 vs. 19%, p < 0.001) and 6 months (54 vs. 22%, p < 0.001). Length of stay and destination post-discharge were not different between groups.

CONCLUSIONS

Early patient management after a newly detected vertebral fracture during hospitalization was a more efficacious strategy of secondary fracture prevention than delayed outpatient management following discharge.

Fracture liaison programs

In view of the high imminent risk of having subsequent fractures after a fracture, early evaluation and treatment decisions to prevent subsequent fractures are advocated. After a hip fracture, the fracture liaison service (FLS) and orthogeriatric care are considered the most appropriate organisational approaches for secondary fracture prevention following a recent fracture. Their introduction and implementation have been shown to increase evaluation and treatment of patients at high risk for subsequent fracture. Of real-world cohort studies, most, but not all studies, indicate a lower incidence of fracture and longer survival after treatment with nitrogen-containing bisphosphonates.

Healthcare Policy Changes in Osteoporosis Can Improve Outcomes and Reduce Costs in the United States

In the United States, osteoporosis affects over 10 million adults, has high societal costs ($22 billion in 2008), and is currently being underdiagnosed and undertreated. Given an aging population, this burden is expected to rise. We projected the fracture burden in US women by modeling the expected demographic shift as well as potential policy changes. With the anticipated population aging and growth, annual fractures are projected to increase from 1.9 million to 3.2 million (68%), from 2018 to 2040, with related costs rising from $57 billion to over $95 billion. Policy‐driven expansion of case finding and treatment of at‐risk women could lower this burden, preventing 6.1 million fractures over the next 22 years while reducing payer costs by $29 billion and societal costs by $55 billion. Increasing use of osteoporosis‐related interventions can reduce fractures and result in substantial cost‐savings, a rare and fortunate combination given the current landscape in healthcare policy. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Use of antiosteoporotic drugs and calcium/vitamin D in patients with fragility fractures: impact on re-fracture and mortality risk

PURPOSE

To evaluate the impact of pharmacological treatment in osteoporosis patients with recent fracture and to assess the incidence of subsequent fracture and all-cause mortality.

METHODS

This observational retrospective study was based on data from administrative databases of five Italian Local Health Units. Osteoporosis patients aged ≥ 50 years with hospitalization for vertebral or hip fracture occurring between 01/01/2011 and 31/12/2015 were included. Treatment adherence was calculated using the medication possession ratio. Multivariable proportional hazard Cox model was used to identify factors associated with time to re-fracture and all-cause mortality.

RESULTS

A cohort of 3475 patients were included and 41.5% of them did not receive any specific anti-fracture treatment. Among treated patients (N = 2032), the majority (83.6%) received calcium/vitamin D supplementation. Over a mean follow-up of 3 years, the risk of subsequent fractures was 44.4% lower in treated patients compared to untreated ones (HR = 0.556, 95% CI = 0.420-0.735, p < 0.001) and 64.4% lower in those receiving calcium/vitamin D supplementation compared to osteoporosis treatment only (HR = 0.356, 95% CI = 0.237-0.533, p < 0.001). The risk of re-fracture was 77.2% lower in treated patients who were adherent to medication (HR = 0.228, 95% CI = 0.139-0.376, p < 0.001). Treated patients had 64% lower mortality risk over the follow-up compared to untreated ones (HR = 0.360, 95% CI = 0.310-0.418, p < 0.001).

CONCLUSIONS

A consistent proportion of osteoporosis patients did not receive specific treatment after a fracture, showing poor adherence to national guidelines on osteoporosis treatment. Osteoporosis drug treatment, and to a greater extent in combination with calcium/vitamin D, and adherence were correlated with lower risk of both re-fracture and all-cause mortality.

Risk of subsequent fracture after prior fracture among older women

Among 377,561 female Medicare beneficiaries who sustained a fracture, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years. Timely management to reduce risk of subsequent fracture is warranted following all nontraumatic fractures, including nonhip nonvertebral fractures, in older women.

INTRODUCTION

Prior fracture is a strong predictor of subsequent fracture; however, postfracture treatment rates are low. Quantifying imminent (12-24 month) risk of subsequent fracture in older women may clarify the need for early postfracture management.

METHODS

This retrospective cohort study used Medicare administrative claims data. Women ≥ 65 years who sustained a clinical fracture (clinical vertebral and nonvertebral fracture; index date) and were continuously enrolled for 1-year pre-index and ≥ 1-year (≥  2 or ≥ 5 years for outcomes at those time points) post-index were included. Cumulative incidence of subsequent fracture was calculated from 30 days post-index to 1, 2, and 5 years post-index. For appendicular fractures, only those requiring hospitalization or surgical repair were counted. Death was considered a competing risk.

RESULTS

Among 377,561 women (210,621 and 10,969 for 2- and 5-year outcomes), cumulative risk of subsequent fracture was 10%, 18%, and 31% at 1, 2, and 5 years post-index, respectively. Among women age 65-74 years with initial clinical vertebral, hip, pelvis, femur, or clavicle fractures and all women ≥ 75 years regardless of initial fracture site (except ankle and tibia/fibula), 7-14% fractured again within 1 year depending on initial fracture site; risk rose to 15-26% within 2 years and 28-42% within 5 years. Risk of subsequent hip fracture exceeded 3% within 5 years in all women studied, except those < 75 years with an initial tibia/fibula or ankle fracture.

CONCLUSIONS

We observed a high and early risk of subsequent fracture following a broad array of initial fractures. Timely management with consideration of pharmacotherapy is warranted in older women following all fracture types evaluated.

Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature

Fracture liaison services (FLS), implemented in different ways and countries, are reported to be a cost-effective or even a cost-saving secondary fracture prevention strategy. This presumed favorable cost-benefit relationship is encouraging and lends support to expanded implementation of FLS per International Osteoporosis Foundation Best Practice Standards. This study summarizes the economic impact and cost-effectiveness of FLS implemented to reduce subsequent fractures in individuals with osteoporosis. This systematic review identified studies reporting economic outcomes for FLS in osteoporotic patients aged 50 and older through a comprehensive search of MEDLINE, EMBASE, Cochrane Central, and PubMed of studies published January, 2000 to December, 2016. Grey literature (e.g., Google scholar, conference abstracts/posters) were also hand searched through February 2017. Two independent reviewers screened titles and abstracts and conducted full-text review on qualified articles. All disagreements were resolved by discussion between reviewers to reach consensus or by a third reviewer. In total, 23 qualified studies that evaluated the economic aspects of FLS were included: 16 cost-effectiveness studies, 2 cost-benefit analyses, and 5 studies of cost savings. Patient populations varied (prior fragility fracture, non-vertebral fracture, hip fracture, wrist fracture), and FLS strategies ranged from mail-based interventions to comprehensive nurse/physician-coordinated programs. Cost-effectiveness studies were conducted in Canada, Australia, USA, UK, Japan, Taiwan, and Sweden. FLS was cost-effective in comparisons with usual care or no treatment, regardless of the program intensity or the country in which the FLS was implemented (cost/QALY from $3023-$28,800 US dollars (USD) in Japan to $14,513-$112,877 USD in USA. Several studies documented cost savings. FLS, implemented in different ways and countries, are reported to be cost-effective or even cost-saving. This presumed favorable cost-benefit relationship is encouraging and lends support to expanded implementation of FLS per International Osteoporosis Foundation Best Practice Standards.

Frequency of Bone Health Presentations at National Hand Meetings

PURPOSE

The purpose of this study was to determine the frequency with which osteoporosis topics (screening, medical treatment, and fracture prevention) are presented at national hand surgery meetings. This was compared with the frequency of the same topics presented at the Orthopaedic Trauma Association (OTA) annual meetings.

METHODS

The annual meeting programs for the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the OTA from the previous 10 years (2007-2016) were searched for presentations that covered bone health at each of these meetings. We categorized the presentations as either instructional or research.

RESULTS

There were 2 bone health instructional presentations at hand surgery meetings in contrast to 13 presentations at OTA meetings over the last 10 years. For the last 9 years, the OTA has featured at least 1 instructional presentation on bone health every year. We identified 11 research presentations at the hand surgery meetings compared with 16 at the OTA meetings.

CONCLUSIONS

Osteoporosis and bone health are infrequently presented instructional topics at national hand meetings compared with OTA meetings. The cause of the difference is unclear and likely multifactorial, varying each year with different program chairs and committees. The level of involvement of hand surgeons in osteoporosis management is controversial; however, incorporation of this topic may stimulate discussion and help identify solutions for this controversy.

CLINICAL RELEVANCE

It may benefit hand surgeons to place more importance on osteoporosis screening and treatment. We believe that there should be an annual instructional course on this topic at the ASSH and AAHS meetings.