Healthcare Resource Utilization and Direct Medical Costs for Patients With Osteoporotic Fractures in China

Prediction of Bone Mineral Density based on Computer Tomography Images Using Deep Learning Model

INTRODUCTION

The problem of population aging is intensifying worldwide. Osteoporosis has become an important cause affecting the health status of older populations. However, the diagnosis of osteoporosis and people's understanding of it are seriously insufficient. We aim to develop a deep learning model to automatically measure bone mineral density (BMD) and improve the diagnostic rate of osteoporosis.

METHODS

The images of 801 subjects with 2,080 vertebral bodies who underwent chest or abdominal paired computer tomography (CT) and quantitative computer tomography (QCT) scanning was retrieved from June 2020 to January 2022. The BMD of T11-L4 vertebral bodies was measured by QCT. Developing a multistage deep learning-based model to simulate the segmentation of the vertebral body and predict BMD. The subjects were randomly divided into training dataset, validation dataset and test dataset. Analyze the fitting effect between the BMD measured by the model and the standard BMD by QCT. Accuracy, precision, recall and f1-score were used to analyze the diagnostic performance according to categorization criterion measured by QCT.

RESULTS

410 males (51.2%) and 391 females (48.8%) were included in this study. Among them, there were 154 (19.2%) males and 118 (14.7%) females aged 23-44; 182 (22.7%) males and 205 (25.6%) females aged 45-64; 74 (9.2%) males and 68 (8.5%) females aged 65-84. The number of vertebral bodies in the training dataset, the validation dataset, and the test dataset was 1433, 243, 404, respectively. In each dataset, the BMD of males and females decreases with age. There was a significant correlation between the BMD measured by the model and QCT, with the coefficient of determination (R2) 0.95-0.97. The diagnostic accuracy based on the model in the three datasets was 0.88, 0.91, and 0.91, respectively.

CONCLUSION

The proposed multistage deep learning-based model can achieve automatic measurement of vertebral BMD and performed well in the prediction of osteoporosis.

Understanding the long-term impact of incident osteoporotic fractures on healthcare utilization and costs in Korean postmenopausal women

This study provides long-term evidence that healthcare resource utilization and costs of care in women who experienced incident osteoporotic fractures remained higher than those in women without fractures over a span of 5 years. These findings emphasize the importance of early diagnostics and treatment for osteoporosis.

PURPOSE

To evaluate healthcare resource utilization (HCRU) and costs of care over 5 years after the incident osteoporotic fractures (OF) in postmenopausal women.

METHODS

We used data from the National Health Insurance Service databases 2011-2018. Women aged ≥ 50 years with incident OF (OF group) were matched to women without OF (non-OF group). HCRU (inpatient, outpatient, and emergency room [ER] visits) and costs of care (inpatient, outpatient, and ER visits) during the 5-year follow-up period were derived after propensity score matching (PSM). Additionally, we identified women with subsequent fractures within the first 2 years after the incident OF.

RESULTS

After PSM, 47,238 OF and 134,813 non-OF women were identified. HCRU rates and costs of care were highest in the first year after OF and decreased substantially, but remained higher in the OF group during the entire follow-up period. The increase in cumulative HCRU rates over 5 years was highest in inpatient admissions with ER visits (138% higher in OF vs non-OF). The cumulative total costs over 5 years were 73% higher in the OF group than in the non-OF group, which was mostly driven by inpatient costs. Trends were similar for women with subsequent fractures, but they generally showed higher HCRU and costs than those in the total OF group.

CONCLUSION

OF imposes a substantial and sustained economic burden on women, resulting in an approximately twofold increase in the cumulative cost over 5 years compared to women without fracture, which highlights the need for early diagnostics and treatment of osteoporosis.

Cost Effectiveness of Denosumab for Secondary Prevention of Osteoporotic Fractures Among Postmenopausal Women in China: An Individual-Level Simulation Analysis

OBJECTIVE

This study evaluated the cost effectiveness of denosumab versus alendronate for secondary prevention of osteoporotic fractures among post-menopausal women in China.

METHODS

A validated individual-level simulation model of osteoporotic fractures in the Chinese setting was adapted. Allowing both treatment discontinuation and waning effects, the analysis aimed to evaluate the incremental cost-effectiveness ratio of denosumab compared to alendronate by simulating a cohort of previously fractured individuals over the residual lifetime from the healthcare system perspective. Hip, vertebral, and wrist/humeral fractures were tracked along with the associated medical costs and quality-adjusted life-years. Age-related health state utility values, health state utility values of fractures, costs, fracture incidence, and mortality risks for Chinese were used whenever available. Comparative effectiveness data were obtained from a published network meta-analysis. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

In the base case, denosumab was dominated by alendronate with incremental costs of CN¥2743 (US$425) and incremental health outcomes of - 0.20 quality-adjusted life-years at its current price in mainland China. It remained dominated in all one-way sensitivity analysis robustness checks. However, denosumab was cost effective if both drugs did not carry any waning effects. In the probabilistic sensitivity analysis, denosumab remained dominated in all replications.

CONCLUSIONS

Denosumab is not cost effective for preventing secondary fractures among overall postmenopausal women in China. It is advisable to identify alternative denosumab regimens for high-risk subgroups among previously fractured postmenopausal women.

Proximity to major roads and the incidence of osteoporotic fractures in elderly women: The BONE study in Beijing

BACKGROUND

There is growing evidence to suggest that living near major roads (and suffering from the air pollution of urban streets) can have an adverse effect on bone health. However, little is known about its relationship to fractures caused by osteoporosis.

OBJECTIVE

This study was designed to investigate the relationship between residents living near major roads and the incidence of osteoporotic fractures.

METHODS

A retrospective cohort of 529 subjects was established based on community populations in older women aged 65-91. All participants lived in Beijing between September 27, 2007 and September 26, 2017. The distance between the residential sites of the subjects and the main roads was determined by the authors. Osteoporotic fracture diagnosis was based on medical histories and imaging examinations (DXA and X-rays). The Cox proportional hazard model was used to assess the association between traffic proximity and osteoporotic fractures, with suitable adjustments for individual and background factors.

RESULTS

The age range of all participants was 65-91 years, with an average age of 75.8 years (and a standard deviation 6.8 years). Of these, 19 (3.59%) suffered from diabetes, and 48 (9%) had hypertension; 85 (14%) families had annual incomes below US $30,000 and 402 (76%) had received a secondary school education or higher. Nearly 25% of people lived within 50 m of a main road, while 50% lived within 300 m. Between 2007 and 2017, a total of 96 osteoporotic fractures were observed. For people living <50 m from a main road, the adjusted hazard ratio (HR) for osteoporotic fractures was 2.509 (95% CI 1.345-4.680), while it was 1.830 (95% CI 1.029-3.255) for those living at a distance of 50-300 m from a main road vs. those living further than 300 m away.

CONCLUSION

In this community-based cohort, living near a major road was associated with a higher incidence of osteoporotic fractures.

Opportunistic osteoporosis screening using chest CT with artificial intelligence

Osteoporosis has a high incidence and a low detection rate. If it is not detected in time, it will cause osteoporotic fracture and other serious consequences. This study showed that the attenuation values of vertebrae on chest CT could be used for opportunistic screening of osteoporosis. This will be beneficial to improve the detection rate of osteoporosis and reduce the incidence of adverse events caused by osteoporosis.

INTRODUCTION

To explore the value of the attenuation values of all thoracic vertebrae and the first lumbar vertebra measured by artificial intelligence on non-enhanced chest CT to do osteoporosis screening.

METHODS

On base of images of chest CT, using artificial intelligence (AI) to measure the attenuation values (HU) of all thoracic and the first vertebrae of patients who underwent CT examination for lung cancer screening and dual-energy X-ray absorptiometry (DXA) examination during the same period. The patients were divided into three groups: normal group, osteopenia group, and osteoporosis group according to the results of DXA. Clinical baseline data and attenuation values were compared among the three groups. The correlation between attenuation values and BMD values was analyzed, and the predictive ability and diagnostic efficacy of attenuation values of thoracic and first lumbar vertebrae on osteopenia or osteoporosis risk were further evaluated.

RESULTS

CT values of each thoracic vertebrae and the first lumbar vertebrae decreased with age, especially in menopausal women and presented high predictive ability and diagnostic efficacy for osteopenia or osteoporosis. After clinical data correction, with every 10 HU increase of CT values, the risk of osteopenia or osteoporosis decreased by 32 ~ 44% and 61 ~ 80%, respectively. And the combined diagnostic efficacy of all thoracic vertebrae was higher than that of a single vertebra. The AUC of recognizing osteopenia or osteoporosis from normal group was 0.831and 0.972, respectively.

CONCLUSIONS

The routine chest CT with AI is of great value in opportunistic screening for osteopenia or osteoporosis, which can quickly screen the population at high risk of osteoporosis without increasing radiation dose, thus reducing the incidence of osteoporotic fracture.

Orthopedic Patients with Mental Disorder: Literature Review on Preoperative and Postoperative Precautions

Because of the increasing global trend of patients with mental disorders, orthopedic surgeons are more likely to encounter orthopedic patients with mental disorders in clinical settings. Identifying the characteristics of these patients and implementing psychiatric management can affect the clinical outcome of orthopedic treatment. Thus, orthopedic surgeons need to assess the psychiatric medical history of orthopedic patients with mental disorders before surgery and understand the psychological and behavioral patterns of patients with mental disorders. In addition, appropriate psychiatric consultations and evaluations are necessary to prevent worsening of mental disorders before and after surgery.

Secular trends in the incidence of fracture hospitalization between 2000 and 2015 among the middle-aged and elderly persons in Taiwan: A nationwide register-based cohort study

OBJECTIVE

Fractures are a common reason for hospital admissions. However, regional and short-term studies show a varying incidence rate (IR) of fractures, and most of the surveys were conducted from only a few medical centers. Therefore, this study aims to investigate the epidemiological data of fracture hospitalizations of middle-aged and elderly persons in Taiwan between 2000 and 2015.

MATERIALS AND METHODS

Data from fractures occurring between 2000 and 2015 were obtained from the National Health Insurance Research Database in Taiwan for this study. The IR of fracture admission in patients, aged 40 years or older at the time of admission and first-time diagnosed with a fracture following admission, was calculated.

RESULTS

We found that the IR of the fracture hospitalizations declined considerably from 95.70 per 10,000 person-years in 2000, to 68.48 per 10,000 person-years in 2015. The three most common fracture hospitalizations accounting for more than 50% of all fractures were fractures of the femur/hip, radius or ulna, and vertebral column. The IR of fracture hospitalization increased with age and was found to be higher in women than in men. The most common cause of fracture hospitalization for men and patients under 65 years of age was traffic accidents. In contrast, falls were the most frequent causes of fracture hospitalization for women and patients over 65 years of age.

CONCLUSION

The present study furnishes an updated picture of the incidence of fracture hospitalization over a 16-year period among middle-aged and elderly persons in Taiwan.

Sociodemographic and health system factors associated with variations in hospitalization costs for fractures in adults aged 45 years and over: a cross-sectional study of provincial health accounts in Jiangsu Province, China

This study reports hospitalization costs of fracture in Chinese patients aged over 45 years and evaluates their related factors in different fracture groups.

PURPOSE

To report hospitalization costs of treating fractures in Chinese patients aged over 45 years and to investigate the sociodemographic and health system factors related to variation in the costs.

METHODS

Study participants were selected from the 2016 Health Accounts Database in Jiangsu in which patients' hospitalization costs were kept at various levels in hospitals. A multi-stage stratified sampling method was used to select study participants. Electronic medical records of patients aged 45 years and over with fractures were included. The International Classification of Diseases, Tenth Revision (ICD-10) was used to identify patients who were hospitalized due to fractures. A generalized linear model was used to estimate the extent to which a range of health system and sociodemographic factors were associated with the variation on hospitalization costs. Costs data were presented and analyzed using 2016 U.S. dollars.

RESULTS

A total of 39,300 patients were included in the study. Vertebra, tibia/fibula, and hip were the most frequent fracture sites. The mean (median) of hospitalization cost of included fractures ranged from USD 3142 (USD 2420) for hand and wrist fractures to USD 10,355 (USD 9673) for hip fractures. Longer length of hospital stay, higher hospital level, and being covered by a health insurance were associated with higher hospitalization costs for all fracture types.

CONCLUSION

Our study reports hospital costs of the fracture using a large health accounts database in China and investigates the associated factors of hospital costs. Our results may inform cost-of-illness studies and economic evaluations of fracture preventions.

Annual out-of-pocket expenditure associated with healthcare use among Australian older women with osteoporosis: a cross-sectional study

This research aimed to determine the health care cost and utilisation of older Australian women with osteoporosis. A wide range of healthcare services were used and approximately AU$593.9 was spent over a 12-month period for these services. This highlights the significant cost burden of osteoporosis on the healthcare system.

PURPOSE

Osteoporosis is a common skeletal condition among women that has a considerable impact on quality of life. The purpose of this study is to determine the prevalence of healthcare use and to estimate associated out-of-pocket expenditure for the management of osteoporosis in older Australian women.

METHODS

Data was obtained from 393 Australian women from the 45 and Up Study who had osteoporosis. The women were asked about healthcare use for their osteoporosis, including conventional medicine, complementary medicine, and self-care practices or self-care products, and associated out-of-pocket expenditure for that use over 12 months.

RESULTS

The average age of participants was 72.0 years. Over a 12-month period, the majority of participants (72%) consulted a doctor for their osteoporosis, 24% consulted an allied health practitioner, and 20% consulted a complementary medicine practitioner. Participants had a mean of 6.8 consultations with healthcare practitioners in the previous 12 months for the osteoporosis. In addition, 46% participants used three or more types of complementary medicine products/practices in the previous 12 months. Overall, the participants incurred a (arithmetic) mean ofAU$594 (median = $350; inter-quartile range = $450) in out-of-pocket expenditure for healthcare use over the 12-month period.

CONCLUSIONS

Women with osteoporosis use a wide range of healthcare services that are associated with significant annual out-of-pocket expenditure. Preventive strategies can help decrease the cost burden of osteoporosis on the healthcare system.

Population-based Analysis for Risk of Suicide Death in Elderly Patients after Osteoporotic Fracture: a Nested Case-Control Study

BACKGROUND

The purpose of study was to investigate the incidence rate of suicide in elderly patients with osteoporotic fractures in a nested case-control model and to analyze the change in the risk of suicide death over time after each osteoporotic fracture.

METHODS

We used the National Health Insurance Service-Senior cohort of South Korea. Suicide cases and controls were matched based on sex and age at the index date. Controls were randomly selected at a 1:5 ratio from the set of individuals who were at risk of becoming a case at the time when suicide cases were selected. Conditional logistic regression analysis was performed to evaluate the association between each type of osteoporotic fracture and the risk of suicide death.

RESULTS

Three thousand seventy suicide cases and 15,350 controls were identified. Patients with hip fracture showed an increased risk of suicide death within 1 year of fracture (adjusted odds ratio [aOR] = 2.64; 95% confidence interval [CI], 1.57-4.46; P < 0.001) compared to controls. However, the increased risk of suicide death in patients with hip fracture lasted up to 2 years (aOR = 1.59; 95% CI, 1.04-2.41; P = 0.031). Spine fracture increased the risk of suicide deaths for all observation periods. There was no evidence that humerus fracture increased the risk of suicide death during the observational period. Radius fracture increased only the risk of suicide death within 2 years of fracture (aOR = 1.43; 95% CI, 0.74-2.77; P = 0.282).

CONCLUSION

There were noticeable differences in both degree and duration of increased suicide risks depending on the type of osteoporotic fracture. Mental stress and suicide risk in elderly patients after osteoporotic fracture should be assessed differently depending on the types of fracture.

Aging and direct medical costs of osteoporotic fractures

INTRODUCTION

This study estimated the direct medical costs of osteoporotic fractures from a large claims database in Korea.

MATERIALS AND METHODS

We compared the medical costs of hip, vertebral, and wrist fractures between two age groups (50-64 years vs 65 years and older). We used a generalized linear model to investigate the drivers of osteoporotic fracture medical costs.

RESULTS

Hip fractures had the highest costs, regardless of age, followed by vertebral and wrist. The cost of hip fracture was USD 7285 for those aged 65 years and over and USD 6589 for those aged 50-64 years. The length of hospital days was higher in hip fracture patients, regardless of age, followed by vertebral and wrist. As the number of hospitalizations increased, the medical cost increased by 33.0% (p < 0.0001). Patients older than 65 years who were hospitalized for a fracture had a longer total length of hospital stay, compared to patients aged 50-64, regardlessness of the site of the fracture. The cost of treating fractures among those 65 years and older increased by 31.8% compared to those 50-64 years old (p < 0.0001). The direct medical costs increased by 8.6% as the number of fractures increased (p = 0.041).

CONCLUSIONS

We identified that osteoporotic fracture-related medical costs and hospitalization days increased with age. Interventions are effective in reducing fracture risk the potential to yield substantial cost savings.

The Influence of Renal Dialysis on All-Cause Mortality in Older Patients with Hip Fracture: a Korean Nationwide Cohort Study

BACKGROUND

The purpose of this study was to analyze the all-cause mortality rate over time after elderly hip fracture in end-stage renal disease (ESRD) patients with dialysis, using a Korean nationwide claims database.

METHODS

This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Senior cohort (NHIS-Senior). The NHIS-Senior (total of 588,147 participants) was constructed by 10% random sampling and was designed to represent the elderly living in Korea. Subjects were patients aged 65-99 years who underwent surgical treatment for femoral neck fractures or intertrochanteric fractures. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) to measure associations between renal dialysis and cumulative mortality in various time frames.

RESULTS

The total number of patients included in this study was 16,818. These patients were divided into two groups: 116 (0.69%) in the dialysis group and 16,702 (99.31%) in the no-dialysis group. The mean length of hospital stay was 43.87 ± 48.45 days in the dialysis group and 36.29 ± 37.49 days in the no-dialysis group (P = 0.095). The effect of renal dialysis on all-cause mortality was 2.29-fold (aRR; 95% CI, 1.29-4.06; P = 0.005) within 30 days and 1.72-fold (aRR; 95% CI, 1.34-2.21; P < 0.001) within 1-year after hip fracture compared to the no-dialysis group. And, the effect of renal dialysis of in-hospital mortality was 2.72-fold (aRR; 95% CI, 1.71-4.33; P < 0.001) compared to the no-dialysis group.

CONCLUSION

Elderly patients who underwent dialysis have very high mortality rates after hip fracture. Therefore, it is considered that postoperative care through multidisciplinary management and understanding of pathophysiology for the ESRD patients is necessary.

Suicide in Elderly Patients with Hip Fracture: A South Korean Nationwide Cohort Study

BACKGROUND

The purpose of the present study was to evaluate the incidence rate (IR) of suicide in elderly patients with hip fracture on the basis of a nationwide cohort and to analyze the change in the hazard ratio for suicide after hip fracture over time in comparison with a control group.

METHODS

Patients with hip fracture and their matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of the Republic of Korea. The NHIS-Senior consists of 558,147 people selected by a 10% simple random-sampling method from a total of 5.5 million subjects ≥60 years of age in 2002. Risk-set matching (1:2) on the propensity score was performed with use of a nearest neighbor matching algorithm with a maximum caliper of 0.1 for the hazard components. The IR of suicide and 95% confidence interval (CI) were calculated on the basis of a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) with use of the Cox proportional-hazard model with a robust variance estimator that accounts for clustering within matched pairs.

RESULTS

A total of 11,477 patients with hip fracture and 22,954 matched controls were included. The mean duration of follow-up was 4.59 years, generating 158,139 person-years. During follow-up, a total of 170 suicides were identified. Comparisons at up to 180 days and 365 days showed that patients with hip fracture were at higher risk for suicide than matched controls (p = 0.009 and 0.004, respectively; stratified log-rank test). During the first 180 days of follow-up, 14 suicides were identified in patients with hip fracture during 11,152 person-years (IR, 266.1 per 100,000 person-years; 95% CI, 157.6 to 449.4). Patients with hip fracture were 2.97 times more likely to kill themselves than their matched controls during the same period (HR = 2.97; 95% CI, 1.32 to 6.69).

CONCLUSIONS

Hip fracture in elderly patients increased suicide risk within a year. A new approach to psychiatric evaluation and management is needed in elderly patients with hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Automatic opportunistic osteoporosis screening using low-dose chest computed tomography scans obtained for lung cancer screening

Objective

Osteoporosis is a prevalent and treatable condition, but it remains underdiagnosed. In this study, a deep learning-based system was developed to automatically measure bone mineral density (BMD) for opportunistic osteoporosis screening using low-dose chest computed tomography (LDCT) scans obtained for lung cancer screening.

Methods

First, a deep learning model was trained and tested with 200 annotated LDCT scans to segment and label all vertebral bodies (VBs). Then, the mean CT numbers of the trabecular area of target VBs were obtained based on the segmentation mask through geometric operations. Finally, a linear function was built to map the trabecular CT numbers of target VBs to their BMDs collected from approved software used for osteoporosis diagnosis. The diagnostic performance of the developed system was evaluated using an independent dataset of 374 LDCT scans with standard BMDs and osteoporosis diagnosis.

Results

Our deep learning model achieved a mean Dice coefficient of 86.6% for VB segmentation and 97.5% accuracy for VB labeling. Line regression and Bland-Altman analyses showed good agreement between the predicted BMD and the ground truth, with correlation coefficients of 0.964–0.968 and mean errors of 2.2–4.0 mg/cm³. The area under the curve (AUC) was 0.927 for detecting osteoporosis and 0.942 for distinguishing low BMD.

Conclusion

The proposed deep learning-based system demonstrated the potential to automatically perform opportunistic osteoporosis screening using LDCT scans obtained for lung cancer screening.

Key Points

• Osteoporosis is a prevalent but underdiagnosed condition that can increase the risk of fracture.

• A deep learning-based system was developed to fully automate bone mineral density measurement in low-dose chest computed tomography scans.

• The developed system achieved high accuracy for automatic opportunistic osteoporosis screening using low-dose chest computed tomography scans obtained for lung cancer screening.

Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service Delivery via Public-Private Partnership: Evidence from China

Private sector participation in the healthcare market via public-private partnership (PPP) could be considered an available approach to narrow down the medical resource gap and improve the operational efficiency of healthcare facilities. Accordingly, this study aims to examine the influence and relative importance among critical factors for the intention and behaviour of the private sector towards participation in Chinese healthcare market (CHM) via PPP. We defined five hypotheses from previous literature and built a theoretical model based on modified theory of planned behaviour. Then, covariance-based structural equation modelling was applied to analyse the questionnaires provided by 248 respondents from construction companies, real estate developers, pharmaceutical companies, private hospitals, asset management companies, and medical industry property investment companies in China. Results indicated that attitude towards behaviour (β = 0.466, P < 0.001), subjective norm (β = 0.167, P < 0.05), perceived behavioural control (β = 0.231, P < 0.01), and facilitating conditions (β = 0.305, P < 0.001) are positively significant to behavioural intention; behavioural intention also shows a strong linkage with behaviour (β = 0.931, P < 0.001). Findings provide reference for governments and public authorities to exert additional efforts in implementing appropriate measures that will stimulate the private sector's motivation to participate in CHM via PPP.