A fracture risk profile using single-site bone density assessment and clinical risk factors

The impact of osteoporosis on adult deformity surgery outcomes in Medicare patients

OBJECTIVE

To identify the impact of osteoporosis (OS) on postoperative outcomes in Medicare patients undergoing ASD surgery.

BACKGROUND

Patients with OP and advanced age experience higher than average rates of ASD. However, poor bone density could undermine the durability of a deformity correction.

METHODS

We queried the MarketScan Medicare Supplemental database to identify patients Medicare patients who underwent ASD surgery from 2007 to 2016.

RESULTS

A total of 2564 patients met the inclusion criteria of this study, of whom n = 971 (61.0%) were diagnosed with osteoporosis. Patients with OP had a similar 90-day postoperative complication rates (OP: 54.6% vs. non-OP: 49.2%, p = 0.0076, not significant after multivariate regression correction). This was primarily driven by posthemorrhagic anemia (37.6% in OP, vs. 33.1% in non-OP). Rates of revision surgery were similar at 90 days (non-OP 15.0%, OP 16.8%), but by 2 years, OP patients had a significantly higher reoperation rate (30.4% vs. 22.9%, p < 0.0001). In multivariate regression analysis, OP increased odds for revision surgery at 1 year (OR 1.4) and 2 years (OR 1.5) following surgery (all p < 0.05). OP was also an independent predictor of readmission at all time points (90 days, OR 1.3, p < 0.005).

CONCLUSION

Medicare patients with OP had elevated rates of complications, reoperations, and outpatient costs after undergoing primary ASD surgery.

Validation of the Cummings’ risk score; how well does it identify women with high risk of hip fracture: The Tromsø Study

OBJECTIVE

We examined a two-step case-finding strategy where the Cummings' risk score (NEJM 1995) was applied in a population-based setting together with bone mineral density (BMD) measurements in order to validate its ability to identify women with high risk of hip fracture.

METHODS

All Tromsø women aged between 65 and 74 were invited to the Tromsø Osteoporosis Study (TROST) together with a 5% random sample of women aged 75-84 years (n = 1410). All had forearm BMD measurements in 1994/95 and were followed for 5 years with respect to first hip fracture. A risk score was constructed matching the Cummings score as closely as possible.

RESULTS

In all 759, 578 and 73 women had 0-2, 3-4 and 5+ risk factors, respectively. Women with 5+ risk factors had a 5-year hip fracture risk of 11% (95% confidence interval (CI) 3.7-18.2%). BMD screening applied to these women identified 74% of them as osteoporotic and 19% as osteopenic with, respectively, 5-year hip fracture risk of 13% and 7.1%.

CONCLUSION

In a population different from the one the score was generated in, this simple risk score identifies a group of women with high risk of hip fractures. With no additional BMD measurements, those high-risk women could benefit from early intervention measures.

Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry

Mass screening for osteoporosis using DXA measurements at the spine and hip is presently not recommended by health authorities. Instead, risk factor questionnaires and peripheral bone measurements may facilitate the selection of women eligible for axial bone densitometry. The aim of this study was to validate a case finding strategy for postmenopausal women who would benefit most from subsequent DXA measurement by using phalangeal radiographic absorptiometry (RA) alone or in combination with risk factors in a general practice setting. The sensitivity and specificity of this strategy in detecting osteoporosis (T-score < or =2.5 SD at the spine and/or the hip) were compared with those of the current reimbursement criteria for DXA measurements in Switzerland. Four hundred and twenty-three postmenopausal women with one or more risk factors for osteoporosis were recruited by 90 primary care physicians who also performed the phalangeal RA measurements. All women underwent subsequent DXA measurement of the spine and the hip at the Osteoporosis Policlinic of the University Hospital of Berne. They were allocated to one of two groups depending on whether they matched with the Swiss reimbursement conditions for DXA measurement or not. Logistic regression models were used to predict the likelihood of osteoporosis versus "no osteoporosis" and to derive ROC curves for the various strategies. Differences in the areas under the ROC curves (AUC) were tested for significance. In women lacking reimbursement criteria, RA achieved a significantly larger AUC (0.81; 95% CI 0.72-0.89) than the risk factors associated with patients' age, height and weight (0.71; 95% C.I. 0.62-0.80). Furthermore, in this study, RA provided a better sensitivity and specificity in identifying women with underlying osteoporosis than the currently accepted criteria for reimbursement of DXA measurement. In the Swiss environment, RA is a valid case finding tool for patients with risk factors for osteoporosis, especially for those who do not qualify for DXA reimbursement.

Comparison of heel ultrasound and finger DXA to central DXA in the detection of osteoporosis. Implications for patient management

The goal of the study was to investigate the potential discordance in patient management when a clinician assumes that a peripheral device is a diagnostic surrogate for central DXA in the detection and treatment of osteoporosis. Over a period of 2 mo, asymptomatic women seeking conventional central DXA evaluation for osteoporosis at a diagnostic imaging center were also evaluated with heel ultrasound and finger DXA peripheral imaging devices. T-Scores of -2.5 or less in screening examinations were used to evaluate the discordance between the two peripheral devices and central DXA in the identification of patients with osteoporosis. Higher T-score cutoffs (>-2.5) were also evaluated. Using central DXA as the standard for comparison, the sensitivity of heel ultrasound for screening cases was 0.34 and specificity was 0.92. For finger DXA, sensitivity was 0.23 and specificity was 0.92. Overall discordance between the peripheral devices and central DXA was 21% (heel) and 23% (finger). Heel ultrasound identified 7 out of every 22 osteoporotic patients diagnosed with central DXA. Finger DXA identified 5 out of every 22 osteoporotic patients. Using lower T-scores for the peripheral devices increased sensitivity but markedly increased discordance with DXA. The peripheral devices we studied cannot be considered equivalent surrogates for central DXA in the screening of asymptomatic women for osteoporosis.

Bone mineral density testing in healthy postmenopausal women. The role of clinical risk factor assessment in determining fracture risk

The ease of measurement and the quantitative nature of bone mineral densitometry (BMD) is clinically appealing. Despite BMD's proven capability to stratify fracture risk, data indicate that clinical risk factors provide complementary information on fracture susceptibility that is independent of BMD. Methods to quantify fracture risk using both clinical and BMD variables would have great appeal for clinical decision-making. We describe a procedure for quantifying hip fracture risk (5-yr and remaining lifetime) based on (1) the individual's age alone (base model, assuming average clinical risk factors and bone density), (2) incorporation of multiple patient-specific clinical risk factor data in the base model, and (3) incorporation of both patient-specific clinical risk factor data and BMD results.