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

A Hip New Standard: Improving Osteoporosis Care with Inpatient Administration of IV Zoledronate

BACKGROUND

Osteoporosis continues to be underdiagnosed and inadequately treated in older hip-fracture patients. Our aim was to improve the rate of osteoporosis treatment with IV bisphosphonate therapy in eligible patients admitted for hip-fracture surgery.

METHODS

The present study was designed as a quality improvement initiative using Plan-Do-Study-Act (PDSA) cycles at an academic medical center in Portland, Oregon, over 2.5 years. A protocol was developed (1) to administer IV zoledronate on postoperative day 2 to inpatients aged ≥50 years who underwent surgery for a low-energy hip fracture and (2) to formally diagnose osteoporosis during admission. The protocol was introduced across 3 care settings in a stepped-wedge manner. Outcome measures were the percentage of inpatient zoledronate administered to eligible patients and formal documented diagnosis of osteoporosis. Balance measures included fever after administration and hospital length of stay (LOS). Measures were assessed through quarterly chart review and tracked via control charts.

RESULTS

The rate of zoledronate administration significantly increased from 34.5% (29 of 84) to 74.6% (53 of 71) following the second PDSA cycle (p < 0.001). Documented osteoporosis diagnosis also significantly improved from 51.0% (53 of 104) to 85.7% (96 of 112) following the second PDSA cycle (p < 0.001). No significant differences were shown for hospital LOS, and 1 of 82 patients had medical work-up for post-infusion acute phase reaction after administration.

CONCLUSIONS

This initiative was effective at improving osteoporosis diagnosis and treatment among older hip-fracture patients at our institution. Protocol development for administrating inpatient zoledronate after hip fracture is a reliable way to predictably offer bone health care and secondary-fracture prevention to hip-fracture patients and can be adapted and implemented at other institutions.

LEVEL OF EVIDENCE

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

Real-World Osteoporosis Treatment Gap and Costs in Spain: Data from Women with a First Fragility Fracture or Diagnosis of Postmenopausal Osteoporosis

INTRODUCTION

Postmenopausal osteoporosis (PMO) increases the risk of fragility fractures (FF), leading to disability, higher mortality, and elevated healthcare costs. Despite available treatments, osteoporosis (OP) remains undertreated, especially in women over 50 years at high risk for FF. Real-world data on OP care in Spain are limited. This study aims to assess the OP treatment gap, healthcare resource utilisation (HCRU), and costs among Spanish women following a first FF or PMO diagnosis.

METHODS

This retrospective study used data from the BIG-PAC® administrative database on women aged ≥ 50 years with a first FF (cohort 1) or newly diagnosed PMO (cohort 2) between 2014 and 2018. Patients were followed for 2 years after the index event. The primary outcome was the proportion of women not prescribed OP medication within 6 months after the index event (treatment gap). Secondary outcomes included fracture incidence, mortality, HCRU, and costs.

RESULTS

The study included 22,142 women: 3190 in cohort 1 and 18,952 in cohort 2. The OP treatment gap was higher in cohort 1 vs cohort 2 (41.5% vs 23.6%). In cohort 1, 59.2% were diagnosed with PMO after the first FF, with 88% experiencing subsequent fracture(s). OP treatment persistence decreased over time in both cohorts. Fracture rates were lower in women prescribed OP treatment vs those who were not (8.35 vs 13.8 per 1000 patient-years) and in those who showed 24-month-persistence and 12-month adherence to treatment vs those who did not (8.98 and 7.66 vs 10.79 and 10.76). The 2-year mean cost per patient was higher in cohort 1 (€10,601) than in cohort 2 (€1659), with the highest costs incurred for hip (€15,833) and vertebral (€10,593) fractures.

CONCLUSION

This study highlights a significant treatment gap in Spanish women aged ≥ 50 with a first FF or newly diagnosed PMO. Costs are particularly high for those with a first FF, especially for hip or vertebral fractures. Improving treatment adherence could reduce fracture risk, healthcare costs, and resource utilisation.

Prevalence and predictors of bone mineral density testing after distal radius fracture in menopausal women

BACKGROUND

Osteoporosis screening guidelines recommend bone mineral density (BMD) testing following fragility fractures. Nevertheless, previous studies have demonstrated low rates of osteoporosis screening. Diagnosis and treatment of osteoporosis is essential for prevention of future fractures, however not much is known about the factors associated with receiving BMD testing in this patient population. The purpose of this study was to evaluate the prevalence, timing, and predictors of BMD testing following distal radius fractures (DRF) in menopausal women.

METHODS

We queried a national insurance database to identify menopausal women aged 45-64 years with a DRF between years 2013 and 2020. The rate of BMD testing within 1 year of injury was calculated. Multivariable logistic regression analysis was used to evaluate the effect of patient- and injury-related variables on the likelihood of undergoing BMD testing following DRF.

RESULTS

Among 31,728 patients meeting inclusion criteria (mean ± SD age: 57.5 ± 4.3), 3,886 (12.2 %) received a BMD test within 1 year following DRF. The rate of BMD tests decreased with the highest rate of 14.5 % in 2015 and the lowest rate of 10.5 % in 2020. Mean time from DRF to BMD testing was 143 ± 102 days. Patients aged 60-64 had the highest adjusted odds of receiving BMD testing (OR 2.85 [95 % CI: 2.26 to 3.64]). Factors associated with increased likelihood of BMD testing included surgical intervention (OR 1.38 [1.28-1.48]), rheumatoid arthritis (OR 1.22 [1.06-1.40]), osteoarthritis (OR 1.28 [1.19-1.37]), breast cancer (OR 1.35 [1.16-1.56]), and vitamin D deficiency (OR 1.29 [1.17-1.43]). Factors associated with decreased likelihood of testing included tobacco use (OR 0.90 [0.84-0.97]), patients with Medicaid (OR 0.73 [0.61-0.86]) or Medicare (OR 0.76 [0.65-0.88]) insurance, and living in Southern (OR 0.67 [0.62-0.73]) or Western (OR 0.69 [0.62-0.77]) regions of the United States. Obesity, diabetes, renal disease, and early menopause were not associated with BMD testing.

CONCLUSIONS

Despite guidelines recommending BMD testing after low-energy fractures, rates of BMD testing were low and decreased among menopausal women with DRF. Mean time to BMD testing was 4.7 months, indicating substantial delays in workup. Known risk factors for osteoporosis did not reliably predict likelihood of BMD testing.

LEVEL OF EVIDENCE

Level III, prognostic.

Developing and Evaluating an Interactive, Case-Based, Web-Based Active Learning Tool for Primary Care Physicians (Community Fracture Capture Learning Hub): Protocol for an Acceptability and Engagement Study

BACKGROUND

The lack of osteoporosis treatment initiation after fragility fractures is a significant gap, especially in primary care. It is unclear whether barriers for primary care physicians (PCPs) arise from uncertainty about investigations, treatment initiation, or medication side effects. Key questions remain about whether active learning platforms improve treatment initiation rates better than passive methods and how PCP demographics affect learning outcomes. With PCPs increasingly using web-based platforms for continuing professional development due to time constraints and heavy workloads, an interactive community fracture capture (CFC) tool may serve as an effective alternative to in-person learning. Our CFC pilot study tested this new program's design and content, showing promising potential.

OBJECTIVE

We aim to evaluate the interactive, case-based, web-based CFC Learning Hub, examining user acceptance and engagement with the platform, focusing on participants' interactions, satisfaction levels, and overall experience.

METHODS

Participating PCPs are recruited through Praxhub, a web-based medical education platform, and provide electronic consent for data use after deidentification. They have been allocated into small groups (12-20 members) and join the CFC Learning Hub, a secure web-based community. This hub includes a web-based discussion forum with participant-contributed case studies and a knowledge repository. Over the 6-week program, participants will receive weekly modules with instructions, resources, discussion threads, and quizzes, along with interactive discussions moderated by experienced PCPs and physicians. The platform also hosts web-based surveys that, in combination with platform analytics, allow assessment of baseline knowledge gaps, level of activity or engagement, and improvements following the course completion. This study protocol demonstrates the creation and proposed evaluation of the CFC Learning Hub, featuring an interactive, case-based, small-group web-based learning platform equipped with flexibly scheduled, tailored modules to address the fracture treatment gap within the community. Both qualitative (via thematic analysis) and quantitative (by using 2-tailed paired t tests, Wilcoxon signed rank tests, and multivariable regression analysis) analyses will be used to assess levels of engagement and acceptance and changes in PCPs' knowledge and confidence after engagement with the CFC Learning Hub.

RESULTS

Recruitment of participants started in May 2022. Data collection, analysis, and reporting will be completed following the completion of four 6-week cycles of the program.

CONCLUSIONS

The study described in this protocol will provide important insights into the function and effectiveness of the CFC Learning Hub. This information will guide the expansion of the program. This initiative offers a simple digital solution for promoting current bone health practices tailored to PCPs' needs and thereafter to expand the rollout of the e-learning hub and implementation of fracture liaison models at a primary care level in Australia and elsewhere. Future applications may extend to other clinical areas and professions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57511.

Effect of donepezil on bone metabolism among older adults with Alzheimer's disease

Older adults with Alzheimer's disease (AD), in addition to significant cognitive disability, have twice the risk of fracture compared to those with normal cognition. Fractures among older adults with AD are associated with substantial morbidity, loss of physical function, and significant mortality. Prior studies have shown a decreased risk of fracture among those taking acetylcholinesterase inhibitors, such as donepezil. With both cognitive and non-cognitive benefits, donepezil would be a valuable component in a fracture prevention program for older adults with AD. Though anti-amyloid therapies are now clinically available, donepezil may still have non-cognitive benefits. However, the specific effects of donepezil on bone metabolism are unknown. We have designed this randomized, double-blind, placebo-controlled clinical trial to investigate the effect of AD treatment with donepezil on bone metabolism. The study will measure the change in bone mineral density, bone turnover markers, and bone quality related to 12-months of donepezil therapy. This will be the first known study of changes in bone metabolism among older adults with AD.

Risk of Subsequent Hip Fractures across Varying Treatment Patterns for Index Vertebral Compression Fractures

Introduction: Vertebral compression fractures (VCFs) pose a considerable healthcare burden and are linked to elevated morbidity and mortality. Despite available anti-osteoporotic treatments (AOTs), guideline adherence is lacking. This study aims to evaluate subsequent hip fracture incidence after index VCF and to elucidate AOT prescribing patterns in VCF patients, further assessing the impact of surgical interventions on these patterns. Materials and Methods: Patients with index VCFs between 2010 and 2021 were identified using the PearlDiver database. Diagnostic and procedural data were recorded using International Classification of Diseases (ICD-9, ICD-10) and Current Procedural Terminology (CPT) codes. Patients under age 50 and follow-up Collapse

Key Words

• anti-osteoporotic treatment
• bisphosphonates
• fragility fracture
• hip fracture
• osteoporosis
• vertebral compression fracture

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Andy Ton Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jennifer A. Bell Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
William J. Karakash Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Thomas D. Alter Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
Mary Kate Erdman Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.) Department of Orthopaedic Surgery, University of Chicago Medical Center, Chicago, IL 60612, USA
Hyunwoo Paco Kang Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Emily S. Mills Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jonathan Mina Ragheb Department of Orthopaedic Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Los Angeles, CA 91101, USA
Mirbahador Athari Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Jeffrey C. Wang Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Ram K. Alluri Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)
Raymond J. Hah Department of Orthopaedic Surgery, Keck School of Medicine, The University of Southern California, Los Angeles, CA 90033, USA; (A.T.); (W.J.K.)

Collapse

Collaborators Collapse

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.

Selective estrogen receptor modulators (SERMs) with vitamin D composite agent can prevent fracture better than SERMs treatment: based on the National Health Claims Database 2017-2019

With the analysis of nationwide health claim data, treatment with the composite agent of SERMs and vitamin D reduces the risk of osteoporotic fracture and hip fracture better compared to SERMs treatment in women with osteoporosis aged ≥ 50 years.

PURPOSE

This study compared the potential of the composite agent of selective estrogen receptor modulators (SERMs) and vitamin D (SERM + VitD) with that of SERMs-only for fracture prevention and mortality reduction in women aged ≥ 50 years.

METHODS

The incidence of osteoporotic fracture (fractures of the vertebrae, hip, wrist, or humerus) and all-cause death after treatment with SERM + VitD and SERMs were characterized using the Korean National Health Insurance Service database 2017-2019. The participants were divided into two groups (SERM + VitD vs SERMs). After exclusion and propensity score matching, 2,885 patients from each group were included in the analysis. Fracture incidence was compared between groups. Kaplan-Meier curves were used to compare mortality. Cox proportional hazards regression analysis was used to compare the risks of fracture occurrence and mortality between the groups.

RESULTS

The incidence rate (138.6/10,000 vs. 192.4/10,000 person-years), and risk of osteoporotic fractures (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.61-0.97; p = 0.024) were lower in the SERM + VitD group than in the SERMs group. Analysis for specific fractures showed a lower hazard of hip fracture in the SERM + VitD group (HR, 0.25; 95% CI, 0.09-0.71; p = 0.009). No difference was observed between the groups regarding mortality.

CONCLUSION

The risk of osteoporotic fractures, especially hip fractures, was lower in the SERM + VitD group than in the SERMs group. Therefore, the composite agent of SERMs and vitamin D can be considered as a viable option for postmenopausal women with a relatively low fracture risk.

Bone Health Evaluations and Secondary Fragility Fractures in Hip Fracture Patients

Purpose

This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures.

Materials and Methods

A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment.

Results

A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications.

Conclusion

Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.

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.

Safety of Inpatient Zoledronic Acid in the Immediate Postfracture Setting

CONTEXT

Zoledronic acid (ZA) administered during the initial hospitalization for a fragility fracture improves the osteoporosis pharmacotherapy rate. Distinguishing the safety profile of inpatient ZA (IP-ZA) in this context is crucial if this approach is to be widely adopted.

OBJECTIVE

To study the acute safety profile of IP-ZA.

METHODS

An observational study of patients admitted to the Massachusetts General Hospital with fragility fractures who were eligible to receive IP-ZA. Patients were treated with or without IP-ZA. Acetaminophen, either as a single pre-ZA dose or standing multiple-doses-per-day regimen for 48 hours or longer after ZA infusion, was also administered along with protocolized vitamin D and calcium supplementation. Changes in body temperature, serum creatinine, and serum calcium were measured.

RESULTS

A total of 285 consecutive patients, meeting inclusion and exclusion criteria, are included in this analysis; 204 patients received IP-ZA. IP-ZA treatment was associated with a transient mean rise of body temperature of 0.31 °C on the day following its administration. Temperatures above 38 °C were seen in 15% of patients in the IP-ZA group and 4% in the nontreated group. Standing multiple-doses-per-day but not a single pre-ZA dose of acetaminophen effectively prevented this temperature increase. IP-ZA did not affect serum creatinine levels. Mean levels of serum total calcium and albumin-corrected calcium decreased by 0.54 mg/dL and 0.40 mg/dL, respectively, at their nadirs (Day 5). No patient experienced symptomatic hypocalcemia.

CONCLUSION

IP-ZA along with standing multiple-doses-per-day acetaminophen, administered to patients in the immediate postfracture period, is not associated with significant acute adverse effects.

Real-World Management of Patients With Osteoporosis at Very High Risk of Fracture

INTRODUCTION

Lack of consideration for risk-based assessments that inform osteoporosis treatment decisions may contribute to disease burden. In this study, we examined the prevalence of patients at very high risk of fracture and evaluated real-world treatment practices for these patients.

METHODS

This retrospective observational cohort study used real-world data linked to commercial and Medicare medical claims from Symphony Health PatientSource. Patients 50 years and older with osteoporosis (determined by the presence of a diagnosis code) and at very high risk of fracture according to the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) (AACE/ACE) 2020 guidelines between January 1, 2018, and December 31, 2018, were included. The number and proportion of patients treated with any osteoporosis medication were evaluated.

RESULTS

Of the 10,739,286 patients with osteoporosis, 5,078,111 (47.3%) were identified as meeting the AACE criteria for very high risk of fracture and were selected for the analysis. Most (5,033,106 [99.1%]) had a high risk of falls and/or a history of falls resulting in injury. Among the 1,667,794 patients (32.8%) eligible for treatment, 280,777 (16.8%) received treatment. Of these, 63.6% received alendronate, an alternative therapy, and 21.2% received a risk-based guideline-recommended medicine (teriparatide, zoledronic acid, denosumab, abaloparatide, or romosozumab). A greater proportion of men were untreated, 161,978 (90.5) compared with 1,185,003 women (81.8).

DISCUSSION

Most patients at very high risk of fracture remain untreated. Most of those treated do not receive the appropriate recommended treatments for patients at high risk. Risk-based treatment decisions may allow for more appropriate medication selection.

Prevalence of osteoporosis in older male veterans receiving hip-containing computed tomography scans: opportunistic use of biomechanical computed tomography analysis (BCT)

Osteoporosis care in men is suboptimal due to low rates of testing and treatment. Applying biomechanical computed tomography (BCT) analysis to existing CT scans, we found a high proportion of men with osteoporosis have never been diagnosed or treated. BCT may improve identification of patients at high risk of fracture.

PURPOSE

Osteoporosis care in men is suboptimal due to low rates of DXA testing and treatment. Biomechanical computed tomography analysis (BCT) can be applied "opportunistically" to prior hip-containing CT scans to measure femoral bone strength and hip BMD.

METHODS

In this retrospective, cross-sectional study, we used BCT in male veterans with existing CT scans to investigate the prevalence of osteoporosis, defined by hip BMD (T-score ≤  - 2.5) or fragile bone strength (≤ 3500 N). 577 men, age ≥ 65 with abdominal/pelvic CTs performed in 2017-2019, were randomly selected for BCT analysis. Clinical data were collected via electronic health records and used with the femoral neck BMD T-score from BCT to estimate 10-year hip fracture risks by FRAX.

RESULTS

Prevalence of osteoporosis by BCT increased with age (13.5% age 65-74; 18.2% age 75-84; 34.3% age ≥ 85), with an estimated overall prevalence of 18.3% for men age ≥ 65. In those with osteoporosis (n = 108/577), only 38.0% (41/108) had a prior DXA and 18.6% (7/108) had received osteoporosis pharmacotherapy. Elevated hip fracture risk by FRAX (≥ 3%) did not fully capture those with fragile bone strength. In a multivariate logistic regression model adjusted for age, BMI, race, and CT location, end stage renal disease (odds ratio 7.4; 95% confidence interval 2.3-23.9), COPD (2.2; 1.2-4.0), and high-dose inhaled corticosteroid use (3.7; 1.2-11.8) were associated with increased odds of having osteoporosis by BCT.

CONCLUSION

Opportunistic BCT in male veterans provides an additional avenue to identify patients who are at high risk of fractures.

Risk factors for refracture after proximal femur fragility fracture

Introduction

Proximal femur fragility fractures (PFFFs) are a growing worldwide concern. Recognizing the risk factors for subsequent fracture is essential for secondary prevention. This study aimed to analyze the risk factors for refracture and mortality rates in patients who suffered a PFFF.

Methods

Patients aged 65 years or older with PFFF who underwent surgical treatment during the year of 2017 in the same institution were retrospectively analyzed and at least four years after the index fracture were evaluated.

Results

From a total of 389 patients, 299 patients were included, with a median age of 83 years, and 81% female. Thirty-two (10.7%) suffered a refracture, with a mean time to refracture of 19.8 ± 14.80 months, being the female sex a risk factor for refracture (OR-4.69; CI [1.05-20.95]). The 1-year mortality rate was 15.4%. Seventy-three (24.4%) patients had previous fragility fractures. After the index fracture, 79% remained untreated for osteoporosis. No statistical association was found between antiosteoporotic treatment and refracture. Patients with refracture had higher prefracture functional level compared with patients without refracture (OR-1.33; CI [1.08-1.63]) and were discharged more often to rehabilitation units (31% versus 16%, P =.028). After 4 years of follow-up, patients with refracture had lower functional level compared with patients without. Chronic kidney disease was a risk factor (P = .029) for early refracture (<24 months).

Conclusion

Female sex and higher prefracture functional level may increase the risk of refracture. Chronic kidney disease was associated with a shorter refracture time. Despite having a PFFF or other fragility fractures, the majority of patients remained untreated for osteoporosis.

Inpatient Zoledronic Acid and Integrated Orthopedic and Fracture Liaison Services Improve Osteoporosis Treatment Rates

CONTEXT

Fragility fractures increase risks for future fractures, morbidity, and mortality. Available pharmacotherapy for underlying osteoporosis is safe and effective but underused.

OBJECTIVE

To improve pharmacotherapy rate representing secondary prevention of osteoporotic fractures.

METHODS

This single-center, observational, follow-up study included patients with fragility fractures admitted to the Massachusetts General Hospital between February 2016 and December 2019. For patients admitted to the orthopedics service with fragility fracture, the Massachusetts General Hospital Fracture Liaison Service (FLS) was systematically consulted. Initial outpatient follow-up with FLS was established in conjunction with the orthopedic postoperative follow-up visit. Patients at risk for failing timely outpatient follow-up were administered zoledronic acid (ZA) during the index fracture hospitalization. The main outcome measures were percentage of patients with fragility fracture(s) started on pharmacotherapy for osteoporosis and average length of stay and 30-day readmission rate of patients treated with ZA.

RESULTS

Compared with baseline (8-11%) and reference (5-20%) rates, integration of FLS to the orthopedics service, along with appropriate inpatient administration of ZA, increased the pharmacotherapy rate to 70% (412/589) among eligible patients with verified treatment status. Inpatient ZA administration neither affected the average length of stay nor 30-day readmission rate. Treatment status of 37.9% (471/1240) of the study patients remained unknown due to lack of or unknown follow-up.

CONCLUSION

Integration of a FLS and orthopedics services along with inpatient ZA administration improved the osteoporosis pharmacotherapy rate among patients with fragility fracture(s) who often had obstacles for outpatient follow-up.

Osteoporosis Treatment After Osteoporotic Fractures: Data From a Single Medical Center

OBJECTIVE

Most patients do not receive osteoporosis treatment after osteoporotic fracture. This study reviewed osteoporosis treatment after osteoporotic fractures in a center without a Fracture Liaison Service.

METHODS

We identified all patients with hip, vertebral, humeral or radial fractures, evaluated in Meir Medical Center, in 2017. The exclusion criteria were not a Clalit Health Services member, high-energy fracture or 30-day postoperative mortality. The primary endpoint was osteoporosis drugs issued within 12 months of fracture. Secondary endpoints included bone densitometry and 1-year mortality.

RESULTS

Five-hundred-eighty-two patients (average age 78.6 ± 11.1 years, 75.8% women) were included. There were 321 (55.5%) hip, 84 (14.1%) humeral, 33 (5.6%) vertebral, and 144 (24.7%) radial fractures. Osteoporosis drugs were issued to 26.5% of the patients; those with humeral fractures received the least (21.4%) and vertebral, the most (30.3%; P = .51). Bone densitometry was performed in 23.2% of patients. One-year mortality after hip fracture was 12.1%, followed by humeral (3.6%; P < .05). Logistic regression showed that previous treatment (odds ratio [OR] = 7.4; 95% confidence interval [CI] 3.6-15.2), bone densitometry (OR = 4.4; 95% CI 2.6-7.4) and endocrinology visit (OR = 2.6; 95% CI, 1.4-4.6) were the most important factors associated with treatment.

CONCLUSION

Fewer than one third of patients received pharmacotherapy within 1 year after fracture. Because pharmacotherapy reduces future fractures and mortality, we recommend that medical staff who care for patients with fracture adopt practical and effective strategies to increase treatment rates among patients with osteoporotic fractures.

A micro-costing analysis of post-fracture care pathways: results from the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

This study identified the costs and health-related quality of life impacts of several post-fracture multidisciplinary care pathways specific to individual skeletal site (hip, distal forearm, vertebrae, humerus). These care pathways may assist healthcare providers in allocating resources for osteoporotic fractures in more effective and cost-efficient ways.

INTRODUCTION

This micro-costing study was undertaken to provide the estimated healthcare costs of several fracture site-specific health service use pathways associated with different trajectories of health-related quality of life (HRQoL) 12-months post-fracture.

METHODS

The study included 4126 adults aged ≥ 50 years with a fragility fracture (1657 hip, 681 vertebrae, 1354 distal forearm, 434 humerus) from the International Costs & Utilities Related to Osteoporotic fractures Study (ICUROS). ICUROS participants were asked to recall the frequency and duration (where applicable) of their health and community care service use at 4- and 12-month follow-up visits. Patient-level costs were identified and aggregated to determine the average cost of healthcare use related to the fracture in each care pathway (presented in Australian 2021 dollars). Mean cost differences were calculated and analysed using a one-way analysis of variance (ANOVA) and post hoc Bonferroni correction to determine any statistically significant differences.

RESULTS

The total direct cost of fractures was estimated at $89564, $38926, $18333, and $38461AUD per patient for hip, vertebral, wrist, and humeral participants, respectively. A Kruskal-Wallis test yielded a statistically significant difference in cost values between most care pathways (p < 0.001). Of the 20 care pathways, those associated with recovery of HRQoL had lower mean costs per patient across each fracture site.

CONCLUSIONS

This study identified the costs and HRQoL impacts of several multidisciplinary care pathways for individual fracture sites based on the health service utilization of an international cohort of older adults. These care pathways may assist healthcare providers in allocating resources for fragility fractures in more effective and cost-efficient ways.

Prevalence of FRAX risk factors and the osteoporosis treatment gap among women ≥ 70 years of age in routine primary care across 8 countries in Europe

We studied whether elderly women at risk for fractures receive primary care treatment to prevent fracture. We found that across Europe, women at risk are often not identified, and less than half of such women receive appropriate treatment. Finally, women diagnosed with osteoporosis are much more likely to receive treatment.

PURPOSE

To examine the relationship between risk factors for fragility fracture (FF) and osteoporosis (OP) treatment gap in elderly women across Europe, and compare the prevalence of risk factors between countries.

METHODS

Demographic and clinical information was collected from women ≥ 70 years visiting primary care physicians in Belgium, France, Germany, Ireland, Poland, Slovakia, Switzerland, and the UK. Increased risk of FF was defined by the presence of 1 or more criteria (history of fracture, 10-year fracture probability, or T-score ≤  - 2.5).

RESULTS

There were 3798 women in total. Treatment gap (proportion at increased risk of FF not receiving treatment for OP) varied from 53.1 to 90.8% across countries, and the proportion of patients at increased risk of FF varied from 41.2 to 76.1%. Across countries, less than 50% of patients with increased risk of FF had a diagnosis of OP. Previous fracture was the most common risk factor, with similar prevalence across most countries; other risk factors varied widely. The treatment gap was reduced in patients with an OP diagnosis in all countries, but this reduction varied from 36.5 to 79.4%. The countries with the lowest rates of bone densitometry scans (Poland, France, and Germany; 8.3-12.3%) also had the highest treatment gap (82.2 to 90.8%).

CONCLUSIONS

This study highlights differences across Europe in clinical risk factors for fracture, rates of densitometry scanning, and the rates of OP diagnosis. More emphasis is needed on risk assessment to improve the identification and treatment of elderly women at risk for fracture.

Longitudinal Analysis of Circulating Markers of Bone Turnover Across Multiple Decades in Osteoporotic Women

PURPOSE

The objective of this study was to analyze changes in serum markers of bone turnover across multiple decades in osteoporotic women compared with nonosteoporotic controls, to determine their utility as potential predictors for osteoporosis. Early prediction of those at risk for osteoporosis can enable early intervention before the irreversible loss of critical bone mass.

METHODS

Serum samples were obtained from 20 women given the diagnosis of osteoporosis after age 46 years and 20 age-matched women with normal bone mineral density from 4 time points in their life (ages 25-31, 32-38, 39-45, and 46-60 years). Serum levels of bone turnover markers (propeptide of type I collagen, parathyroid hormone, bone-specific alkaline phosphatase, osteocalcin, C-terminal telopeptide of type I collagen, sclerostin, osteoprotegerin, osteopontin, and 25-OH vitamin D) were measured using commercially available arrays and kits. We used logistic regression to assess these individual serum markers as potential predictors of osteoporosis, and mixed-effects modeling to assess the change in bone turnover markers between osteoporotic and control groups over time, then performed fivefold cross-validation to assess the classification ability of the models.

RESULTS

Markers of bone turnover, bone-specific alkaline phosphatase, C-terminal telopeptide of type I collagen, sclerostin, and osteocalcin were all independent predictors at multiple time points; osteopontin was an independent predictor in the 39- to 45-year age group. Receiver operating characteristic analyses demonstrated moderately strong classification ability at all time points. Sclerostin levels among groups diverged over time and were higher in the control group than the osteoporotic group, with significant differences observed at time points 3 and 4.

CONCLUSIONS

Serum markers of bone turnover may be used to estimate the likelihood of osteoporosis development in individuals over time. Although prospective validation is necessary before recommending widespread clinical use, this information may be used to identify patients at risk for developing low bone mineral density long before traditional screening would ostensibly take place.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Sex differences in recovery of quality of life 12 months post-fracture in community-dwelling older adults: analyses of the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS)

In this study of 695 Australian older adults (aged ≥50 years), we found that men and women had a similar trajectory of health-related quality of life (HRQoL) recovery following fragility fracture at any skeletal site. These results provide us with critical knowledge that improves our understanding of health outcomes post-fracture.

INTRODUCTION

Mortality is higher in men than that in women following a fragility fracture, but it is unclear whether recovery of patient-reported outcomes such as health-related quality of life (HRQoL) differs between sexes. This study aimed to identify sex differences in HRQoL recovery 12 months post-fracture.

METHODS

Data were from the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS). Participants recruited to AusICUROS were adults aged ≥50 years who sustained a fragility fracture. HRQoL was measured using the EQ-5D-3L at three time-points post-fracture: within 2 weeks (including pre-fracture recall) and at 4 and 12 months. Multivariate logistic regression analyses were undertaken, adjusting for confounders including age, education, income, and healthcare utilization post-fracture.

RESULTS

Overall, 695 AusICUROS participants (536 women, 77.1%) were eligible for analysis with fractures at the hip (n = 150), distal forearm (n = 261), vertebrae (n = 61), humerus (n = 52), and other skeletal sites (n = 171). At the time of fracture, men were younger, reported a higher income, and were more likely to be employed, compared with women. For all fracture sites combined, there were no differences between men and women in recovery to pre-fracture HRQoL at 12-month follow-up (adjusted OR = 1.09; 95% CI: 0.75-1.61). When stratified by fracture site, no significant sex differences were seen for hip (OR = 1.02; 95% CI: 0.42-2.52), distal forearm (OR = 1.60; 95% CI: 0.68-3.78), vertebral (OR = 2.28; 95% CI: 0.61-8.48), humeral (OR = 1.62; 95% CI: 0.16-9.99), and other fractures (OR = 1.00; 95% CI: 0.44-2.26).

CONCLUSION

Community-dwelling men and women who survived the 12 months following fragility fracture had a similar trajectory of HRQoL recovery at any skeletal site.

Barriers and Resources to Optimize Bone Health in Orthopaedic Education: Own the Bone (OTB): Bone Health Education in Residency

Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs).

Development and validation of a one year predictive model for secondary fractures in osteoporosis

The number of osteoporosis-related fractures in the United States is no longer declining. Existing risk-based assessment tools focus on long-term risk. Payers and prescribers need additional tools to identify patients at risk for imminent fracture. We developed and validated a predictive model for secondary osteoporosis fractures in the year following an index fracture using administrative medical and pharmacy claims from the Optum Research Database and Symphony Health, PatientSource. Patients ≥50 years with a case-qualifying fracture identified using a validated claims-based algorithm were included. Logistic regression models were created with binary outcome of a second fracture versus no second fracture within a year of index fracture, with the goal of predicting second fracture occurrence. In the Optum Research Database, 197,104 patients were identified with a case-qualifying fracture (43% commercial, 57% Medicare Advantage). Using Symphony data, 1,852,818 met the inclusion/exclusion criteria. Average patient age was 70.09 (SD = 11.09) and 71.28 (SD = 14.24) years in the Optum Research Database and Symphony data, respectively. With the exception of history of falls (41.26% vs 18.74%) and opioid use (62.80% vs 46.78%), which were both higher in the Optum Research Database, the two populations were mostly comparable. A history of falls and steroid use, which were previously associated with increased fracture risk, continue to play an important role in secondary fractures. Conditions associated with bone health (liver disease), or those requiring medications that impact bone health (respiratory disease), and cardiovascular disease and stroke—which may share etiology or risk factors with osteoporosis fractures—were also predictors of imminent fractures. The model highlights the importance of assessment of patient characteristics beyond bone density, including patient comorbidities and concomitant medications associated with increased fall and fracture risk, in alignment with recently issued clinical guidelines for osteoporosis treatment.

Perspectives of patients with depression and chronic pain about bone health after a fragility fracture: A qualitative study

Background

Compromised bone health is often associated with depression and chronic pain.

Objective

To examine: (1) the experience of existing depression and chronic nonfracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain.

Design

A phenomenological study guided by Giorgi's analytical procedures.

Setting and Participants

Fracture patients who reported taking prescription medication for one or more comorbidities, excluding compromised bone health.

Main Variables Studied

Patients were interviewed within 6 weeks of their fracture, and 1 year later. Interview questions addressed the recent fracture and patients' experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions.

Results

Twenty‐six patients (5 men, 21 women) aged 45–84 years old with hip (n = 5) and nonhip (n = 21) fractures were recruited. Twenty‐one participants reported depression and/or chronic nonfracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent, based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain.

Conclusion

Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients' more general emotional and physical state.

Patient Contribution

A patient representative was involved in the study conception, data interpretation and manuscript writing.

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS

Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old.

METHODS

In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old.

RESULTS

Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251).

CONCLUSION

A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Correlation of Hounsfield Unit Measurements on Computed Tomography of the Shoulder With Dual-Energy X-ray Absorptiometry Scans and Fracture Risk Assessment Tool Scores: A Potential for Opportunistic Screening

BACKGROUND

The diagnosis of bone mineral density (BMD) abnormalities involves dual-energy x-ray absorptiometry (DXA), but few patients complete this after a fragility fracture. The assessment of BMD using Hounsfield unit (HU) measurements from computed tomography (CT) scans has been correlated with DXA results in previous studies. We aimed to evaluate the correlation between shoulder CT HU and DXA scores.

METHODS

Billing databases of 3 academic institutions were queried for patients who underwent both DXA and CT scan of the upper extremity within 1 year of each other. DXA T-scores for spine, hip, and femoral neck were recorded. BMD status was defined based on composite T-scores, using the lowest T-score in the spine, hip, or proximal femur. CT scans were measured for HU over 4 slices, recorded to create a bone column, then averaged. The patients' risks of major osteoporosis-related fracture and hip fracture were calculated using the Fracture Risk Assessment Tool.

RESULTS

In total, 300 patients were included. A positive correlation was found between composite T-scores and HU for glenoid and proximal humerus (0.36; 0.17). The proximal humerus HU was significantly associated with the BMD T-score for the hip (P = 0.01); the glenoid HU was significantly associated with BMD T-scores for the hip, spine, and femoral neck (P = 0.002; P = 0.001; P = 0.002). A 10-year risk of hip fracture >3% was associated with lower proximal humerus HU.

CONCLUSIONS

Our study is the first to discover significant correlations between HU at the glenoid and proximal humerus and risk factors as established by the Fracture Risk Assessment Tool scoring system.

LEVEL OF EVIDENCE

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

Rate of Bone Mineral Density Testing and Subsequent Fracture-Free Interval After Distal Forearm Fracture in the Medicare Population

PURPOSE

Distal forearm fractures are prevalent among the Medicare population. Many patients who sustain these fractures have poor bone health and are at increased risk for subsequent fractures. We sought to determine the rate of bone mineral density (BMD) testing and subsequent fragility fracture-free interval after distal forearm fractures in the Medicare population.

METHODS

We examined the 5% Medicare Standard Analytic File dataset using the PearlDiver Application from 2005 to 2014 to identify patients with distal forearm fractures based on International Classification of Diseases-Ninth Revision and Current Procedural Terminology codes. We queried these records to determine the incidence and timing of BMD testing after fracture and the number of patients who went on to hip or vertebral fractures. Survival curves were generated using Kaplan-Meier analysis with hip or vertebral fracture as the end point.

RESULTS

A total of 37,473 patients with distal forearm fractures were identified who did not have BMD testing within the 2 years before fracture. Only 9,605 of this unscreened cohort underwent testing after the fracture (26%) and only 2,684 underwent testing within 6 months (7%). The patients least likely to be tested were males (9%), those aged over 85 years (12%), and those less than 65 years (22%). Twenty percent of these patients sustained a subsequent hip or vertebral fracture (n = 7,326). Patients who underwent testing after fracture had a longer fracture-free interval compared with patients without BMD testing (819 vs 579 days). When separated by sex and controlling for comorbidities, males with BMD testing had a worsened fracture-free interval whereas females had an improved fracture-free interval.

CONCLUSIONS

Bone mineral density testing is underused nationwide in patients sustaining distal forearm fractures despite current guidelines. Orthopedic surgeons should ensure proper testing of patients because this may be an important time point for intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis II.

Contralateral non-simultaneous proximal femoral fractures in patients over 65 years old

Purpose

Epidemiological and clinical parameters according to the Parker-Palmer Index (PPI) have not been specifically studied as predictors of re-fracture time in patients over 65 years old with contralateral hip fracture. The main purpose of this study was to assess whether these parameters could represent a prognostic factor in this population.

Methods

This retrospective study included all consecutive patients older than 65 years that suffered from a proximal femoral fracture, 31 according to Association for Osteosynthesis/Orthopaedic Trauma Association classification, treated at our unit between Feb 1st 2019 and Feb 1st 2020.

Results

This study enrolled 387 patients. Thirty-seven of them had already incurred a contralateral hip fracture: seven males and 30 females. The median time between the first and second hip fractures was 3.5 years. This study revealed that increasing age (p = 0.003), male sex (p = 0.029) and a PPI value ≥ 5 between the first and second hip fracture (p = 0.015) are risk factors associated with a contralateral hip fracture in the first three years after the first episode. There were no statistically significant differences regarding anti-osteoporotic therapy and the anatomic site of the first hip fracture episode.

Conclusion

The results of the present study suggest that several risk factors have a crucial role in hip re-fracture time in patients over 65 years old.

Incidence of subsequent osteoporotic fractures after distal radius fractures and mortality of the subsequent distal radius fractures: a retrospective analysis of claims data of the Korea National Health Insurance Service

A better understanding of the features of subsequent fractures after distal radius fracture (DRF) is important for the prevention of further osteoporotic fractures. This study found that the cumulative incidence of subsequent osteoporotic fractures in South Korea increased over time and that the mortality rates of subsequent DRFs were lower than those of first-time DRFs.

INTRODUCTION

We examined the incidence of osteoporotic fractures following distal radius fractures (DRFs) and the mortality rate after subsequent DRFs using claims data from the Korea National Health Insurance (KNHI) Service.

METHODS

We identified records for 41,417 patients with first-time DRFs in 2012. The occurrence of osteoporotic fractures of the spine, hip, wrist, and humerus at least 6 months after the index DRF was tracked through 2016. All fractures were identified by specific diagnosis and procedure codes. One-year mortality rates and standardized mortality ratios (SMRs) for initial and subsequent DRFs were calculated for all patients.

RESULTS

The 4-year cumulative incidence of all subsequent osteoporotic fractures was 14.74% (6105/41,417; 9.47% in men, 15.9% in women). The number of associated subsequent fractures was 2850 for the spine (46.68%), 2271 for the wrist (37.2%), 708 for the hip (11.6%), and 276 for the humerus (4.52%). The cumulative mortality rate 1 year after the first-time and subsequent DRF was 1.47% and 0.71%, respectively, and the overall SMR was 1.48 (95% CI: 1.37-1.61) and 0.71 (95% CI: 0.42-1.21), respectively.

CONCLUSION

The cumulative incidence of osteoporotic fractures following DRFs increased over the study period and was higher among women. The cumulative mortality rates and SMRs of subsequent DRFs were lower than those of first-time DRFs at the 1-year follow-up. Given the increasing incidence rate of DRFs, the incidence of subsequent osteoporotic fractures may also increase.

Prediction of osteoporotic fragility re-fracture with lumbar spine DXA-based derived bone strain index: a multicenter validation study

A new qualitative index of bone strength, based on finite element analysis and named bone strain index, has been recently developed from lumbar DXA scan. This study shows that BSI predicts subsequent re-fracture in osteoporotic patients affected by fragility fractures.

INTRODUCTION

Dual-energy X-ray absorptiometry (DXA) can provide quantitative (bone mineral density, BMD) and qualitative (trabecular bone score, TBS) indexes of bone status, able to predict fragility fractures in most osteoporotic patients. A new qualitative index of bone strength, based on finite element analysis and named bone strain index (BSI), has been recently developed from lumbar DXA scan. This study presents the validation results of BSI prediction for re-fracture in osteoporotic patients with fragility fractures.

METHODS

In three academic hospitals, 234 consecutive fractured patients with primary osteoporosis (209 females) performed a spine X-ray for the calculation of spine deformity index (SDI) and DXA densitometry for BMD, TBS and BSI at the basal time and in the follow-up at each clinical check. A subsequent fracture was considered as one unity increase of SDI.

RESULTS

For each unit increase of the investigated indexes, the univariate hazard ratio of re-fracture, 95% CI, p value and proportionality test p value are for age 1.040, 1.017-1.064, 0.0007 and 0.2529, respectively, and for BSI 1.372, 1.038-1.813, 0.0261 and 0.5179, respectively. BSI remained in the final multivariate model as a statistically significant independent predictor of a subsequent re-fracture (1.332, 1.013-1.752 and 0.0399) together with age (1.039, 1.016-1.064 and 0.0009); for this multivariate model proportionality test, p value is 0.4604.

CONCLUSIONS

BSI appears to be a valid DXA index of prediction of re-fracture, and it can be used for a more refined risk assessment of osteoporotic patients.

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.

Economic Burden of Osteoporosis-Related Fractures in the US Medicare Population

Background

Osteoporosis-related fractures are an important public health burden.

Objective

To examine health care costs in Medicare patients with an osteoporosis-related fracture.

Methods

Medicare fee-for-service members with an osteoporosis-related fracture between January 1, 2010, to September 30, 2014 were included. A nonfracture comparator group was selected by propensity score matching. Generalized linear models using a gamma distribution were used to compare costs between fracture and nonfracture cohorts.

Results

A total of 885 676 Medicare beneficiaries had fracture(s) and met inclusion criteria. Average age was 80.5 (±8.4) years; 91% were White, and 94% female. Mean all-cause costs were greater in the fracture vs nonfracture cohort ($47 163.25 vs $16 034.61) overall and for men ($52 273.79 vs $17 352.68). The highest mean costs were for skilled nursing facility ($29 216), inpatient costs ($24 190.19), and hospice care ($20 996.83). The highest incremental costs versus the nonfracture cohort were for hip ($71 057.83 vs $16 807.74), spine ($37 543.87 vs $16 860.49), and radius/ulna ($24 505.27 vs $14 673.86). Total medical and pharmacy costs for patients who experienced a second fracture were higher compared with those who did not ($78 137.59 vs $44 467.47). Proportionally more patients in the fracture versus nonfracture cohort died (18% vs 9.3%), with higher death rates among men (20% vs 11%).

Conclusion and Relevance

The current findings suggest a significant economic burden associated with fractures. Early identification and treatment of patients at high risk for fractures is of paramount importance for secondary prevention and reduced mortality.

Trends and Geographical Variability in Osteoporosis Treatment After Hip Fracture: A Multilevel Analysis of 30,965 Patients in the Region of Valencia, Spain

Despite improvements in the therapeutic arsenal and the recommendations of guidelines, low rates of prescribing osteoporosis medications are being reported worldwide for patients surviving a hip fracture, and important geographical variation remain. We aimed to describe trends in the proportion of patients that receive osteoporosis medication after hip fracture and to analyze the geographical variation in the prescription of drug therapy and its associated factors in the region of Valencia, Spain. We studied a population-based retrospective cohort of 30,965 patients aged 65 years and older, discharged from hospital after a hip fracture from January 2008 to December 2015, who were followed up for 3 months after discharge to identify the presence of any prescription of osteoporosis medication. We conducted a multilevel multiple logistic regression analysis with two levels (individuals and health departments [HD]) to determine which individual covariates were associated with receiving a prescription of osteoporosis medication in the 3 months after discharge, as well as the importance of the HD of hospitalization. The percentage of patients treated in the region decreased from a maximum of 28.9% in 2009 to 16.4% in 2015. By sex, the proportion of women treated reached a maximum of 33.4% in 2009 and declined to 19% in 2015, while the proportion of men reached a maximum of 14% in 2011 and reduced to 8.1% in 2015. By health department, there was a noticeable variability in the rate of patients treated, ranging from 40.9% to 11.1% in the whole period (intraclass correlation coefficient [ICC] = 7.54%; median odds ratio [MOR] = 1.64). Proportion of treated patients decreased in 20 of the 24 HDs. Variability could be also observed with regard to choice of medication by HD. This situation pressingly demands action (both at the organizational and professional levels) focused on populations at a higher risk (such as hip fracture patients) that particularly address underutilization and unwarranted variation.

Bone strain index in the prediction of vertebral fragility refracture

Dual-energy x-ray absorptiometry (DXA) can provide quantitative (bone mineral density, BMD) and qualitative (trabecular bone score, TBS) indexes of bone status, able to predict fragility fractures in most osteoporotic patients. A new qualitative index of bone strength, based on finite element analysis and named bone strain index (BSI), has been recently developed from lumbar DXA scan. We present the preliminary results about the BSI ability to predict a refracture in patients with fragility fractures. A total of 143 consecutive fractured patients with primary osteoporosis (121 females) performed a spine x-ray examination for the calculation of spine deformity index (SDI) and a DXA densitometry for BMD, TBS, and BSI at basal time and in the follow-up. A refracture was considered as a one-unit increase in SDI. For each unit increase of the investigated indexes, the hazard ratio of refracture, 95% confidence interval, p value, and proportionality test p value were for BSI 1.201, 0.982−1.468, 0.074, and 0.218; for lumbar BMD 0.231, 0.028−1.877, 0.170, and 0.305; and for TBS 0.034, 0.001−2.579, 0.126, and 0.518, respectively. BSI was the index predictive of refracture nearest to statistical significance. If confirmed, it may be used for a better risk assessment of osteoporotic patients.

Interventions to improve osteoporosis care: a systematic review and meta-analysis

Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription.

The crisis of inadequate treatment in osteoporosis

The number of fractures related to osteoporosis is expected to increase dramatically in the next few decades because of an increase in the number of elderly patients at high risk of falls and fractures. Developments in the diagnosis and treatment of osteoporosis might change our strategies for management of patients with osteoporosis: the imminent risk of fracture concept, the issue of how to correctly sequence treatment, the potential effectiveness of screening, and goal-directed treatment strategies. Despite advances, few patients receive appropriate treatment for osteoporosis, even after a fracture. The crisis in the treatment of osteoporosis is related to several factors, including the fears and beliefs that patients and physicians have about the adverse effects of treatments. Strategies to address this crisis pose a considerable challenge; nonetheless, prevention of fragility fractures is within our reach. To that end, careful selection of patients at high risk of fracture, selection of the best therapeutic strategy, and accurate communication about fracture risk and bone fragility must be improved.

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.

Association of Disease Definition, Comorbidity Burden, and Prognosis With Hip Fracture Probability Among Late-Life Women

IMPORTANCE

Advanced age is associated with lower use of drug treatment to prevent fractures, but concerns about comorbidities and prognosis increase the complexity of managing osteoporosis in this age group.

OBJECTIVE

To determine the association of disease definition, number of comorbidities, and prognosis with 5-year hip fracture probabilities among women who are 80 years and older.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (4 US sites) included 1528 community-dwelling women identified as potential candidates for initiation of osteoporosis drug treatment.

MAIN OUTCOMES AND MEASURES

Women were contacted every 4 months to ascertain vital status and hip fracture. Five-year hip fracture probability was calculated accounting for competing mortality risk. Participants were classified into 2 distinct groups based on disease definition criteria proposed by the National Bone Health Alliance: with osteoporosis (n = 761) and without osteoporosis but at high fracture risk (n = 767). Comorbid conditions were assessed by self-report. Prognosis was estimated using a mortality prediction index. All analysis was performed between March 2018 and January 2019.

RESULTS

The study had 1528 participants, all of whom were women, with a mean (SD) age of 84.1 (3.4) years. During follow-up, 125 (8.0%) women experienced a hip fracture and 287 (18.8%) died before experiencing this event. Five-year mortality probability was 24.9% (95% CI, 21.8-28.1) among women with osteoporosis and 19.4% (95% CI, 16.6-22.3) among women without osteoporosis but at high fracture risk. In both groups, mortality probability similarly increased with more comorbidities and poorer prognosis. In contrast, 5-year hip fracture probability was 13.0% (95% CI, 10.7-15.5) among women with osteoporosis and 4.0% (95% CI, 2.8-5.6) among women without osteoporosis but at high fracture risk. The difference was most pronounced among women with more comorbidities or worse prognosis. For example, among women with 3 or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) among women with osteoporosis vs 2.5% (95% CI, 1.3-4.2) among women without osteoporosis but at high fracture risk.

CONCLUSIONS AND RELEVANCE

Women 80 years and older who have osteoporosis, including those with more comorbidities or poorer prognosis, have a high 5-year probability of hip fracture despite accounting for competing mortality risk. In contrast, among women without osteoporosis but at high fracture risk, competing mortality risk far outweighs hip fracture probability, especially among those with more comorbidities or worse prognosis.

Factors Associated With Osteoporosis Care of Men Hospitalized for Hip Fracture: A Retrospective Cohort Study

Rates of postfracture DXA and pharmacotherapy appear to be declining despite their known benefits in fracture reduction. We sought to identify factors associated with osteoporosis care among male veterans aged 50 years and older after hip fracture and to evaluate trends in rates of care with an observational cohort design using US Department of Veterans Affairs’ (VA) inpatient, pharmacy, and outpatient encounters and Centers for Medicare and Medicaid Services outpatient pharmacy claims (2007 to 2014) from men aged 50 years and older treated for hip fracture (N = 7317). We used the Cox proportional hazards model with random effects for the admitting facility. A sensitivity analysis was performed for a subset of patients aged 65 to 99 dually enrolled in Medicare ( N = 5821). Overall, approximately 13% of patients had evidence of osteoporosis care within one year of fracture. In the adjusted model, rural residence was associated with lower likelihood of care, and several comorbidities were associated with higher likelihood of receiving care. In sensitivity analyses of patients dually enrolled in Medicare, rural residence remained associated with lower likelihood of osteoporosis care. Overall rates of care decreased over time, but rates of DXA in the VA remained stable. These findings highlight the ongoing problem of low rates of postfracture care among a population with the highest risk of future fracture and its associated morbidity and mortality. The rural disparity in care and differences in rates of care across healthcare delivery systems illustrates the importance of healthcare delivery systems in promoting pharmacotherapy and DXA after sentinel events. Because the VA removes a majority of cost barriers to care, this integrated healthcare system may outperform the private sector in access to care. However, declining rates of pharmacotherapy imply knowledge gaps that undermine quality care. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

The trend of osteoporosis and osteoporotic fragility fractures in inpatients: results from a national database

Osteoporosis is associated with an increased risk of pathologic fractures; however, most patients do not receive diagnosis and adequate treatment. The aim of our study was to compare the yearly trends of osteoporosis and osteoporotic fragility fractures in the USA (US) inpatients. We used National (Nationwide) Inpatient Sample database to identify adults ≥18 years with diagnoses of osteoporosis and pathologic fractures and excluded pathologic fractures due to other etiologies. We then studied the annual trends, in terms of annual percentage change (APC), of osteoporosis and osteoporotic fractures. Among overall hospitalizations, osteoporosis was noted to have an increasing trend from 2000 to 2009 (APC = 5.81, p < 0.05) with a decline thereafter (APC = - 3.88, p < 0.05). In contrast, osteoporotic fracture showed an initial downward trend from 2000 to 2010 (APC = -7.31, p < 0.05), followed by a slowly rising trend (APC = 2.0, p = NS). The initially increasing trend of osteoporosis was followed by a decreasing trend thereafter. In contrast, there was a halt in a previously declining trend of osteoporotic fracture. Potential explanations include inadequate screening and treatment per guidelines along with decreasing patient compliance. In conclusion, primary and secondary prevention measures for osteoporosis have been underutilized by both physicians and patients alike.

Incidence of Osteoporotic Refractures Following Proximal Humerus Fractures in Adults Aged 50 Years and Older in Korea

Background

The purpose of this study was to investigate the incidence and characteristics of osteoporotic refractures after proximal humerus fracture in Korean adults aged above 50 years.

Methods

Patients aged 50 years or older with initial proximal humerus fractures reported in 2012 were enrolled and followed up until 2016 using the Korean National Health Insurance data. Based on the last claim date, the refractures were classified as osteoporotic fractures including spine, hip, distal radius, and humerus 6 months after the index fracture involving the proximal humerus. Each osteoprotic fracture was identified using specific International Classification of Diseases, 10th Revision codes and site-specific physician claims for procedures.

Results

A total of 5,587 first-time fractures involving proximal humerus were reported in 2012. Among them, a total of 1,018 osteoporotic refractures occured between 2012 and 2016. The total cumulative incidence of osteoporotic refractures was 4.85% (271/5,587) at 1 year, 9.61% (537/5,587) at 2 years, 14.21% (794/5,587) at 3 years, and 18.22% (1,018/5,587) at 4 years. In terms of site by year, the incidence of associated refractures was as follows: spine, 48.62% (495/1,018); hip, 25.83% (263/1,018); wrist 18.57% (189/1,018); and humerus 6.97% (71/1,018) during all the follow-up periods.

Conclusions

Our study showed that the cumulative incidence of osteoporotic refractures following proximal humerus fractures in the elderly population has been increasing over the years. Given that osteoporotic refractures are associated with an increased mortality risk, a public health strategy to prevent the refracture after proximal humerus fracture in the elderly is imperative.

Failure in diagnosis and under-treatment of osteoporosis in elderly patients with fragility fractures

We evaluated whether osteoporosis is adequately managed and treated in patients suffering from fragility fractures. Factors that influenced osteoporosis diagnosis and treatment rates were also assessed. To this end, patients with the principal diagnosis of low-energy hip, vertebral, or distal radius fractures were recruited for the study. Collected data included risk factors for osteoporosis, history of previous fractures, known history of osteoporosis, and osteoporosis treatment at the time of admission. The patients' prefracture risk profile was also assessed to determine whether osteoporosis could have been identified prior to the index fracture. We identified 308 patients with fragility fractures, including 214 hip, 41 vertebral, and 53 distal radius fractures. Overall, 238 patients (77.3%) had at least one risk factor for osteoporosis. Eighty-eight patients (28.6%) had sustained ≥ 1 prior fragility fractures in the past. However, only 79 patients (25.6%) were aware that they had osteoporosis and even fewer (66 patients, 21.4%) had been receiving osteoporosis treatment preceding the current admission. Anti-osteoporotic agents were more commonly prescribed in patients 66-75 years old (p = 0.008), with a family history of osteoporosis (p = 0.009) or history of a prior fragility fracture (p = 0.012). The treatment rate was higher in women than men (p = 0.026) and in patients with vertebral or multiple prior fractures compared to patients with prior hip fractures. The current study provides evidence that individuals who experience fragility fractures are not adequately managed for osteoporosis. Only few of the historically known risk factors for osteoporosis were adequately recognized and associated with osteoporosis evaluation and treatment.

The Sensitivity of Orthopaedic Surgeons to the Secondary Prevention of Fragility Fractures

BACKGROUND

Orthopaedic surgeons must play an important role in the secondary prevention of fragility fractures; however, some surgeons are more aware than others of their responsibility regarding fracture prevention. The purpose of the present study was to identify which factors can lead to a higher sensitivity for fracture prevention.

METHODS

A cross-sectional survey was distributed to orthopaedic surgeons via online invitation or at academic conferences in China from July through October 2015. A total of 452 surgeons responded. As the primary outcome measure, we created a sensitivity scoring system for fracture prevention based on the respondents' answers to 5 questions regarding behavior in the following areas: risk-factor evaluation, pharmacologic therapy, nonpharmacologic therapy, patient education, and follow-up. Multivariable linear regression and multivariable logistic regression analyses were used to identify factors related to surgeon sensitivity to fracture prevention.

RESULTS

Very few surgeons reported having received adequate training regarding fracture prevention or reading guidelines or other fracture prevention literature (22% and 30%, respectively). Most respondents initiated pharmacologic or nonpharmacologic therapy (82% and 75%, respectively) for the treatment of confirmed osteoporosis among patients with fragility fractures, but only half performed a risk-factor evaluation, patient education, or timely patient follow-up (51%, 52%, and 48%, respectively). In the multivariable linear regression model, the orthopaedic surgeon's age (β = 0.09, p = 0.003), self-rated knowledge level regarding osteoporosis or related issues (β = 0.16, p < 0.001), self-perceived effectiveness in using preventive measures for patients with a fragility fracture (β = 0.62, p < 0.001), and use of clinical pathways for fragility fractures in his or her workplace (β = 1.24, p < 0.001) were independently associated with sensitivity scores for fracture prevention. Similar results were obtained from a multivariable logistic regression model.

CONCLUSIONS

In China, the sensitivity of orthopaedic surgeons to the secondary prevention of fragility fractures is relatively low. Implementation of a comprehensive prevention approach and targeted continuing medical education are required to encourage surgeons to take greater responsibility for screening, treating, educating, and following their patients with fragility fractures.

Academic Geriatric Orthopaedics: A New paradigm for Inpatient Care

Purpose of review

Healthcare systems are embarking on innovative, technologically savvy approaches to caring for our most rapidly growing population worldwide- the elderly. As healthcare systems respond, adapt and strategically plan for this rapidly growing population, it is paramount that we develop new paradigms of care for older patients. This review highlights some of the approaches academic medical centers are taking to improve the musculoskeletal and orthopaedic health of older adults.

Recent Findings

Academic health centers are posed to set and lead the standard of care for the next generation of orthopaedic care for older adults by leveraging innovative informatics platforms, quality improvement methodologies, game-changing research initiatives, education to the next generation of providers and helping change policies to help patients receive the best quality of life possible across the aging spectrum.

Summary

Academic geriatric orthopaedics can help society embrace a new paradigm in care for older adults by leveraging rapidly developing technologically and innovative approaches to care, advanced research, and education.

The Use of Distal Ulnar Hounsfield Units to Predict Future Fragility Fracture Risk

PURPOSE

Distal ulnar Hounsfield unit (HU) measurements obtained from computed tomography (CT) scans of the wrist can be used to accurately screen for low bone mineral density. It is unknown whether HU measurements can also predict the risk of future fragility fractures. Therefore, the purpose of this study was to determine if the HU values of the distal ulna correlate to fragility fracture risk.

METHODS

An electronic database of radiographs at a single institution was searched for all wrist CT scans, obtained for any reason, between January 1, 2002, and December 31, 2008, to allow a minimum of 5-year follow-up. Manual measurement of HU on sequential coronal CT slices of the distal ulnar head was taken, and mean values were recorded. Previously determined cutoff values for the diagnosis of low bone mineral density were implemented to stratify patients as at risk or not at risk for future fragility fracture. Medical records were then manually reviewed for the occurrence of any future fragility fracture (hip, spine, proximal humerus, or rib).

RESULTS

There were 161 CTs in 157 patients and 34 fragility fractures in 21 patients, with a prevalence of 13.4%. The mean HU in the fragility fracture group was significantly lower (134.2 vs 197.1 HU). The percentage of low HU patients with fragility fractures was significantly higher (22.7% vs 3.8%). The odds ratio for fragility fracture in the low HU group was 7.4 (95% confidence interval, 2.1-26.2). Using previously determined cutoff values, the sensitivity and specificity of distal ulna HU values for identifying patients who would sustain at least 1 future fragility fracture were 85.7% and 55.2%, respectively.

CONCLUSIONS

Patients with low distal ulnar HU were significantly more likely to sustain a subsequent fragility fracture. A determination of distal ulnar HUs represents a quick, simple tool to identify patients potentially at risk for fragility fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Working to Increase Stability through Exercise (WISE): Study protocol for a pragmatic randomized controlled trial of a coached exercise program to reduce serious fall-related injuries

Approximately one-third of older adults fall each year and fall-related injuries are a leading cause of death and disability among this rapidly expanding age group. Despite the availability of bisphosphonates to reduce fractures, concerns over side effects have dramatically reduced use, suggesting that other treatment options are needed. Though many smaller studies have shown that physical activity programs can reduce falls, no study has been adequately powered to detect a reduction in fall-related injuries. We present the design of a three-year randomized controlled clinical trial of 1130 adults age 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The main aim is to determine the impact of a community-based multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers (or delivered via DVD) and accompanied by coaching and oversight, by telephone and in-person, by a fitness professional. The main outcome measure is serious fall-related injuries. Secondary outcomes include health care utilization, bone and muscle mass, loneliness, health-related quality of life and mood. The study represents the first large clinical trial of a comprehensive physical activity program to reduce secondary injuries among patients with a history of fragility fracture.

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.