Patients' preferences for fracture risk communication: the Risk Communication in Osteoporosis (RICO) study.

The RICO study indicated that most patients would like to receive information regarding their fracture risk but that only a small majority have actually received it. Patients globally preferred a visual presentation of fracture risk and were interested in an online tool showing the risk. PURPOSE: The aim of the Risk Communication in Osteoporosis (RICO) study was to assess patients' preferences regarding fracture risk communication. METHODS: To assess patients' preferences for fracture risk communication, structured interviews with women with osteoporosis or who were at risk for fracture were conducted in 11 sites around the world, namely in Argentina, Belgium, Canada at Hamilton and with participants from the Osteoporosis Canada Canadian Osteoporosis Patient Network (COPN), Japan, Mexico, Spain, the Netherlands, the UK, and the USA in California and Washington state. The interviews used to collect data were designed on the basis of a systematic review and a qualitative pilot study involving 26 participants at risk of fracture. RESULTS: A total of 332 women (mean age 67.5 ± 8.0 years, 48% with a history of fracture) were included in the study. Although the participants considered it important to receive information about their fracture risk (mean importance of 6.2 ± 1.4 on a 7-point Likert scale), only 56% (i.e. 185/332) had already received such information. Globally, participants preferred a visual presentation with a traffic-light type of coloured graph of their FRAX® fracture risk probability, compared to a verbal or written presentation. Almost all participants considered it important to discuss their fracture risk and the consequences of fractures with their healthcare professionals in addition to receiving information in a printed format or access to an online website showing their fracture risk. CONCLUSIONS: There is a significant communication gap between healthcare professionals and patients when discussing osteoporosis fracture risk. The RICO study provides insight into preferred approaches to rectify this communication gap.

Variation in bone mineral density and fractures over 20 years among Canadians: a comparison of the Canadian Multicenter Osteoporosis Study and the Canadian Longitudinal Study on Aging.

International variations in osteoporosis and fracture rates have been reported, with temporal trends differing between populations. We observed higher BMD and lower fracture prevalence in a recently recruited cohort compared to that of a cohort recruited 20 years ago, even after adjusting for multiple covariates. PURPOSE: We explored sex-specific differences in femoral neck bone mineral density (FN-BMD) and in prevalent major osteoporotic fractures (MOF) using two Canadian cohorts recruited 20 years apart. METHODS: We included men and women aged 50-85 years from the Canadian Multicentre Osteoporosis Study (CaMos, N = 6,479; 1995-1997) and the Canadian Longitudinal Study on Aging (CLSA, N = 19,534; 2012-2015). We created regression models to compare FN-BMD and fracture risk between cohorts, adjusting for important covariates. Among participants with prevalent MOF, we compared anti-osteoporosis medication use. RESULTS: Mean (SD) age in CaMos (65.4 years [8.6]) was higher than in CLSA (63.8 years [9.1]). CaMos participants had lower mean body mass index and higher prevalence of smoking (p < 0.001). Adjusted linear regression models (estimates [95%CI]) demonstrated lower FN-BMD in CaMos women (- 0.017 g/cm2 [- 0.021; - 0.014]) and men (- 0.006 g/cm2 [- 0.011; 0.000]), while adjusted odds ratios (95%CI) for prevalent MOF were higher in CaMos women (1.99 [1.71; 2.30]) and men (2.33 [1.82; 3.00]) compared to CLSA. In women with prevalent MOF, menopausal hormone therapy use was similar in both cohorts (43.3% vs 37.9%, p = 0.076), but supplements (32.0% vs 48.3%, p < 0.001) and bisphosphonate use (5.8% vs 17.3%, p < 0.001) were lower in CaMos. The proportion of men with MOF who received bisphosphonates was below 10% in both cohorts. CONCLUSION: Higher BMD and lower fracture prevalence were noted in the more recently recruited CLSA cohort compared to CaMos, even after adjusting for multiple covariates. We noted an increase in bisphosphonate use in the recent cohort, but it remained very low in men.

Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update.

BACKGROUND: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. METHODS: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. RECOMMENDATIONS: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. INTERPRETATION: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life.

Transition from Pediatric to Adult Health Care in Osteogenesis Imperfecta.

PURPOSE: Here, we review issues regarding the transition from pediatric to adult-focused health care for individuals with osteogenesis imperfecta (OI). RECENT FINDINGS: The clinical consequences of OI change during the lifespan. Fracture rates are lower in adults than in children with OI, whereas other manifestations are typically becoming more prominent in adults. The evidence base for the transition to adult health care in OI is thin, as the literature on the topic is limited to qualitative investigations on a small number of participants. A few tools to help with transition, such as a program to improve self-management skills, have been developed. The transition process varies markedly between health care systems, which makes generalizations difficult. However, a better definition of follow-up requirements and care of adults with OI might be helpful for the transition from pediatric to adult health care.

Non-pharmacological management of osteoporotic vertebral fractures: Patient perspectives and experiences.

OBJECTIVE: To understand perceptions on rehabilitation after vertebral fracture, non-pharmacological strategies, and virtual care from the perspective of individuals living with vertebral fractures. DESIGN AND SETTING: We conducted semi-structured interviews online and performed a thematic and content analysis from a post-positivism perspective. PARTICIPANTS: Ten individuals living with osteoporotic vertebral fractures (9F, 1 M, aged 71 ± 8 years). RESULTS: Five themes emerged: pain is the defining limitation of vertebral fracture recovery; delayed diagnosis impacts recovery trajectory; living with fear; being dissatisfied with fracture management; and "getting back into the game of life" using non-pharmacological strategies. CONCLUSION: Participants reported back pain and an inability to perform activities of daily living, affecting psychological and social well-being. Physiotherapy, education, and exercise were considered helpful and important to patients; however, issues with fracture identification and referral limited the use of these options. Participants believed that virtual rehabilitation was a feasible and effective alternative to in-person care, but perceived experience with technology, cost, and individualization of programs as barriers.

Race/ethnic differences in the prevalence of osteoporosis, falls and fractures: a cross-sectional analysis of the Canadian Longitudinal Study on Aging.

Most of the published epidemiology on osteoporosis is derived from White populations; still many countries have increasing ethno-culturally diverse populations, leading to gaps in the development of population-specific effective fracture prevention strategies. We describe differences in prevalent fracture and bone mineral density patterns in Canadians of different racial/ethnic backgrounds. INTRODUCTION: We described prevalent fracture and bone mineral density (BMD) patterns in Canadians by their racial/ethnic backgrounds. METHODS: For this cross-sectional analysis, we used the Canadian Longitudinal Study on Aging baseline data (2011-2015) of 22,091 randomly selected participants of Black, East Asian, South or Southeast Asian (SSEA) and White race/ethnic backgrounds, aged 45-85 years with available information on the presence or absence of self-reported prevalent low trauma fractures and femoral neck BMD (FNBMD) measurement. Logistic and linear regression models examined associations of race/ethnic background with fracture and FNBMD, respectively. Covariates included sex, age, height, body mass index (BMI), grip strength and physical performance score. RESULTS: We identified 11,166 women and 10,925 men. Self-reported race/ethnic backgrounds were: 139 Black, 205 East Asian, 269 SSEA and 21,478 White. White participants were older (mean 62.5 years) than the other groups (60.5 years) and had a higher BMI (28.0 kg/m2) than both Asian groups, but lower than the Black group. The population-weighted prevalence of falls was 10.0%, and that of low trauma fracture was 12.0% ranging from 3.3% (Black) to 12.3% (White), with Black and SSEA Canadians having lower adjusted odds ratios (aOR) of low trauma fractures than White Canadians (Black, aOR = 0.3 [95% confidence interval: 0.1-0.7]; SSEA, aOR = 0.5 [0.3-0.8]). The mean (SD) FNBMD varied between groups: Black, 0.907 g/cm2 (0.154); East Asian, 0.748 g/cm2 (0.119); SSEA, 0.769 g/cm2 (0.134); and White, 0.773 g/cm2 (0.128). Adjusted linear regressions suggested that Black and both Asian groups had higher FNBMD compared to White. CONCLUSION: Our results support the importance of characterizing bone health predictors in Canadians of different race/ethnic backgrounds to tailor the development of population-specific fracture prevention strategies.

Perceptions of fracture and fall risk and of the benefits and barriers to exercise in adults with diabetes.

The increased risk of fractures and falls is under-appreciated by adults living with diabetes and by their healthcare providers. Strategies to overcome perceived exercise barriers and exercise programs optimized for bone health should be implemented. PURPOSE: The purpose of the study was to assess the perceptions of fracture and fall risk, and the perceived benefits of and barriers to exercise in adults ≥ 50 years old living with type 1 (T1D) and type 2 diabetes (T2D). METHODS: Participants were recruited through social media and from medical clinics and invited to complete a self-administered online survey, comprising 38 close-ended questions and 4 open-ended questions. RESULTS: A total of 446 participants completed the survey: 38% T1D, 59% T2D, and 3% with unreported diabetes type. Most participants did not believe that having diabetes increased their risk of fractures (81%) nor falls (68%), and more than 90% reported having not been informed about diabetes-related fracture risk by their physicians. Among exercise types, participation in moderate aerobic exercise was most common (54%), while only 31%, 32%, and 37% of participants engaged in strenuous aerobic, resistance, and balance/flexibility exercise, respectively. The most prevalent barrier to exercise for both T1D and T2D was a lack of motivation, reported by 54% of participants. Lack of time and fear of hypoglycemia were common exercise barriers reported by participants with T1D. Most participants owned a smart phone (69%), tablet (60%), or computer (56%), and 46% expressed an interest in partaking in virtually delivered exercise programs. CONCLUSIONS: Adults living with diabetes have limited awareness of increased fall and fracture risk. These risks are insufficiently highlighted by health care providers; strategies to overcome perceived exercise barriers and exercise programs optimized for bone health should be implemented.

Evaluation of Increasing Dairy Intake on Bone Density in Postpubertal Youth: A Randomized Controlled Trial Using Motivational Interviewing.

BACKGROUND: Adequate nutrition is important for bone health, especially for bone mineral accretion. OBJECTIVES: The primary objective tested whether increasing dairy intake using the motivational interviewing technique (MInt) improves lumbar spine (LS) bone mineral density (BMD) after 2 y in postpubertal adolescents with habitual dairy intake of <2 dairy servings/d. METHODS: Participants (aged 14-18.9 y) were randomly allocated to: group 1 (control), group 2 (target of 3 dairy servings/d), or group 3 (target of ≥4 dairy servings/d) for 12 mo, with groups 2 and 3 using MInt, with an additional 12-mo nonintervention follow-up. The primary outcome was LS BMD, and secondary outcomes were: whole body, total hip (TH), and 33% distal radius BMD using DXA, bone geometry using peripheral quantitative computed tomography, and bone biomarkers. RESULTS: Ninety-four adolescents (16.6 ± 1.5 y) were recruited. Seventy-six (80.9%) completed the 12-mo assessments. From baseline to 12 mo, dairy intake in female groups 2 and 3 increased by 107% and 208%, respectively; and by 48% and 153% in males of groups 2 and 3, respectively. In females, group 3 had greater increases in TH BMD (4.3% to 7.5%) compared with control (3.7% to 4.9%, P = 0.04) and group 2 (0.0% to 1.7%, P = 0.04) at 12 and 24 mo. No effects due to dairy intake were observed for DXA outcomes in males for radial and tibial volumetric BMD in both sexes. None of the bone biomarkers were different among the dairy groups in females or males. CONCLUSIONS: MInt effectively increased dairy intake with benefits to bone health only in female adolescents with previously low calcium intake who consumed ≥4 dairy servings/d for 12 mo. Larger studies are required to explain the lack of intervention effect in males.

Evaluation of Increasing Dairy Intake on Bone Density in Postpubertal Youth: A Randomized Controlled Trial Using Motivational Interviewing.

BACKGROUND: Adequate nutrition is important for bone health, especially for bone mineral accretion. OBJECTIVES: The primary objective tested whether increasing dairy intake using the motivational interviewing technique (MInt) improves lumbar spine (LS) bone mineral density (BMD) after 2 y in postpubertal adolescents with habitual dairy intake of <2 dairy servings/d. METHODS: Participants (aged 14-18.9 y) were randomly allocated to: group 1 (control), group 2 (target of 3 dairy servings/d), or group 3 (target of ≥4 dairy servings/d) for 12 mo, with groups 2 and 3 using MInt, with an additional 12-mo nonintervention follow-up. The primary outcome was LS BMD, and secondary outcomes were: whole body, total hip (TH), and 33% distal radius BMD using DXA, bone geometry using peripheral quantitative computed tomography, and bone biomarkers. RESULTS: Ninety-four adolescents (16.6 ± 1.5 y) were recruited. Seventy-six (80.9%) completed the 12-mo assessments. From baseline to 12 mo, dairy intake in female groups 2 and 3 increased by 107% and 208%, respectively; and by 48% and 153% in males of groups 2 and 3, respectively. In females, group 3 had greater increases in TH BMD (4.3% to 7.5%) compared with control (3.7% to 4.9%, P = 0.04) and group 2 (0.0% to 1.7%, P = 0.04) at 12 and 24 mo. No effects due to dairy intake were observed for DXA outcomes in males for radial and tibial volumetric BMD in both sexes. None of the bone biomarkers were different among the dairy groups in females or males. CONCLUSIONS: MInt effectively increased dairy intake with benefits to bone health only in female adolescents with previously low calcium intake who consumed ≥4 dairy servings/d for 12 mo. Larger studies are required to explain the lack of intervention effect in males.

Performance of the Garvan Fracture Risk Calculator in Individuals with Diabetes: A Registry-Based Cohort Study.

Diabetes increases fracture and falls risks. We evaluated the performance of the Garvan fracture risk calculator (FRC) in individuals with versus without diabetes. Using the population-based Manitoba bone mineral density (BMD) registry, we identified individuals aged 50-95 years undergoing baseline BMD assessment from 1 September 2012, onwards with diabetes and self-reported falls in the prior 12 months. Five-year Garvan FRC predictions were generated from clinical risk factors, with and without femoral neck BMD. We identified non-traumatic osteoporotic fractures (OF) and hip fractures (HF) from population-based data to 31 March 2018. Fracture risk stratification was assessed from area under the receiver operating characteristic curves (AUROC). Cox regression analysis was performed to examine the effect of diabetes on fractures, adjusted for Garvan FRC predictions. The study population consisted of 2618 women with and 14,064 without diabetes, and 636 and 2201 men with and without the same, respectively. The Garvan FRC provided significant OF and HF risk stratification in women with diabetes, similar to those without diabetes. Analyses of OF in men were limited by smaller numbers; no significant difference was evident by diabetes status. Cox regression showed that OF risk was 23% greater in women with diabetes adjusted for Garvan FRC including BMD (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.49), suggesting it slightly underestimated risk; a non-significant increase in diabetes-related HF risk was noted (HR 1.37, 95% CI 0.88-2.15). Garvan FRC shows similar fracture risk stratification in individuals with versus without diabetes, but may underestimate this risk.

Determinants of pain assessment documentation in intensive care units.

PURPOSE: The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation. METHODS: A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed. RESULTS: All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (ß = 0.37), using only breakthrough doses (ß = 0.24), and lower opioid doses (ß = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25). CONCLUSION: Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.

RéSUMé: OBJECTIF: La sous-évaluation de la douleur constitue un obstacle majeur à une gestion efficace de la douleur, et le manque de documentation de l'évaluation de la douleur a été associé à des conséquences défavorables pour les patients. Cette étude visait à : 1) décrire les facteurs contextuels liés à l'évaluation et à la gestion de la douleur dans cinq unités de soins intensifs (USI) du Québec; 2) décrire leurs pratiques de documentation de l'évaluation de la douleur; et 3) identifier les déterminants sociodémographiques et cliniques liés à la documentation de l'évaluation de la douleur. MéTHODE: Un devis de recherche rétrospectif descriptif-corrélationnel a été utilisé. Les données sociodémographiques (c.-à-d. l'âge, le sexe), les données cliniques (c.-à-d. le diagnostic, la ventilation mécanique, le niveau de conscience, la gravité de la maladie, les opioïdes, les sédatifs) et les évaluations de la douleur ont été extraites de 345 dossiers médicaux avec admissions à l'USI de cinq hôpitaux universitaires entre 2017 et 2019. Des statistiques descriptives et une régression linéaire multiple ont été effectuées. RéSULTATS: Tous les sites ont déclaré utiliser l'échelle d'évaluation numérique de 0 à 10, mais l'implantation d'une échelle de douleur comportementale variait d'un site à un autre. Une médiane de trois évaluations de douleur étaient documentées par 24 heures, ce qui est inférieur à la recommandation minimale de huit à 12 évaluations de douleur par 24 heures. Dans l'ensemble, l'évaluation de la douleur était présente dans 70 % des dossiers, mais seulement 20 % des doses d'opioïdes étaient suivies d'une réévaluation documentée de la douleur dans l'heure suivant leur'administration. Un niveau de conscience plus élevé (ß = 0,37), l'utilisation exclusive d'entredoses d'opioïdes pour les percées de douleur (ß = 0,24) et des doses d'opioïdes plus faibles (ß = -0,21) ont constitué les déterminants significatifs dans la documentation de l'évaluation de la douleur (R2 ajusté = 0,25). CONCLUSION: La documentation de l'évaluation de la douleur est sous-optimale dans les USI, en particulier pour les patients incapables de s'exprimer ou ceux qui reçoivent des doses plus élevées d'opioïdes. Les résultats de cette étude soulignent l'importance d'implanter des outils pour optimiser l'évaluation et la documentation de la douleur.

Clinical manifestations of osteogenesis imperfecta in adulthood: An integrative review of quantitative studies and case reports.

Osteogenesis imperfecta (OI) is a rare genetic disorder of the bones caused by a mutation in Type I collagen genes. As adults with OI are aging, medical concerns secondary to OI may arise. This integrative review sought to review, appraise, and synthesize the clinical manifestations faced by adults with OI. Four electronic bibliographic databases were searched. Published quantitative, qualitative, and mixed-methods studies, as well as case reports from 2000 to March 2019, addressing a clinical manifestation in adulthood, were reviewed. Eligible studies and case reports were subsequently appraised using the Mixed Methods Appraisal Tool and Case Report Checklist, respectively. Twenty quantitative studies and 88 case reports were included for review regardless of the varying methodological quality score. These studies collectively included 2,510 adults with different OI types. Several clinical manifestations were studied, and included: hearing loss, cardiac diseases, pregnancy complications, cerebrovascular manifestations, musculoskeletal manifestations, respiratory manifestations, vision impairment, and other clinical manifestations. Increased awareness may optimize prevention, treatment, and follow-up. Opportunities to enhance the methodological quality of research including better design and methodology, multisite collaborations, and larger and diverse sampling will optimize the generalizability and transferability of findings.

New Developments in Fracture Risk Assessment for Current Osteoporosis Reports.

PURPOSE OF REVIEW: Identifying individuals at high fracture risk can be used to target those likely to derive the greatest benefit from treatment. This narrative review examines recent developments in using specific risk factors used to assess fracture risk, with a focus on publications in the last 3 years. RECENT FINDINGS: There is expanding evidence for the recognition of individual clinical risk factors and clinical use of composite scores in the general population. Unfortunately, enthusiasm is dampened by three pragmatic randomized trials that raise questions about the effectiveness of widespread population screening using clinical fracture prediction tools given suboptimal participation and adherence. There have been refinements in risk assessment in special populations: men, patients with diabetes, and secondary causes of osteoporosis. New evidence supports the value of vertebral fracture assessment (VFA), high resolution peripheral quantitative CT (HR-pQCT), opportunistic screening using CT, skeletal strength assessment with finite element analysis (FEA), and trabecular bone score (TBS). The last 3 years have seen important developments in the area of fracture risk assessment, both in the research setting and translation to clinical practice. The next challenge will be incorporating these advances into routine work flows that can improve the identification of high risk individuals at the population level and meaningfully impact the ongoing crisis in osteoporosis management.

Correction to: New Developments in Fracture Risk Assessment.

The article, "New Developments in Fracture Risk Assessment for Current Osteoporosis Reports.

Factors Associated With Bone Density Monitoring While on Antiosteoporosis Treatment in Routine Clinical Practice: A Registry-Based Cohort Study.

The role for bone mineral density (BMD) monitoring while on antiosteoporosis therapy remains controversial. The current study used population-based registries to identify factors associated with BMD monitoring in women within 5 yr of receiving antiosteoporosis treatment vs treatment without monitoring in routine clinical practice. The analytical dataset consisted of women age 40 yr and older at baseline receiving antiosteoporosis therapy: 6877 with BMD monitoring (mean interval 3.2 yr) and 6747 without BMD monitoring. There was a significant negative secular trend in BMD monitoring during the study period (p < 0.001). Multivariable logistic regression demonstrated that parental hip fracture, glucocorticoid and aromatase inhibitor use, and lower baseline BMD were independently and positively associated with BMD monitoring. Individuals with increasing age, greater body mass index, smoking, rheumatoid arthritis, later calendar year, diabetes, rural residency, lower income, and greater comorbidity score were less likely to undergo monitoring. A shorter monitoring interval (<23 mo) was strongly associated with glucocorticoid and aromatase inhibitor use. In conclusion, our study identifies factors associated with BMD monitoring over 5 yr in patients receiving antiosteoporosis therapy.

Variation in surgical demand and time to hip fracture repair: a Canadian database study.

BACKGROUND: Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals. METHODS: We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay. RESULTS: For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1-6.1), 12.2% (95% CI 10.3-14.2), and 22.0% (95% CI 17.7-26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay. CONCLUSION: Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

Fracture Risk in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry-Based Cohort Study.

BACKGROUND: Aromatase inhibitors (AIs) used in breast cancer induce loss in bone mineral density (BMD) and are reported to increase fracture risk. MATERIALS AND METHODS: Using a population-based BMD registry, we identified women aged at least 40 years initiating AIs for breast cancer with at least 12 months of AI exposure (n = 1,775), women with breast cancer not receiving AIs (n = 1,016), and women from the general population (n = 34,205). Fracture outcomes were assessed to March 31, 2017 (mean, 6.2 years for AI users). RESULTS: At baseline, AI users had higher body mass index (BMI), higher BMD, lower osteoporosis prevalence, and fewer prior fractures than women from the general population or women with breast cancer without AI use (all p < .001). After adjusting for all covariates, AI users were not at significantly greater risk for major osteoporotic fractures (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.93-1.42), hip fracture (HR, 0.90; 95% CI, 0.56-1.43), or any fracture (HR, 1.06; 95% CI, 0.88-1.28) compared with the general population. CONCLUSION: Higher baseline BMI, BMD, and lower prevalence of prior fracture at baseline may offset the adverse effects of AI exposure. Although confirmatory data from large cohort studies are required, our findings challenge the view that all women with breast cancer initiating AI therapy should be considered at high risk for fractures. IMPLICATIONS FOR PRACTICE: In a population-based observational registry that included 1,775 patients initiating long-term aromatase inhibitor therapy, risk for major osteoporotic fracture, hip fracture, or any fracture was similar to the general population. Higher baseline body mass index, bone mineral density, and lower prevalence of prior fracture at baseline may offset the adverse effects of aromatase inhibitor exposure.

Frailty and health services use among Quebec seniors with non-hip fractures: a population-based study using adminsitrative databases.

BACKGROUND: The number of frail elderly will increase as the world population ageing accelerates. Since frail elders are at risk of falls, hospitalizations and disabilities, they will require more health care and services. To assess frailty prevalence using health administrative databases, to examine the association between frailty and the use of medical services and to measure the excess use of health services following a non-hip fracture across frailty levels among community-dwelling seniors. METHODS: A population-based cohort study was built from the Quebec Integrated Chronic Disease Surveillance System, including men and women ≥65 years old, non-institutionalized in the pre-fracture year. Frailty was measured using the Elders Risk Assessment (ERA) index. Multivariate Generalized Estimating Equation models were used to examine the relationship between frailty levels and health services while adjusting for covariates. The excess numbers of visits to Emergency Departments (ED) and to Primary Care Practitioners (PCP) as well as hospitalizations were also estimated. RESULTS: The cohort included 178,304 fractures. There were 13.6 and 5.2% frail and robust seniors, respectively. In the post-fracture year, the risks of ED visits, PCP visits and hospitalizations, were significantly higher in frail vs. non-frail seniors: adjusted relative risk (RR) = 2.69 [95% CI: 2.50-2.90] for ED visits, RR = 1.28 [95% CI: 1.23-1.32] for PCP visits and RR = 2.34 [95% CI: 2.14-2.55] for hospitalizations. CONCLUSION: Our results suggest that it is possible to characterize seniors' frailty status at a population level using health administrative databases. Furthermore, this study shows that non-institutionalized frail seniors require more health services after an incident fracture. Screening for frailty in seniors should be part of clinical management in order to identify those at a higher risk of needing health services.

Mortality effects of timing alternatives for hip fracture surgery.

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay. METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram. RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%). INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.