Should vertebral fracture assessment be performed in Fracture Liaison Service patients with non-vertebral fracture?

Prior non-vertebral fractures, except of the ankle, are associated with increased likelihood of vertebral fracture. As knowledge of vertebral fracture presence may alter care, vertebral fracture assessment (VFA) is indicated in patients with prior fracture. INTRODUCTION: Vertebral fractures are often unappreciated. It was recently advocated that all Fracture Liaison Service (FLS) patients have densitometric VFA performed. We evaluated the likelihood of vertebral fracture identification with VFA in patients with prior fracture using the Manitoba Bone Density database. METHODS : VFA was performed in patients with T-scores below - 1.5 and age 70 + (or younger with height loss or glucocorticoid use) obtaining bone densitometry in Manitoba from 2010 to 2018. Those with prior clinical vertebral fracture, pathologic fracture, or uninterpretable VFA were excluded. Vertebral fractures were identified using the modified ABQ method. Health records were assessed for non-vertebral fracture (excluding head, neck, hand, foot) diagnosis codes unassociated with trauma prior to DXA. Multivariable odds ratios (ORs) for vertebral fracture were estimated without and with adjustment for age, sex, body mass index, ethnicity, area of residence, income level, comorbidity score, diabetes mellitus, falls in the last year, glucocorticoid use, and lowest BMD T-score. RESULTS: The study cohort consisted of 12,756 patients (94.4% women) with mean (SD) age 75.9 (6.8) years. Vertebral fractures were identified in 1925 (15.1%) overall. Vertebral fractures were significantly more likely (descending order) in those with prior pelvis, hip, humerus, other sites, and forearm, but not ankle fracture. There was modest attenuation with covariate adjustment but statistical significance was maintained. CONCLUSIONS: Prior hip, humerus, pelvis, forearm, and other fractures are associated with an increased likelihood of previously undiagnosed vertebral fracture, information useful for risk stratification and monitoring. These data support recommending VFA in FLS patients who are age 70 + with low BMD.

Time since prior fracture affects mortality at the time of clinical assessment: a registry-based cohort study.

Fractures are associated with increased long-term mortality in patients surviving to undergo baseline DXA. Notably, excess mortality risk does not decline with increasing time since prior hip or humerus fractures, even after accounting for comorbid medical conditions and other risk factors. INTRODUCTION: Mortality risk increases following most types of fracture. In routine clinical practice, patients with prior fractures seen for dual-energy X-ray absorptiometry scan (DXA) are "survivors;" whether they remain at increased mortality risk is unknown. We tested the association between prior fracture and all-cause mortality, stratified by time since fracture, in patients undergoing baseline DXA. METHODS: We conducted a DXA registry-based cohort study and linked to population-based health services data for the Province of Manitoba, Canada. We identified women and men ≥ 40 years with minimum 10 years of prior healthcare coverage undergoing baseline DXA and ascertained prior fracture codes since 1984 and mortality to 2017. Time since prior fracture was calculated between the clinical encounter for the fracture and baseline DXA (index date). Cox proportional hazards models estimated hazard ratios for all-cause mortality in those with compared to those without prior fracture adjusted for (1) age and sex, and (2) age, sex, comorbidities, and other covariates. RESULTS: The study cohort consisted of 74,474 individuals (mean age 64.6 years, 89.7% female). During mean follow-up 9.2 years, we ascertained 14,923 (20.0%) deaths. Except for forearm fractures, all fracture sites were associated with increased mortality risk compared to those without prior fracture, even after multivariable adjustment. Excess mortality risk tended to decline slightly with time since fracture and was no longer significant > 10 years after vertebral fracture. However, excess mortality persisted > 10 years following hip or humerus fracture. CONCLUSIONS: Prior fractures are associated with increased long-term mortality in patients surviving to undergo baseline DXA. Excess mortality risk does not decline with time since prior hip or humerus fractures, after accounting for potential confounders. Fracture prevention may have important long-term benefits preserving life expectancy.

Pre-fracture individual characteristics associated with high total health care costs after hip fracture.

Older women with pre-fracture slow walk speed, high body mass index, and/or a high level of multimorbidity have significantly higher health care costs after hip fracture compared to those without those characteristics. Studies to investigate if targeted health care interventions for these individuals can reduce hip fracture costs are warranted. INTRODUCTION: The aim of this study is to estimate the associations of individual pre-fracture characteristics with total health care costs after hip fracture, using Study of Osteoporotic Fractures (SOF) cohort data linked to Medicare claims. METHODS: Our study population was 738 women age 70 and older enrolled in Medicare Fee for Service (FFS) who experienced an incident hip fracture between January 1, 1992 and December 31, 2009. We assessed pre-fracture individual characteristics at SOF study visits and estimated costs of hospitalizations, skilled nursing facility and inpatient rehabilitation stays, home health care visits, and outpatient utilization from Medicare FFS claims. We used generalized linear models to estimate the associations of predictor variables with total health care costs (2010 US dollars) after hip fracture. RESULTS: Median total health care costs for 1 year after hip fracture were $35,536 (inter-quartile range $24,830 to $50,903). Multivariable-adjusted total health care costs for 1 year after hip fracture were 14 % higher ($5256, 95 % CI $156 to $10,356) in those with walk speed <0.6 m/s compared to ≥1.0 m/s, 25 % higher ($9601, 95 % CI $3314 to $16,069) in those with body mass index ≥30 kg/m2 compared to 20 to 24.9 mg/kg2, and 21 % higher ($7936, 95 % CI $346 to $15,526) for those with seven or more compared to no comorbid medical conditions. CONCLUSIONS: Pre-fracture poor mobility, obesity, and multiple comorbidities are associated with higher total health care costs after hip fracture in older women. Studies to investigate if targeted health care interventions for these individuals can reduce the costs of hip fractures are warranted.

Use of a performance algorithm improves utilization of vertebral fracture assessment in clinical practice.

SUMMARY: A performance algorithm can be successfully used by bone density technologists at the time of a bone density test to identify patients with an indication for vertebral fracture assessment (VFA). Doing so appropriately increases physician prescription of fracture prevention medication. INTRODUCTION: Densitometric spine imaging (vertebral fracture assessment, VFA) can identify prevalent vertebral fracture but is underutilized. We developed an algorithm by which DXA technologists identify patients for whom VFA should be performed. Following this algorithm, VFA was performed in patients whose lowest T-score (lumbar spine, total hip, or femoral neck) was between -1.5 and -2.4 inclusive and with one of the following: age, ≥ 65 years; height loss, ≥ 1.5 in.; or current systemic glucocorticoid therapy. Our main objectives were to assess change in VFA utilization at two other healthcare organizations after algorithm implementation, and to estimate the association of VFA results with prescription of fracture prevention medication. METHODS: The proportions of patients with an indication for VFA who had one performed before and after algorithm implementation were compared. Logistic regression was used to estimate the multivariable-adjusted association of VFA results with subsequent prescription of fracture prevention medication adjusted for healthcare organization (study site). RESULTS: After algorithm introduction, appropriate VFA use rose significantly Patients with a VFA positive for vertebral fracture had an odds ratio of 3.2 (95 % C.I., 2.1- 5.1) for being prescribed new fracture prevention medication, adjusted for age, sex, prior clinical fracture, use of glucocorticoid medication, femoral neck bone mineral density T-score, and study site. CONCLUSIONS: An algorithm to identify those for whom VFA is indicated can successfully be implemented by DXA technologists. Documentation of vertebral fracture increases prescription of fracture prevention medication for patients who otherwise lack an apparent indication for such therapy.

Magnitude and consequences of misclassification of incident hip fractures in large cohort studies: the Study of Osteoporotic Fractures and Medicare claims data.

UNLABELLED: In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report. INTRODUCTION: Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported. METHODS: We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF. RESULTS: Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data. CONCLUSIONS: A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).

Cost-effectiveness of bone densitometry among Caucasian women and men without a prior fracture according to age and body weight.

UNLABELLED: We used a microsimulation model to estimate the threshold body weights at which screening bone densitometry is cost-effective. Among women aged 55-65 years and men aged 55-75 years without a prior fracture, body weight can be used to identify those for whom bone densitometry is cost-effective. INTRODUCTION: Bone densitometry may be more cost-effective for those with lower body weight since the prevalence of osteoporosis is higher for those with low body weight. Our purpose was to estimate weight thresholds below which bone densitometry is cost-effective for women and men without a prior clinical fracture at ages 55, 60, 65, 75, and 80 years. METHODS: We used a microsimulation model to estimate the costs and health benefits of bone densitometry and 5 years of fracture prevention therapy for those without prior fracture but with femoral neck osteoporosis (T-score ≤ -2.5) and a 10-year hip fracture risk of ≥3%. Threshold pre-test probabilities of low BMD warranting drug therapy at which bone densitometry is cost-effective were calculated. Corresponding body weight thresholds were estimated using data from the Study of Osteoporotic Fractures (SOF), the Osteoporotic Fractures in Men (MrOS) study, and the National Health and Nutrition Examination Survey (NHANES) for 2005-2006. RESULTS: Assuming a willingness to pay of $75,000 per quality adjusted life year (QALY) and drug cost of $500/year, body weight thresholds below which bone densitometry is cost-effective for those without a prior fracture were 74, 90, and 100 kg, respectively, for women aged 55, 65, and 80 years; and were 67, 101, and 108 kg, respectively, for men aged 55, 75, and 80 years. CONCLUSIONS: For women aged 55-65 years and men aged 55-75 years without a prior fracture, body weight can be used to select those for whom bone densitometry is cost-effective.

Potential for bone turnover markers to cost-effectively identify and select post-menopausal osteopenic women at high risk of fracture for bisphosphonate therapy.

INTRODUCTION AND HYPOTHESIS: Over half of all fractures among post-menopausal women occur in those who do not have osteoporosis by bone density criteria. Measurement of bone turnover may cost-effectively identify a subset of women with T-score >-2.5 for whom anti-resorptive drug therapy is cost-effective. METHODS: Using a Markov model, we estimated the cost per quality adjusted life year (QALY) for five years of oral bisphosphonate compared to no drug therapy for osteopenic post-menopausal women aged 60 to 80 years with a high (top quartile) or low (bottom 3 quartiles) level of a bone turnover marker. RESULTS: For women with high bone turnover, the cost per QALY gained with alendronate compared to no drug therapy among women aged 70 years with T-scores of -2.0 or -1.5 were $58,000 and $80,000 (U.S. 2004 dollars), respectively. If bisphosphonates therapy also reduced the risk of non-vertebral fractures by 20% among osteopenic women with high bone turnover, then the costs per QALY gained were $34,000 and $50,000 for women age 70 with high bone turnover and T-scores of -2.0 and -1.5, respectively. CONCLUSION: Measurement of bone turnover markers has the potential to identify a subset of post-menopausal women without osteoporosis by bone density criteria for whom bisphosphonate therapy to prevent fracture is cost-effective. The size of that subset highly depends on the assumed efficacy of bisphosphonates for fracture risk reduction among women with both a T-score >-2.5 and high bone turnover and the cost of bisphosphonate treatment.

Team managed outpatient care for early onset chronic inflammatory arthritis.

OBJECTIVE: To determine whether an outpatient team management program for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional, nonteam outpatient rheumatologic care in a clinic setting. METHODS: One hundred eighteen patients with chronic inflammatory arthritis were randomly assigned to a team managed outpatient care program (TEAMCARE) or to traditional, one on one, nonteam managed rheumatologic care (TRADCARE). The TEAMCARE program consisted of a half day educational program, a needs assessment intake interview, and quarterly telephone calls, monthly team meetings, and routine rheumatologic care. TRADCARE patient received unconstrained, routine primary and specialty outpatient care as practised typically by rheumatologists at this large multi-specialty clinic. All patients had numerous physical and laboratory outcome assessments by rheumatologists at office visit. Every 6 months, patients completed several self-report measures of functional status, pain, psychosocial status, and costs. RESULTS: One hundred seven patients completed one year of study participation. No significant differences were found between groups in measures of physical status, physical functioning, psychosocial status, or pain. There were no differences between groups in economic or utilization measures. CONCLUSION: This team managed outpatient program for persons with recent onset chronic inflammatory arthritis afforded no advantage to routine outpatient care, characterized mainly by one on one relationships between patients and primary care doctors and rheumatologists, in our active outpatient clinical environment.