Self-perception of fracture risk: what can it tell us?

In this study, we report that self-perception of fracture risk captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is associated with improved medication uptake. It suggests that adequate appreciation of fracture risk may be beneficial and lead to greater healthcare engagement and treatment. INTRODUCTION: This study aimed to assess how well self-perception of fracture risk, and fracture risk as estimated by the fracture prediction tool FRAX, related to fracture incidence and uptake and persistence of anti-osteoporosis medication among women participating in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS: GLOW is an international cohort study involving 723 physician practices across 10 countries in Europe, North America and Australia. Aged ≥ 55 years, 60,393 women completed baseline questionnaires detailing medical history, including co-morbidities, fractures and self-perceived fracture risk (SPR). Annual follow-up included self-reported incident fractures and anti-osteoporosis medication (AOM) use. We calculated FRAX risk without bone mineral density measurement. RESULTS: Of the 39,241 women with at least 1 year of follow-up data, 2132 (5.4%) sustained an incident major osteoporotic fracture over 5 years of follow-up. Within each SPR category, risk of fracture increased as the FRAX categorisation of risk increased. In GLOW, only 11% of women with a lower baseline SPR were taking AOM at baseline, compared with 46% of women with a higher SPR. AOM use tended to increase in the years after a reported fracture. However, women with a lower SPR who were fractured still reported lower AOM rates than women with or without a fracture but had a higher SPR. CONCLUSIONS: These results suggest that SPR captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is also associated with improved medication uptake.

Use of pharmacologic agents for the primary prevention of osteoporosis among older women with low bone mass.

UNLABELLED: We examined the use of pharmacologic agents for the primary prevention of osteoporosis among older women with osteopenia. We found that these individuals were not managed in concordance with the National Osteoporosis Foundation (NOF) guidelines and that self-perceived osteoporosis risk and lower bone density were strongly associated with receipt of treatment. INTRODUCTION: Although osteoporosis medications are used for the primary prevention of osteoporosis among persons with low bone mass (osteopenia), their use may be discordant with clinical practice guidelines. METHODS: We studied women 55 years and older participating in the Global Longitudinal Study of Osteoporosis in Women (GLOW). Eligible participants had a dual energy x-ray absorptiometry (DXA) test performed at the University of Alabama at Birmingham hospital and had an osteopenia diagnosis based on their DXA test results. Participants' demographics, fracture risk factors, and exposure to osteoporosis medications were determined from the GLOW survey. We examined the proportions of women managed in concordance with the National Osteoporosis Foundation 2008 guidelines, and we assessed factors independently associated with osteoporosis treatment decisions. Women with a prior spine or hip fracture were excluded. RESULTS: Among 597 eligible women from GLOW, the mean age ± standard deviation (SD) was 70 ± 7 years. Among all subjects, 309 (52%) were treated in concordance with the NOF 2008 guidelines. Greater self-perceived osteoporosis risk and lower bone mineral density were significantly and consistently associated with receipt of osteoporosis treatment, both for those considered appropriate and for those considered inappropriate for treatment based on the NOF guidelines. CONCLUSIONS: We found significant discordance between NOF 2008 guidelines and pharmacologic management of women with osteopenia. A person's self-perceived osteoporosis risk and bone mineral density were most strongly associated with receipt of osteoporosis medication use among women with low bone mass.

Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW).

UNLABELLED: We evaluated healthcare utilization associated with treating fracture types in >51,000 women aged ≥55 years. Over the course of 1 year, there were five times more non-hip, non-spine fractures than hip or spine fractures, resulting in twice as many days of hospitalization and rehabilitation/nursing home care for non-hip, non-spine fractures. INTRODUCTION: The purpose of this study is to evaluate medical healthcare utilization associated with treating several types of fractures in women ≥55 years from various geographic regions. METHODS: Information from the Global Longitudinal Study of Osteoporosis in Women (GLOW) was collected via self-administered patient questionnaires at baseline and year 1 (n = 51,491). Self-reported clinically recognized low-trauma fractures at year 1 were classified as incident spine, hip, wrist/hand, arm/shoulder, pelvis, rib, leg, and other fractures. Healthcare utilization data were self-reported and included whether the fracture was treated at a doctor's office/clinic or at a hospital. Patients were asked if they had undergone surgery or been treated at a rehabilitation center or nursing home. RESULTS: During 1-year follow-up, there were 195 spine, 134 hip, and 1,654 non-hip, non-spine fractures. Clinical vertebral fractures resulted in 617 days of hospitalization and 512 days of rehabilitation/nursing home care; hip fractures accounted for 1,306 days of hospitalization and 1,650 days of rehabilitation/nursing home care. Non-hip, non-spine fractures resulted in 3,805 days in hospital and 5,186 days of rehabilitation/nursing home care. CONCLUSIONS: While hip and vertebral fractures are well recognized for their associated increase in health resource utilization, non-hip, non-spine fractures, by virtue of their 5-fold greater number, require significantly more healthcare resources.

Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: the Global Longitudinal study of Osteoporosis in Women (GLOW).

UNLABELLED: Among 50,461 postmenopausal women, 1,822 fractures occurred (57% minor non-hip, non-vertebral [NHNV], 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D, followed by major NHNV and hip fractures. Decreases in physical function and health status were greatest for spine or hip fractures. INTRODUCTION: There is growing evidence that NHNV fractures result in substantial morbidity and healthcare costs. The aim of this prospective study was to assess the effect of these NHNV fractures on quality of life. METHODS: We analyzed the 1-year incidences of hip, spine, major NHNV (pelvis/leg, shoulder/arm) and minor NHNV (wrist/hand, ankle/foot, rib/clavicle) fractures among women from the Global Longitudinal study of Osteoporosis in Women (GLOW). Health-related quality of life (HRQL) was analyzed using the EuroQol EQ-5D tool and the SF-36 health survey. RESULTS: Among 50,461 women analyzed, there were 1,822 fractures (57% minor NHNV, 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D summary scores, followed by major NHNV and hip fractures. The number of women with mobility problems increased most for those with major NHNV and spine fractures (both +8%); spine fractures were associated with the largest increases in problems with self care (+11%), activities (+14%), and pain/discomfort (+12%). Decreases in physical function and health status were greatest for those with spine or hip fractures. Multivariable modeling found that EQ-5D reduction was greatest for spine fractures, followed by hip and major/minor NHNV. Statistically significant reductions in SF-36 physical function were found for spine fractures, and were borderline significant for major NHNV fractures. CONCLUSION: This prospective study shows that NHNV fractures have a detrimental effect on HRQL. Efforts to optimize the care of osteoporosis patients should include the prevention of NHNV fractures.

Are existing measures of overall diet quality associated with peak bone mass in young premenopausal women?

BACKGROUND: Low peak bone mass in young adulthood is associated with an increased risk of osteoporosis and fracture after menopause, and an understanding of the modifiable factors that contribute to low peak bone mass is important for fracture prevention. Diet is an important modifiable factor linked to bone health and, although studies have examined the role of individual dietary components in bone health, bone growth and maintenance are complex processes, and such studies may not adequately represent the role of diet in these processes. METHODS: To address this issue, a cross-sectional analysis of 226 healthy, premenopausal women aged 18-30 years was conducted to determine whether existing indices of overall diet quality are associated with bone density in premenopausal women nearing peak bone mass. Bone density was measured using dual-energy X-ray absorptiometry and diet quality was measured using two overall diet scores based on current dietary guidelines: the Recommended Food Score and the Alternate Healthy Eating Index (AHEI). RESULTS: In the multiple linear regression, bone density did not increase across quartiles of either diet quality score and was not associated with continuous diet quality variables. Furthermore, none of the individual AHEI components (e.g. fruit intake, vegetable intake) were associated with bone density. CONCLUSIONS: These findings suggest that existing diet quality scores are not appropriate for studies of peak bone mass, most likely because they do not give sufficient weight to foods and nutrients important to bone health. We recommend the development of a diet pattern index that better predicts bone mass measures.

Failure to perceive increased risk of fracture in women 55 years and older: the Global Longitudinal Study of Osteoporosis in Women (GLOW).

UNLABELLED: We compared self-perception of fracture risk with actual risk among 60,393 postmenopausal women aged ≥55 years, using data from the Global Longitudinal Study of Osteoporosis in Women (GLOW). Most postmenopausal women with risk factors failed to appreciate their actual risk for fracture. Improved education about osteoporosis risk factors is needed. INTRODUCTION: This study seeks to compare self-perception of fracture risk with actual risk among postmenopausal women using data from GLOW. METHODS: GLOW is an international, observational, cohort study involving 723 physician practices in 17 sites in ten countries in Europe, North America, and Australia. Participants included 60,393 women ≥55 years attended by their physician during the previous 24 months. The sample was enriched so that two thirds were ≥65 years. Baseline surveys were mailed October 2006 to February 2008. Main outcome measures were self-perception of fracture risk in women with elevated risk vs women of the same age and frequency of risk factors for fragility fracture. RESULTS: In the overall study population, 19% (10,951/58,434) of women rated their risk of fracture as a little/much higher than that of women of the same age; 46% (27,138/58,434) said it was similar; 35% (20,345/58,434) believed it to be a little/much lower. Among women whose actual risk was increased based on the presence of any one of seven risk factors for fracture, the proportion who recognized their increased risk ranged from 19% for smokers to 39% for current users of glucocorticoid medication. Only 33% (4,185/12,612) of those with ≥2 risk factors perceived themselves as being at higher risk. Among women reporting a diagnosis of osteopenia or osteoporosis, only 25% and 43%, respectively, thought their risk was increased. CONCLUSION: In this international, observational study, most postmenopausal women with risk factors failed to appreciate their actual risk for fracture.

The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design.

SUMMARY: The Global Longitudinal study of Osteoporosis in Women (GLOW) is a prospective cohort study involving 723 physicians and 60,393 women subjects >or=55 years. The data will provide insights into the management of fracture risk in older women over 5 years, patient experience with prevention and treatment, and distribution of risk among older women on an international basis. INTRODUCTION: Data from cohort studies describing the distribution of osteoporosis-related fractures and risk factors are not directly comparable and do not compare regional differences in patterns of patient management and fracture outcomes. METHODS: The GLOW is a prospective, multinational, observational cohort study. Practices typical of each region were identified through primary care networks organized for administrative, research, or educational purposes. Noninstitutionalized patients visiting each practice within the previous 2 years were eligible. Self-administered questionnaires were mailed, with 2:1 oversampling of women >or=65 years. Follow-up questionnaires will be sent at 12-month intervals for 5 years. RESULTS: A total of 723 physicians at 17 sites in ten countries agreed to participate. Baseline surveys were mailed (October 2006 to February 2008) to 140,416 subjects. After the exclusion of 3,265 women who were ineligible or had died, 60,393 agreed to participate. CONCLUSIONS: GLOW will provide contemporary information on patterns of management of fracture risk in older women over a 5-year period. The collection of data in a similar manner in ten countries will permit comparisons of patient experience with prevention and treatment and provide insights into the distribution of risk among older women on an international basis.

A simple clinical score for estimating the long-term risk of fracture in post-menopausal women.

BACKGROUND: Simple tools are needed to identify patients at high risk of fracture. AIM: To develop a simple clinical tool for assessing 5-year risk of fracture. DESIGN: Cohort study. METHODS: The study population consisted of all women aged 50+ included in the THIN Research Database (containing computerized medical records of UK general practices). Using Cox proportional hazards models, a risk score was initially estimated from age, body mass index, and clinical risk factors. The 5-year risk of fracture (survival function) was estimated for each score. RESULTS: The study population included 366 104 women aged > or = 50 years (mean follow-up 5.8 years). Of these, 6453 suffered a hip fracture. Several characteristics independently contributed to the fracture risk score (age, body mass index, fracture and fall history, previous diagnoses and use of medication). The 5-year risks for hip fracture for patients with total scores of 10, 30 and 50 were 0.3% (95%CI 0.3-0.4%), 2.2% (95%CI 2.1-2.2%), and 13.1% (95%CI 12.5-13.7%), respectively. A woman aged 65 years with low BMI and a history of both fracture and falling would have a hip fracture risk score of 37, with a corresponding 5-year risk for a hip fracture of 4.1% (4.0-4.2%). The risk score was validated and tested in another population (from GPRD), with a good concurrence between predicted and observed risks of fracture. DISCUSSION: This risk score predicts the long-term risk of fracture, and could be used for targeting patients for further investigation, such as bone densitometry.

Instantaneous and continuous cardiac output obtained with a Doppler pulmonary artery catheter.

A newly developed, flow-directed, Doppler pulmonary artery catheter, capable of measuring instantaneous and continuous cardiac output, was evaluated in both an in vitro pump model and an animal model. Quantitative flow was calculated with use of the instantaneous, space-average velocity (obtained from the velocity profile) and the instantaneous area (obtained from the vessel diameter) and compared with electromagnetic flow. Additionally, simultaneous thermodilution flow measurements were obtained. Doppler catheter-determined flow was highly predictive of electromagnetic flow in both continuous and pulsatile pump models (r2 = 0.98, slope or m = 1.04, SEE = 0.44; and r2 = 0.97, m = 1.04 and SEE = 0.33, respectively). Thermodilution was less predictive and appeared to underestimate electromagnetic flow in both the continuous and the pulsatile model (r2 = 0.99, m = 0.91, SEE = 0.20 and r2 = 0.95, m = 0.84 and SEE = 0.34, respectively). In the animal model, Doppler catheter-determined cardiac output appeared to modestly underestimate electromagnetic flow (r2 = 0.80, m = 0.87, SEE = 0.61). However, Doppler determinations of flow remained more accurate than did simultaneous thermodilution measurements (r2 = 0.73, m = 0.79, SEE = 0.72). Accurate, continuous and instantaneous cardiac output measurements appear possible with use of a flow-directed, Doppler pulmonary artery catheter. This catheter system also provides instantaneous diameter measurements and mapping of instantaneous velocity profiles within the main pulmonary artery and may lead to more accurate Doppler-derived assessment of cardiac output in humans.

Resource utilization among intensive care patients. Managed care vs traditional insurance.

BACKGROUND: There is considerable evidence that members of managed care organizations use fewer hospital resources than patients covered by traditional health insurance. While intensive care might seem to be an unlikely setting for such differences to exist, the relationship between health coverage and use of intensive care has not been examined. METHODS: We conducted a cross-sectional analysis of consecutive intensive care unit admissions at a regional tertiary care teaching hospital. Patients in managed care plans (n = 159) and with traditional insurance (n = 389) were compared with respect to length of stay, hospital charges, charges for specific services, and use of mechanical ventilation. The analysis controlled for severity of illness, as measured by the Mortality Probability Model, case mix, and mortality. The whole sample as well as subsamples representing medical, emergency surgery, and elective surgery patients were examined. RESULTS: The managed care group, on average, had short stays (both hospital and intensive care unit), lower charges, and less use of mechanical ventilation than the traditionally insured group. Average differences of about 30% to 40% were observed. The finding held for the whole sample as well as the medical and emergency surgery subsamples. The differences were more pronounced in the patients with lowest severity of illness. CONCLUSION: Even in a setting where there would appear to be relatively little room for discretion in treatment decisions, incentives associated with type of health insurance seemed to affect resource use.

Caregivers and elderly relatives. The prevalence of caregiving in a family practice.

Persons 65 years and older are the most rapidly growing age group in the United States. As age increases, functional ability deteriorates and the need for help from another person escalates. Caring for elderly persons experiencing functional deterioration is stressful, creating hidden patients among caregivers. This study surveyed randomly selected active family practice patients 40 years and older to determine the prevalence and extent of the caregiving role and functional disability among elderly relatives. One in five patients (126/602) surveyed had caregiving responsibilities for noninstitutionalized relatives (total, 153 patients). One third of caregivers lived with the relative; most of the remaining two thirds visited their relative at least twice weekly. Caregivers reported some functional impairment in 60% of their relatives, and substantial impairment in 40%. The caregiving experience is common, and the potential for stress from managing an elderly relative's disability is substantial. Further research is needed to elaborate on the burden of the caregiver.

Recurrence of skin disease in a nursery: ineffectuality of hexachlorophene bathing.

An outbreak of streptococcal and staphylococcal skin disease was discovered in a full-term nursery after the discontinuation of bathing infants with hexachlorophene. The epidemic was only temporarily controlled by conventional means and recurred despite reinstitution of hexachlorophene bathing. Measures that decreased infants' exposure to visitors and hospital personnel and enforced aseptic techniques in the nursery were more important than use of hexachlorophene soap in achieving and maintaining control.

Early termination of breast-feeding: identifying those at risk.

In a private pediatric practice, 94 infants who were breast-feeding were followed for the first 2 months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would predict mothers and infants at risk for early cessation. At 8 weeks, 30% of the mothers had stopped nursing. Factors associated with cessation were: maternal lack of confidence in breast-feeding (P less than .001); anticipated duration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant's excessive crying (P = .007), infant's demanding personality (P = .007), trouble with feeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the mothers who terminated breast-feeding. Supplementing with formula before the 2-week office visit also led to termination of breast-feeding by 8 weeks (P = .006). This decision was frequently made without medical advice. Nearly 64% (14/22) of the mothers who added formula within the first 2 weeks did so without contacting the pediatric practice.

Epidemiology for medical students: a course relevant to clinical practice.

A new course was designed to make epidemiology clinically relevant to medical undergraduates. The objectives were that students should (1) know the epidemiology of common diseases, (2) understand epidemiological concepts useful in diagnosis and treatment, and (3) be able to critically assess published medical evidence. Results of a written examination showed that objectives 1 and 2 had been 'easily' achieved by 80% and 68% of students respectively. Student opinion of the course, assessed by an anonymous questionnaire, showed that the majority of students considered the course to be an important part of medical education. Before the course 19% felt 'reasonably able' or 'very able' to achieve nine specific objectives related to epidemiological concepts in diagnosis and treatment. By the end of the course this had risen to 78%.

Epidemiology for medical students: a controlled trial of three teaching methods.

Medical students taking a course in epidemiology for clinical practice were taught by either lectures, small group seminars or self-learning packages. Examination performances were no different for the three groups, but self-perceived mastery of learning objectives, and satisfaction with the course were higher for students who received self-learning packages. Sixty per cent of self instruction students found the teaching method was successful compared with 37% of the seminar students and only 19% who received lectures. A combination of self-instructional package and seminar would seem to hold most promise for a workable and effective course.

Evaluating worksite health programs.

Worksite health enhancement programs utilize screening and early disease detection or risk reduction as health promotion activities. Objectives for these include improving the health and productivity of employees and reducing health care costs. However, critical questions about the effectiveness of programs should be answered before managers initiate these activities. Issues include accuracy of measurement and subject classification, adequate use of comparisons and follow-up in evaluation studies, and evidence of cost effectiveness.

Changes in the use of diagnostic technologies among Medicare patients, 1985 and 1990.

This paper examines changes in the use of selected diagnostic technologies for Medicare patients in 1985 and 1990. The analysis compares patients across five common, medical tracer conditions: acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and gastrointestinal (GI) hemorrhage. The relationship of hospital characteristics to patterns of technology use was assessed by grouping hospitals by a composite measure of "costliness." The overall use of 21 diagnostic tests rose by 27% over the 5-year period. Increases were most marked among the three cardiovascular tracers and for related technologies, such as cardiac angiography and cardiac ultrasound. There was evidence that newer technologies partially replaced older diagnostic tests that were used for similar indications: rates of noninvasive cerebrovascular imaging rose while rates of cerebral angiography declined. However, for several common, long-established tests, such as electrocardiogram and chest radiograph, there were consistent increases that are unexplained. High-cost hospitals performed diagnostic tests at much higher rates than lower-cost hospitals in both 1985 and 1990, but the rate of increase in test use across the two study years was generally greater for the lower-cost hospitals.

Bacterial diseases of the colon.

Acute diarrhea of bacterial origin is discussed for seven enteric pathogens, and specific antimicrobial therapy based on positive identification is stressed. Selection of patients with self-limited disease not requiring antimicrobial therapy is emphasized in order to avoid costly laboratory tests. The role of daycare facilities in the spread of enteric pathogens in this country is discussed. This article includes a review of newer methods for treating infants and children with oral rehydration and rapid refeeding.

Pesticide containers: their contribution to poisoning.

Pesticide containers play an important role in the epidemiology of pesticide poisonings. Investigations of short-term exposures have shown that difficulty in disposal of used containers, inappropriate pesticide paskaging, and lack of safety containers for household products contribute to morbidity. Remedies for some of the container-associated hazards could be achieved under existing laws.

Protective clothing as a means of reducing nicotine absorption in tobacco harvesters.

Green tobacco sickness is an occupational illness of tobacco illness of tobacco harvesters that is thought to be caused by dermal absorption of nicotine from contact with green tobacco leaf. Wearing of rubberized nylon rainsuits effectively prevented nicotine absorption in volunteers who picked wet tobacco. Nicotine absorption was demonstrated in workers who wore clothing that was not waterproof.