Denise Greene

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. “Atypical” nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T‐score −2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age‐adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5–2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3–156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years.

Osteoporosis Disease Management: The Role of the Orthopaedic Surgeon

Osteoporosis is a major medical problem affecting 8 million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated 1.5 million people in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of

Hip fracture in postmenopausal women after cessation of hormone therapy: Results from a prospective study in a large health management organization

18 billion1. The problem of osteoporosis is now reaching epidemic proportions with the rapidly aging population2. One-half of all women and one-third of all men will sustain a fragility fracture in their lifetime3. There is a huge cost associated with osteoporosis in terms of morbidity, mortality, and the financial impact on society4. The most devastating complication of osteoporosis is a hip fracture. According to the most recent statistics published in the 2004 United States Surgeon Generals report on osteoporosis, of the 325,000 patients who sustain a hip fracture each year, 24% end up in nursing homes, 50% never reach their previous functional capacity, and 25% die within the first year after the fracture2. The first-year mortality rate after a hip fracture is almost twice as high in men as in women (30% compared with 17%)5. The mortality rate due to osteoporosis-related fractures is greater than the rates for breast cancer and cervical cancer combined6. Only 20% of patients with a previous hip or other fragility fracture receive treatment for osteoporosis7-12. For example, in one study, between 12% and 25% of patients with a hip fracture had testing of bone density, fewer than 25% were given calcium and vitamin-D supplements, and fewer than 10% were treated with effective anti-osteoporosis medications13. There are certainly many missed opportunities for fracture prevention. The World Health Organization now has a tool to assess a …

Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know

Objective:Millions of women in the United States and across the globe abruptly discontinued postmenopausal hormone therapy (HT) after the initial Womens Health Initiative trial publication. Few data describing the effects of HT cessation on hip fracture incidence in the general population are available. We evaluated the impact of HT cessation on hip fracture incidence in a large cohort from the Southern California Kaiser Permanente health management organization. Methods:In this longitudinal observational study, 80,955 postmenopausal women using HT as of July 2002 were followed up through December 2008. Data on HT use after July 2002, antiosteoporotic medication use, and occurrence of hip fracture were collected from the electronic medical record system. Bone mineral density (BMD) was assessed in 54,209 women once during the study period using the dual-energy x-ray absorptiometry scan. Results:After 6.5 years of follow-up, age- and race-adjusted Cox proportional hazard models showed that women who discontinued HT were at 55% greater risk of hip fracture compared with those who continued using HT (hazard ratio, 1.55; 95% CI, 1.36-1.77). Hip fracture risk increased as early as 2 years after cessation of HT (hazard ratio, 1.52; 95% CI, 1.26-1.84), and the risk incrementally increased with longer duration of cessation (P for trend < 0.0001). Longer duration of HT cessation was linearly correlated with lower BMD (&bgr; estimate [SE]) = −0.13 [0.003] T-score SD unit per year of HT cessation; P < 0.0001). Conclusions:Women who discontinued postmenopausal HT had significantly increased risk of hip fracture and lower BMD compared with women who continued taking HT. The protective association of HT with hip fracture disappeared within 2 years of cessation of HT. These results have public health implications with regard to morbidity and mortality from hip fracture.

Is Osteoporosis Disease Management Cost Effective

According to recent information from the National Osteoporosis Foundation1 and the Office of the Surgeon General2, osteoporosis is a major medical problem. The disease currently affects 8 million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated 1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of 18 billion dollars. With the rapidly aging U.S. population, the problem of osteoporosis is now reaching epidemic proportions. There are 75 million baby boomers entering the stage in their lives when they are most at risk for osteoporosis. One-half of all women and one-third of all men will sustain a fragility fracture during their lifetime. There is a huge cost associated with osteoporosis in terms of morbidity, mortality, and the financial impact on society. The most devastating complication of osteoporosis is a hip fracture. According to the most recent statistics published in the United States Surgeon Generals 2004 report on osteoporosis, of the 325,000 patients who sustain a hip fracture each year, 25% will find it necessary to enter a nursing home, 50% will never reach their previous functional capacity, and 25% will die within the first year after the fracture2. The first-year mortality rate after a hip fracture is almost twice as high in men as it is in women (30% compared with 17%). The mortality rate associated with osteoporosis-related fractures is greater than the rates associated with breast cancer and cervical cancer combined1-6. Only 20% of patients who have had a previous hip fracture or other fragility fracture receive treatment for osteoporosis7-13. There are certainly many missed opportunities for fracture prevention14. To achieve …

Outcomes of an osteoporosis disease‐management program managed by nurse practitioners

Can osteoporosis disease management be cost effective? To answer that question, we conducted an extensive review of osteoporosis and fragility fracture prevention literature in peer-reviewed scientific journals and evidence-based guidelines from professional societies and government health organizations. We explored different strategies suggested by the literature to find how programs can be structured to be cost effective and to decrease fracture rates. We focused on ways to cost effectively identify, risk stratify, treat, and then track patients at risk for osteoporosis and fragility fractures. Studies have shown that osteoporosis management can decrease the hip fracture rate by 25% to 50% and be cost effective at the same time.

Distal Radius Fracture Risk Reduction With a Comprehensive Osteoporosis Management Program

Purpose: To detail the outcomes of an osteoporosis disease‐management program where nurse practitioners (NPs) have taken a leadership role in screening, diagnosing, and treating patients at risk for osteoporosis. Data sources: An electronic medical record (EMR) was used to collect demographic, pharmacy, dual x‐ray absorptiometry (DXA) scan, and fracture data from a population of over 625,000 patients with one or more risk factors for osteoporosis. Monthly reports were generated and distributed to the NPs to assist them in identifying patients that required screening or treatment. Conclusions: Over a 6‐year period there was a 263% increase in the number of screening DXA scans done each year, a 153% increase in the number of patients on anti‐osteoporosis medications each year, and a 38.1% decrease in the expected hip fracture rate. Implications for practice: NPs play an important leadership role in managing osteoporosis within a large health maintenance organization. The screening and interventions used can be applied by any NP in any practice setting on an individual basis to reduce hip fracture rates in the United States.

Minimizing Disparities in Osteoporosis Care of Minorities With an Electronic Medical Record Care Plan

PURPOSE To study risk factors associated with osteoporotic distal radius fractures and evaluate the effectiveness of the screening and treatment components of a comprehensive osteoporosis program. METHODS We retrospectively identified a cohort of patients aged 60 years or older from a large health maintenance organization. For the period 2002 to 2008, information on age, race, sex, diabetes status, osteoporosis diagnosis, osteoporosis screening activity, medications dispensed, and fracture events, including distal radius, proximal humerus, and hip fractures were recorded. We compared demographic and clinical characteristics for patients with and without distal radius fractures. We estimated multivariable estimates of the associations between pharmacologic treatment, and osteoporosis screening and distal radius fracture risk using Cox proportional hazards methods, and adjusted them for age, sex, race, diabetes status, and prior history of hip or proximal humerus fractures. RESULTS Overall, 1.7% of the cohort (n = 8,658) of the study population (N = 524,612) sustained a new distal radius fracture during 2002 to 2008. In the multivariable model, we found that patients who received pharmacological intervention were 48% less likely to sustain a distal radius fracture. Similarly, patients who were screened for osteoporosis were 83% less likely to sustain a distal radius fracture. Patients with osteoporosis were 8.9 times more likely to have a distal radius fracture than patients without osteoporosis. White subjects had a 1.6 times higher risk of distal radius fracture than non-whites, and women had a 3.8 times higher risk than men. CONCLUSIONS White race, female sex, and a diagnosis of osteoporosis are high risks for distal radius fracture. Screening for and pharmacologic management of osteoporosis using a multidisciplinary team approach in a comprehensive osteoporosis management program resulted in a statistically significant decrease in the risk of distal radius fracture. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Increasing Incidence of Hip Fracture in Postmenopausal Women after Cessation of Hormone Therapy: Data from a Large Health Management Organization

BackgroundEthnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.Questions/purposesWe evaluated variations in osteoporosis treatment by age, sex, and race/ethnicity by (1) measuring the rates of patients after a fragility fracture who had been evaluated by dual-energy xray absorptiometry and/or in whom antiosteoporosis treatment had been initiated and (2) determining the rates of osteoporosis treatment in patients who subsequently had a hip fracture.Patients and MethodsWe implemented an integrated osteoporosis prevention program in a large health plan. Continuous screening of electronic medical records identified patients who met the criteria for screening for osteoporosis, were diagnosed with osteoporosis, or sustained a fragility fracture. At-risk patients were referred to care managers and providers to complete practice guidelines to close care gaps. Race/ethnicity was self-reported. Treatment rates after fragility fracture or osteoporosis treatment failures with later hip fracture were calculated. Data for the years 2008 to 2009 were stratified by age, sex, and race/ethnicity.ResultsWomen (92.1%) were treated more often than men (75.2%) after index fragility fracture. The treatment rate after fragility fracture was similar among race/ethnic groups in either sex (women 87.4%–93.4% and men 69.3%–76.7%). Osteoporotic treatment before hip fracture was more likely in white men and women and Hispanic men than other race/ethnic and gender groups.ConclusionsRacial variation in osteoporosis care after fragility fracture in race/ethnic groups in this healthcare system was low when using the electronic medical record identifying care gaps, with continued reminders to osteoporosis disease management care managers and providers until those care gaps were closed.