Louis M. Sherwood

Predictive value of low BMD for 1-year fracture outcomes is similar for postmenopausal women ages 50-64 and 65 and Older: results from the National Osteoporosis Risk Assessment (NORA).

The relationship of low bone mass and fracture in younger postmenopausal women has not been extensively studied. In a large cohort of postmenopausal women ≥50 years of age, we found the relationship of BMD measured at peripheral sites and subsequent 1‐year fracture risk to be similar between women <65 and those ≥65 years of age.

Recency and duration of postmenopausal hormone therapy : effects on bone mineral density and fracture risk in the National Osteoporosis Risk Assessment (NORA) study

ObjectivesResults from the Womens Health Initiative showed that postmenopausal hormone replacement therapy (HRT) prevents fractures but has an overall unfavorable risk:benefit ratio, leading to the recommendation that HRT be used only for women with troublesome menopause symptoms, and for as short a time as possible. This recommendation has important implications for the timing and duration of HRT and the prevention of osteoporosis. The large number of women participating in the National Osteoporosis Risk Assessment (NORA) program provided the opportunity to evaluate bone mineral density (BMD) and 1-year fracture risk in analyses stratified by duration and recency of HRT. DesignParticipants were 170,852 postmenopausal women aged 50 to 104, without known osteoporosis, who were recruited from primary physicians offices across the US. BMD was measured at one of four peripheral sites, and the 1-year risk of osteoporotic fracture was assessed by questionnaire. ResultsAt baseline, current HRT users had the highest T-scores at every age. Among current hormone users, women who had used HRT longest had the highest BMD levels. Women who had stopped HRT more than 5 years previously, regardless of duration of use, had T-scores similar to never-users. Current but not past hormone use at baseline was associated with a 25% to 29% lower risk of osteoporotic fracture (P < 0.0001) in 1 year, compared with nonusers. These findings were independent of age, ethnicity, body mass index, lifestyle, years postmenopausal, and site of BMD measurement. ConclusionsWe conclude that postmenopausal BMD and fracture are closely associated with current, but not prior, HRT use. Use of HRT for 5 years or less, as proposed for treatment of symptomatic women during menopause transition, is unlikely to preserve bone or significantly reduce fracture risk in later years.

Creating a New Structure for Research on Health Care Effectiveness

Effectiveness research (a term we use in preference to the more confining and difficult health services or outcomes research) evaluates the clinical setting and the health care system on which it depends. It uses a variety of health care assessment techniques and the practical clinical trial to inform clinical practice, quality interventions, and health policy decisions. Effectiveness research had not had sufficient public or private funding to produce the information needed to facilitate evidence-based health care improvement. However, recent trends, such as the likelihood for continued substantial increases in health care costs and concern regarding the quality and safety of the US health care system, are among the important arguments for increasing its funding and capacity. We propose a new entity, a public-private consortium to expand and offer new capability and resources in this area. The consortium would consist of all relevant public and private entities. It would be organized into an executive committee, which would identify research priorities and panels to design requests for proposals. Competitive peer-reviewed proposals, transparency and balance of forces in choice of topics, conduct of research, and interpretation of results would be important features. Metrics for success would be use of the data derived from consortium projects in medical decision making and benefit design. The consortium would provide balance and potential mediation of conflicting or competing interests in which all stakeholders will be present to establish the rules. Broad representation of all interests would serve to avoid the economic, policy, and political issues that have bedeviled past efforts. Models for the consortium include the Health Effectiveness Institute, the Centers for Education and Research on Therapeutics, and the Transportation Research Board.

Identification and Fracture Outcomes of Undiagnosed Low Bone Mineral Density in Postmenopausal Women: Results From the National Osteoporosis Risk Assessment

Osteoporotic fractures are a prominent cause of disability, and hip fracture produces 20% excess mortality in the ensuing year. The expanding population of elderly is expected to raise both direct and indirect costs of fractures in the United States and elsewhere in the world. Risk factors for low bone mineral density (BMD) and the incidence of fractures during 12 months of follow-up were studied in 200,160 ambulatory postmenopausal women aged 50 years or older, none of whom had been diagnosed as osteoporotic. Follow-up data were available for 82% of the group, whose mean age was 64.5 years. Nearly 90% of the study population were white. BMD was measured variably in the forearm, finger, or heel. Nearly 4 in 10 of the women tested (39.6%) had osteopenia at one or more of the measurement sites, and another 7.2% had osteoporosis. Advancing age was the outstanding risk factor; the odds ratio for osteoporosis rose from 1.79 in women 55 to 59 years of age to 22.6 for those aged 80 and older. The risk also increased with the years since menopause (independently of age), but only for those at least 30 years postmenopausal. Poor self-rated health, a history of fracture, and a maternal history of either fracture after age 45 or osteoporosis all made osteoporosis significantly more likely. Asian and Hispanic women were more at risk than whites, whereas African American women had just over half the risk level of white women. Increasing body mass index correlated with a lower risk of osteoporosis, as did either the former or especially current use of estrogen postmenopausally. Current exercise also lowered the risk, as did consuming one to six alcoholic beverages per week. On follow-up, analysis using T-score categories showed that osteoporosis increased the risk of fracture 4-fold compared with normal BMD, and women with osteopenia had a 1.8-fold higher fracture rate. In a Cox proportional hazards model, osteoporosis and osteopenia increased the risk of fracture within 12 months by 2.74- and 1.73-fold, respectively. There seems no doubt that a large population of women expected to live well into the present century will be at risk of fracture. The risk exists at the time low BMD is recognized at peripheral skeletal sites.