Thomas A. Abbott

Patients with prior fractures have an increased risk of future fractures : A summary of the literature and statistical synthesis

Numerous studies have reported increased risks of hip, spine, and other fractures among people who had previous clinically diagnosed fractures, or who have radiographic evidence of vertebral fractures. However, there is some variability in the magnitudes of associations among studies. We summarized the literature and performed a statistical synthesis of the risk of future fracture, given a history of prior fracture. The strongest associations were observed between prior and subsequent vertebral fractures; women with preexisting vertebral fractures (identified at baseline by vertebral morphometry) had approximately 4 times greater risk of subsequent vertebral fractures than those without prior fractures. This risk increases with the number of prior vertebral fractures. Most studies reported relative risks of approximately 2 for other combinations of prior and future fracture sites (hip, spine, wrist, or any site). The confidence profile method was used to derive a single pooled estimate from the studies that provided sufficient data for other combinations of prior and subsequent fracture sites. Studies of peri‐ and postmenopausal women with prior fractures had 2.0 (95% CI = 1.8, 2.1) times the risk of subsequent fracture compared with women without prior fractures. For other studies (including men and women of all ages), the risk was increased by 2.2 (1.9, 2.6) times. We conclude that history of prior fracture at any site is an important risk factor for future fractures. Patients with a history of prior fracture, therefore, should receive further evaluation for osteoporosis and fracture risk

Adherence to Bisphosphonate Therapy and Fracture Rates in Osteoporotic Women: Relationship to Vertebral and Nonvertebral Fractures From 2 US Claims Databases

OBJECTIVE To characterize the relationships between adherence (complance and persistence) to bisphosphonate therapy and risk of specific fracture types in postmenopausal women. PATIENTS AND METHODS Data were collected from 45 employers and 100 health plans in the continental United States from 2 claims databases during a 5-year period (January 1, 1999, through December 31, 2003). Claims from patients receiving a bisphosphonate prescription (alendronate or risedronate) were evaluated for 6 months before the Index prescription and during 24 months of follow-up to determine total, vertebral, and nonvertebral osteoporotic fractures, persistence (no gap in refills for >30 days during 24 months), and refill compliance (medication possession ratio > or = 0.80). RESULTS The eligible cohort included 35,537 women (age, > or = 45 years) who received a bisphosphonate prescription. A subgroup with a specified diagnosis of postmenopausal osteoporosis was also evaluated. Forty-three percent were refill compliant, and 20% persisted with bisphosphonate therapy during the 24-month study period. Total, vertebral, nonvertebral, and hip fractures were significantly lower in refill-compliant and persistent patients, with relative risk reductions of 20% to 45%. The relationship between adherence and fracture risk remained significant after adjustment for baseline age, concomitant medications, and fracture history. There was a progressive relationship between refill compliance and fracture risk reduction, commencing at refill compliance rates of approximately 50% and becoming more pronounced at compliance rates of 75% and higher. CONCLUSIONS Adherence to bisphosphonate therapy was associated with significantly fewer fractures at 24 months. Increasing refill compliance levels were associated with progressively lower fracture rates. These findings suggest that incremental changes in medication-taking habits could improve clinical outcomes of osteoporosis treatment.

Osteoporosis and fracture risk in women of different ethnic groups.

Osteoporosis and 1‐year fracture risk were studied in 197,848 postmenopausal American women from five ethnic groups. Weight explained differences in BMD, except among blacks, who had the highest BMD. One SD decrease in BMD predicted a 50% increased fracture risk in each group. Despite similar relative risks, absolute fracture rates differed.

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.

Evaluation and Management of Osteoporosis Following Hospitalization for Low-impact Fracture

OBJECTIVE: To evaluate the pattern of osteoporosis evaluation and management in postmenopausal women who present with low-impact (minimal trauma) fracture.DESIGN: Retrospective chart review of patients admitted with a fracture in the absence of trauma or bone disease. Telephone follow-up survey was conducted at 12 months after discharge to collect information on physician visits, pharmacological therapies for osteoporosis, functional status, and subsequent fractures.PATIENTS/PARTICIPANTS: Postmenopausal women admitted to a hospital in St. Paul, Minnesota between June 1996 and December 1997 for low-impact fractures were identified. Low-impact fracture was defined as a fracture occurring spontaneously or from a fall no greater than standing height. Retrospective review of 301 patient medical records was conducted to obtain data on pre-admission risk factors for osteoporosis and/or fracture, and osteoporosis-related evaluation and management during the course of hospitalization. Follow-up 1 year after the incident fracture was obtained on 227 patients.MEASUREMENTS AND MAIN RESULTS: Two hundred twenty-seven women were included in the study. Osteoporosis was documented in the medical record in 26% (59/227) of the patients at hospital discharge. Within 12 months of hospital discharge, 9.6% (22/227) had a bone mineral density test, and 26.4% (60/227) were prescribed osteoporosis treatment. Of those who were prescribed osteoporosis treatment, 86.6% (52/60) remained on therapy for 1 year. Nineteen women suffered an additional fracture. Compared to women without a prior fracture, women with at least 1 fracture prior to admission were more likely to have osteoporosis diagnosed and to receive osteoporosis-related medications.CONCLUSION: Despite guidelines that recommend osteoporosis evaluation in adults experiencing a low-trauma fracture, we report that postmenopausal women hospitalized for low-impact fracture were not sufficiently evaluated or treated for osteoporosis during or after their hospital stay. There are substantial opportunities for improvement of care in this high-risk population to prevent subsequent fractures.

Evaluation of three population-based strategies for fracture prevention: results of the osteoporosis population-based risk assessment (OPRA) trial.

Background:The integration of bone density testing into well-designed fracture prevention programs that can be applied in populations has not been studied. Objectives:We sought to compare the outcomes of 3 strategies for allocating bone density testing within an HMO-based fracture prevention program. Research Design:Women were randomly sampled and allocated to one of 3 groups: (1) a universal group, in which all were offered bone mineral density (BMD) testing (1986 contacted; 415 participated); 2) the SCORE group, in which women scoring ≥ 7 on the SCORE questionnaire were invited for BMD testing (1940 contacted; 576 participated); and (3) the Study of Osteoporotic Fracture (SOF)-based group, in which women with ≥ 5 hip fracture risk factors were invited for BMD testing (5342 contacted; 2176 participated). Subjects:Women aged 60–80 not taking hormone therapy or osteoporosis medication were included. Measures:Outcomes ascertained during 33 months of follow-up in all women contacted included initiation of osteoporosis treatment and hip and total fracture rates. Outcomes evaluated among all participants included changes in fracture risk factors, osteoporosis knowledge, and satisfaction with the program. Results:Osteoporosis treatment rates did not differ among all women contacted but were slightly higher among trial participants in the universal and SCORE groups (21.1% and 20.2%, respectively; versus 16.7% in the SOF-based group (P value versus universal = 0.04). Among all women contacted, fracture rates were lowest in the universal group (74.11/1000) and differed significantly compared with the SCORE (99.44/1000; P = 0.009) and SOF-based groups (91.77/1000;P = 0.02). Knowledge about osteoporosis risk factors was highest in the universal group and lowest in the SOF-based group (P < 0.01). Conclusions:The degree to which BMD testing was offered to women in a fracture prevention program significantly affected total fracture rates, change in some fracture risk factors, and knowledge about risk factors.

Identifying Postmenopausal Women at High Risk of Fracture in Populations: A Comparison of Three Strategies

OBJECTIVES: To describe the prevalence of risk factors for women at high risk of fracture in a population‐based sample of postmenopausal women who were not using hormone replacement therapy (HRT), to demonstrate how the estimated prevalence of women at high risk of future fracture is affected by the different criteria used for classification, and to characterize the populations identified and missed by each of the criteria. A key study objective was to compare the proportion of postmenopausal women at high risk of fracture in a managed care population using several different definitions of who is at high risk.

Management of osteoporosis in women aged 50 and older with osteoporosis-related fractures in a managed care population.

This study describes the pattern of evaluation and management of osteoporosis in women aged 50 and older following an osteoporosis-related fracture, conducted as a retrospective cohort study using the administrative claims database of a managed care organization. Subjects were women, aged 50 years and older, with at least one osteoporosis-related fracture in the years 1996-1998 who were continuously enrolled in the systems health plan for at least 6 months prior to and post-fracture. Bone mineral density (BMD) testing, diagnosis of osteoporosis, and treatment with any Food and Drug Administration-approved medication for osteoporosis were identified using CPT, ICD-9, and National Drug Codes for the 6-month post-fracture period. There were 658 women with an osteoporosis-related fracture: 189 (29%) hip fractures, 226 (34%) wrist fractures, 127 (19%) vertebral fractures, and 116 (18%) rib fractures. In the post-fracture period, 46 (7%) underwent BMD testing, 153 (23%) had a diagnosis of osteoporosis, and 220 (31%) were treated with a medication approved for the prevention or treatment of osteoporosis. Of the 220 women with medication claims, 124 (56%) were for estrogen, and 96 (44%) were for other antiresorptive agents. Of the 507 women who did not have medication claims during the 6 months prior to the fracture, only 17% had new fills after the fracture. Management of osteoporosis in women aged 50 and older with fractures was inadequate, despite the high risk of subsequent fractures and recommendations that osteoporosis be the presumptive diagnosis. Significant opportunity exists for improvement in assuring post-fracture followup care.

Evaluation of decision rules to identify postmenopausal women for intervention related to osteoporosis

Decision rules for intervention that utilize screening tools for bone mineral density (BMD) testing and incorporating the BMD findings and other risk factors to identify high-risk women to prevent fracture have not been evaluated. We examine the sensitivity and specificity of decision rules for intervention based on two pre-BMD screening tools: Simple Calculated Osteoporosis Risk Estimation (SCORE) and a Study of Osteoporotic Fractures (SOF)-based tool. Women 60 years of age and older without previous osteoporosis diagnosis were randomly selected from a managed care population and invited to receive a BMD test. Four hundred sixteen women had complete information and were included in the study. Women were classified as high risk requiring intervention using three different criteria: World Health Organization (t-score -2.5 or less), National Osteoporosis Foundation (t-score -2.0 or less, or -1.5 or less with one or more risk factors), and the SOF-based criteria (prior fracture; or age 60-64 with t-score less than -2.5 or age 65 or older with z-score less than -0.43 and five or more risk factors). SCORE identified 82% of the women as appropriate for BMD testing, whereas the SOF-based tool identified 26%. Sensitivity and specificity were 89.8%-96.5% and 23.8%-34.8%, respectively, for the decision rule using SCORE as the screening tool and 30.5%-84.9% and 76.0%-95.8%, respectively, for the decision rule based on SOF screening criteria. SCORE correctly identified more women who were at high risk for intervention, whereas the SOF-based tool correctly identified more women who do not meet intervention criteria. The appropriate selection of a screening tool depends upon the objective for intervention and trade-off between not identifying women for BMD testing who are at high risk and identifying more women for BMD testing who are at low risk.

A Population-Based Osteoporosis Screening Program: Who Does Not Participate, and What Are the Consequences?: POPULATION-BASED OSTEOPOROSIS SCREENING PROGRAM

Objectives: To describe differences in osteoporosis risk factors and rates of fracture and antiresorptive therapy use in women who did and did not participate in an osteoporosis screening program.