Osteoporosis Screening Guidelines Research Articles

Post-Stroke Osteoporosis Screening: A Scoping Review.

There are no specific screening recommendations for post-stroke osteoporosis despite evidence that people post-stroke are at heightened risk of fragility fractures. Our objective was to explore the extent of evidence and map the current literature available for osteoporosis screening in the post-stroke population. This scoping review searched for articles in Medline, Embase, and CINAHL databases published in English before May 2024, involving osteoporosis screening for adults after stroke. Title and abstract screening as well as full text review and data extraction was performed by two reviewers. Analysis of the studies is descriptive and narrative. Eight articles met inclusion criteria: five published articles and three peer-reviewed conference abstracts. Three study designs were utilized: four cross-sectional studies, three cohort studies, and one survey. Four studies investigated post-stroke osteoporosis screening rates, two looked at screening pathways for post-stroke osteoporosis, and two assessed novel osteoporosis screening tools. No post-stroke osteoporosis screening guidelines were found. Across all included studies, reported screening rates for post-stroke osteoporosis were less than 10%. This scoping review emphasizes the need for osteoporosis screening guidelines and risk assessment tools specific to the post-stroke population.

What Is the Epidemiology of Cervical and Thoracic Spine Fractures?

Vertebral fractures are associated with enduring back pain, diminished quality of life, as well as increased morbidity and mortality. Existing epidemiological data for cervical and thoracic vertebral fractures are limited by insufficiently powered studies and a failure to evaluate the mechanism of injury. What are the temporal trends in incidence, patient characteristics, and injury mechanisms of cervical and thoracic vertebral fractures in the United States from 2003 to 2021? The United States National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) database collects data on all nonfatal injuries treated in US hospital emergency departments and is well suited to capture epidemiological trends in vertebral fractures. As such, the NEISS-AIP was queried from 2003 to 2021 for cervical and thoracic fractures. The initial search by upper trunk fractures yielded 156,669 injuries; 6% (9900) of injuries, with a weighted frequency of 638,999 patients, met the inclusion criteria. The mean age was 62 ± 25 years and 52% (334,746 of 638,999) of patients were females. Descriptive statistics were obtained. Segmented regression analysis, accounting for the year before or after 2019 when the NEISS sampling methodology was changed, was performed to assess yearly injury trends. Multivariable logistic regression models with age and sex as covariates were performed to predict injury location, mechanism, and disposition. The incidence of cervical and thoracic fractures increased from 2.0 (95% CI 1.4 to 2.7) and 3.6 (95% CI 2.4 to 4.7) per 10,000 person-years in 2003 to 14.5 (95% CI 10.9 to 18.2) and 19.9 (95% CI 14.5 to 25.3) in 2021, respectively. Incidence rates of cervical and thoracic fractures increased for all age groups from 2003 to 2021, with peak incidence and the highest rate of change in individuals 80 years or older. Most injuries occurred at home (median 69%), which were more likely to impact older individuals (median [range] age 75 [2 to 106] years) and females (median 61% of home injuries); injuries at recreation/sports facilities impacted younger individuals (median 32 [3 to 96] years) and male patients (median 76% of sports facility injuries). Falls were the most common injury mechanism across all years, with females more likely to be impacted than males. The proportion of admissions increased from 33% in 2003 to 50% in 2021, while the proportion of treated and released patients decreased from 53% to 35% in the same period. This epidemiological study identified a disproportionate increase in cervical and thoracic fracture incidence rates in patients older than 50 years from 2003 to 2021. Furthermore, high hospital admission rates were also noted resulting from these fractures. These findings indicate that current osteoporosis screening guidelines may be insufficient to capture the true population at risk of osteoporotic fractures, and they highlight the need to initiate screening at an earlier age. Level III, prognostic study.

Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review.

Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management. This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored. A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests. Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence. Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients.

Opportunistic screening for low bone density using abdominopelvic computed tomography scans.

While low bone density is a major burden on US health system, current osteoporosis screening guidelines by the US Preventive Services Task Force are limited to women aged ≥65 and all postmenopausal women with certain risk factors. Even within recommended screening groups, actual screening rates are low (<26%) and vary across socioeconomic groups. The proposed model can opportunistically screen patients using abdominal CT studies for low bone density who may otherwise go undiagnosed. To develop an artificial intelligence (AI) model for opportunistic screening of low bone density using both contrast and non-contrast abdominopelvic computed tomography (CT) exams, for the purpose of referral to traditional bone health management, which typically begins with dual energy X-ray absorptiometry (DXA). We collected 6083 contrast-enhanced CT imaging exams paired with DXA exams within ±6 months documented between May 2015 and August 2021 in a single institution with four major healthcare practice regions. Our fusion AI pipeline receives the coronal and axial plane images of a contrast enhanced abdominopelvic CT exam and basic patient demographics (age, gender, body cross section lengths) to predict risk of low bone mass. The models were trained on lumbar spine T-scores from DXA exams and tested on multi-site imaging exams. The model was again tested in a prospective group (N=344) contrast-enhanced and non-contrast-enhanced studies. The models were evaluated on the same test set (1208 exams)-(1) Baseline model using demographic factors from electronic medical records (EMR) - 0.7 area under the curve of receiver operator characteristic (AUROC); Imaging based models: (2) axial view - 0.83 AUROC; (3) coronal view- 0.83 AUROC; (4) Fusion model-Imaging + demographic factors - 0.86 AUROC. The prospective test yielded one missed positive DXA case with a hip prosthesis among 23 positive contrast-enhanced CT exams and 0% false positive rate for non-contrast studies. Both positive cases among non-contrast enhanced CT exams were successfully detected. While only about 8% patients from prospective study received a DXA exam within 2 years, about 30% were detected with low bone mass by the fusion model, highlighting the need for opportunistic screening. The fusion model, which combines two planes of CT images and EMRs data, outperformed individual models and provided a high, robust diagnostic performance for opportunistic screening of low bone density using contrast and non-contrast CT exams. This model could potentially improve bone health risk assessment with no additional cost. The model's handling of metal implants is an ongoing effort.

A Pilot Study to Assess Opportunistic Use of CT-Scan for Osteoporosis Screening in Chronic Pancreatitis.

Objectives: CT scans are commonly performed in patients with chronic pancreatitis (CP). Osteopathy and fractures are recognized in CP but no osteoporosis screening guidelines are recommended. “Opportunistic” CT scan-derived bone density thresholds are assessed for identifying osteoporosis in CP. Methods: Retrospective pilot cohort study. CP subjects who had CT scans and dual-energy x-ray absorptiometry (DXA) within 1 year were included. CT-derived bone density was measured at the L1 level. Pearson’s correlation was performed between age and CT-derived bone density in Hounsfield unit (HU). Univariate analysis using HU to identify osteoporosis was performed at various thresholds of bone density. The discriminatory ability of the model was evaluated with the area under the receiver operating characteristic (ROC) curve (AUC). Several HU thresholds were tested. Results: Twenty-seven CP subjects were included, of whom 11 had normal bone density, 12 osteopenia, and four osteoporosis on DXA. The mean age was 59.9 years (SD 13.0). There was a negative correlation of age with HU (r = −0.519, p = 0.006). CT-derived bone density predicted DXA-based osteoporosis in the univariable analysis (Odds Ratio (OR) = 0.97 95% Confidence Interval (CI) 0.94–1.00, p = 0.03). HU thresholds were tested. A threshold of 106 HU maximized the accuracy (AUC of 0.870). Conclusions: CT scan may be repurposed for “opportunistic” screening to rule out osteoporosis in CP. A larger study is warranted to confirm these results.

Total Joint Arthroplasty and Osteoporosis: Looking Beyond the Joint to Bone Health

BackgroundMetabolic bone diseases in the total joint arthroplasty (TJA) population are undertested and undertreated, leading to increased risk of adverse outcomes such as periprosthetic fractures. This study aims to better characterize the current state of bone care in TJA patients using Fracture Risk Assessment Tool (FRAX) score risk stratifications. MethodsIn total, 505 consecutive TJA patients who meet the Endocrine Society guidelines for osteoporosis screening were included for review. They were divided into a high risk or low risk group depending on FRAX scores and were compared based on screening, diagnosis, and treatment of metabolic bone disease. Logistic regression models were used to analyze factors influencing screening and treatment. A population analysis involving 2,000 TJA patients, and a complication analysis involving 40 periprosthetic fracture patients were conducted. ResultsAmong high risk patients undergoing TJA, 90% did not receive any pharmacological treatment for osteoporosis, 45% were not treated with vitamin D or calcium, and 88% did not receive bone density testing in the routine care period. Among patients with pre-existing osteoporosis undergoing TJA, 80% were not treated with any osteoporosis medications and 33% of these patients were not taking vitamin D or calcium. Female gender and past fracture history contributed to whether patients received screening and treatment. Patients with periprosthetic hip fractures have significantly higher FRAX scores compared to control THA patients. ConclusionThere are significant gaps in metabolic bone care of the geriatric TJA population regarding both screening and treatment. Metabolic bone care and risk identification with FRAX should be highly considered for TJA patients.

Bone Mineral Density Screening Among People With HIV: A Population-Based Analysis in the United States.

HIV infection is associated with premature bone loss. The potential impact of recently updated osteoporosis screening guidelines is unknown. In a population-based cohort, we found low adherence and sex differences among eligible people with HIV.

Identification of osteoporosis treatment gaps

Background/aims Osteoporosis is implicated in over 8.9 million fragility fractures worldwide with a cost in the United States of America of 19 billion dollars. The number of osteoporosis-related fractures and the associated human and financial costs are projected to continue to rise as the American population ages (Zeldow, 2018). Screening and identification of patients with decreased bone density can prevent or delay the onset of this insidious condition. This study was developed to evaluate the following research questions: 1. Which risk factors are most strongly associated with the completion of Dual x-ray absorptiometry (DXA) screening? 2. When patients are provided instruction on osteoporosis screening guidelines from a health care provider, how likely are they to comply with DXA screening? 3. Which healthcare providers are providing instruction on osteoporosis guidelines to patients? Methods A 22-question osteoporosis survey addressing history of fracture, modifiable and non-modifiable risk factors, and compliance with recommendations was developed by the authors and distributed to a sample of 270 patients presenting to medical offices during a 1-month period in 2018. Results It was found that 49.26% (n=133) of patients reported they received counseling regarding osteoporosis prevention while 50.74% (n=137) of patients reported that bone health was never addressed by any healthcare provider. Those healthcare providers that did discuss bone health with their patients were noted to most frequently practice in the primary care setting 30.7% (n=83). Other healthcare providers patients identified in the survey as discussing bone health were specialists in orthopaedics at 8.5% (n=23), obstetrics/gynecology 7% (n=19), rheumatology 2.6% (n=7), oncology 2.9% (n=8), and endocrinology 1% (n=3). The risk factors most strongly associated with the completion of DXA screening in this survey were loss of height, fracture after 50 years of age, and oral corticosteroid use. Conclusions Osteoporosis is considered a ‘silent disease’ that often goes unrecognised by providers and patients until after fracture occurs. This study highlights the need for providers to educate on bone health and to find better ways to ensure patient compliance.

3159 Bone Turnover Biomarkers May Discriminate Low Bone Mineral Density in HIV-Infected Adults

OBJECTIVES/SPECIFIC AIMS: Persons living with HIV (PLWH) are at increased risk for fragility bone disease. Current osteoporosis screening guidelines do not account for HIV status, and clinical risk assessment tools are not sensitive in PLWH. We examined the value of traditional osteoporosis risk factors, HIV-specific indices, and bone turnover biomarkers in predicting low bone mineral density (BMD) in PLWH. METHODS/STUDY POPULATION: Demographic and clinical characteristics, dual energy x-ray absorptiometry (DXA)-derived BMD, HIV indices (viral load, CD4 count, antiretroviral therapy [ART]), and biomarkers of bone turnover (C-terminal telopeptide of collagen [CTx], osteocalcin [OCN]) were evaluated in a cross-sectional analysis of PLWH (n=248) and HIV- controls (n=183). The primary outcome was low BMD, defined as osteopenia or osteoporosis by WHO criteria. Multivariable logistic and modified Poisson regression models were used to assess associations between low BMD and covariates of interest. RESULTS/ANTICIPATED RESULTS: Overall, median age was 44 years, 48% were male, 88% were black, median body mass index (BMI) was 28 kg/m2, 72% smoked cigarettes, and 53% used alcohol; characteristics did not differ by HIV status. PLWH had a mean CD4 of 408 cells/mm3, 55% were ART-naïve, and 45% had viral suppression on ART. Overall, 25% (109/431) had low BMD, including 31% of PLWH compared to 16% of HIV- controls. In multivariable models, HIV was significantly associated with low BMD (aOR 2.46, 95%CI 1.39-4.34; aRR 1.90, 95%CI 1.18-3.07). Adjusting for HIV, three traditional risks– age, race, and BMI– were independently associated with low BMD in the full cohort. However, bone turnover markers, CTx and OCN, were better able to discriminate low vs. normal BMD in PLWH compared to HIV- controls. In PLWH, mean serum CTx was 23% higher in low vs. normal BMD (mean CTx difference=0.06 ug/mL); in HIV- controls, no association with BMD was observed (mean CTx difference=0 ug/mL). In PLWH, mean serum OCN was 38% higher in those with low vs. normal BMD (mean OCN difference=2.48 ug/mL); in HIV- controls, mean serum OCN was only 16% higher in those with low vs. normal BMD (mean OCN difference=1.08 ug/mL). DISCUSSION/SIGNIFICANCE OF IMPACT: In PLWH as opposed to HIV- controls, serum biomarkers reflecting a high bone turnover state, may discriminate individuals with low versus normal BMD. Because changes in biomarkers precede changes in BMD, these markers should be explored further either alone or in combination with traditional risk assessment tools to improve early screening for osteoporosis in PLWH.

Divergence from osteoporosis screening guidelines in older breast cancer patients treated with anti-estrogen therapy: A population-based cohort study.

Older Breast Cancer (BC) survivors are an increased risk of osteoporosis due to natural aging and long-term cancer treatment-related toxicity. It is well known that anti-estrogen therapy (AET), especially aromatase inhibitors (AI), is associated with rapid bone loss and thus increases the risk of osteoporosis. This study characterizes patterns and predictors of receiving guideline-recommended bone densitometry (BD) screening at AET initiation. A retrospective cohort study (1998-2012) of all women ≥65 years of age initiating AET was designed using claims data from Quebec's universal health care. Associations with BD screening were estimated using a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Among 16,480 women initiating AET, 36.1% received a baseline BD. Among AI users, the rate was 58.4%. In the multivariate analysis, age, lower socioeconomic status, tamoxifen use, lack of periodic health exam and having a general practitioner as the AET prescriber were associated with lower odds of BD screening. In terms of quality of care-related variables, lack of guideline-appropriate radiotherapy (OR: 0.69 (95% CI, 0.57-0.83), or chemotherapy consideration (0.82 (95% CI, 0.71-0.94)) and non-adherence to AET (0.76 (95% CI, 0.68-0.84)) were associated with lower odds of receiving BD screening. Women diagnosed with BC after 2003 had significantly better odds of being screened. Despite an increase in rates since 2003, BD screening remains suboptimal, especially for women at higher risk of osteoporosis. Coordination of health care and service-delivery monitoring can potentially optimize long-term management of treatment-related toxicity in older BC survivors.

DEXA for Females Aged 65+ at an OBGYN Resident Clinic in Hawaii: A Chart Audit on Compliance for Osteoporosis Screening [13I

INTRODUCTION: Osteoporosis is a skeletal disorder of aging, caused by loss of bone mass and deterioration in both bone quality and micro-architecture. The U.S. Preventive Services Task Force (USPSTF) recommends women ages 65 and older without previous known fractures or secondary causes of osteoporosis be screened using Dual-Energy X-ray Absorptiometry (DEXA). METHODS: This retrospective chart review assessed compliance with osteoporosis screening guidelines in a resident clinic. We reviewed all charts of female patients 65 years or older at the Women’s Health Firm of Queen Emma Clinic in Honolulu, Hawaii from July 1, 2014 through July 1, 2015. Age, ethnicity, insurance type, presence of DEXA results and ordering provider type were abstracted. Associations between patient characteristics and DEXA screening were evaluated. RESULTS: 96 charts were reviewed with 87 meeting inclusion criteria, with mean age 69.6 (SD + 4.6) years. Of those, 92% (80/87) were offered DEXA screening with 87% (76/87) undergoing the test. Of the 11 untested, four were offered screening and refused; two refused outright and two declined while awaiting insurance coverage. Of the remaining 7 untested, four women presented for problem visits and three had no charted explanation precluding screening. There was no differences by race (P=.8) or insurance type (P=.5). OBGYNs and Primary Care Providers ordered equal numbers of scans (38/76 for both, P=1.0). CONCLUSION: DEXA scan is the gold-standard for diagnosing osteoporosis and recommended by USPSTF, yet screening referrals are not universal for eligible women in resident clinics. Tailored education for residents regarding this infrequently seen demographic group is needed.

Implementation and adherence to osteoporosis screening guidelines among coeliac disease patients

BackgroundThere are no studies evaluating the implementation of American Gastroenterological Association (AGA) guidelines on osteoporosis screening in coeliac disease. AimsTo investigate implementation of osteoporosis screening guidelines in coeliac disease patients and determine how often bone mineral density (BMD) assessment leads to therapeutic intervention. MethodsWe screened all patients with biopsy-proven coeliac disease at our center from 2003 to 2013 and collected data on indication and results of dual energy X-ray absorptiometry scanning (DXA) and therapeutic interventions. ResultsOf 222 adults with coeliac, only 80 (36%) underwent DXA after their diagnosis. Of those, 43 had DXA for osteoporosis screening specifically related to their coeliac diagnosis. Of these 43 patients, 28 (65.1%) had low BMD. A therapeutic intervention was made in the majority of these patients (21/28, 75%). Of 330 pediatric coeliac cases, 52 (15.8%) had DXA specifically in the context of the coeliac disease diagnosis with only 5 being complicated coeliac disease. Of these, 3 (5.8%) had low BMD and only 2 underwent therapeutic intervention. ConclusionsOsteoporosis screening guidelines are not followed in the majority of patients with coeliac disease but, when followed, frequently lead to therapeutic intervention. Osteoporosis screening guidelines in coeliac disease need to be updated, strengthened and publicized.

Adherence to osteoporosis screening guidelines in seniors with breast cancer treated with anti-estrogen therapy: A population-based study.

72 Background: Aromatase inhibitors (AI) improve recurrence and survival rates in women ≥ 65 with hormone-receptor positive (HR+) breast cancer (BC). However, AI’s are associated to increased bone demineralization in a population already at risk for osteoporosis. Bone mineral densitometry (BMD) is therefore recommended at treatment start, to minimize treatment-related toxicity. This study assesses compliance to BMD recommendations in older BC survivors treated with an AI and identifies predictors of non-adherence to guidelines. Methods: A population-based historical prospective cohort study was conducted in Quebec (Canada), where universal health insurance provides medical and pharmaceutical services. All women ≥ 65 with incident stage I, II or III BC (1998-2012) were identified from the provincial cancer registry. Administrative claims were accessed to track receipt of BMD (±12 months from treatment start) and potential predictors: age, economic status, Charlson comorbidity index, breast and axillary surgery, chemotherapy, radiotherapy, bisphosphonate use, adherence to anti-estrogen therapy (AET), physician specialty and having a primary care physician (PCP). Multivariate logistic regression was performed using generalized estimating equations to identify predictors of BMD, adjusting for clustering within physicians. Results: Of 16,480 patients, 36.1% had a BMD at AET start. This increased to 58.4% for women on AI. Factors predicting baseline BMD non-use in AI patients were: older age (OR 0.42; 95% CI, 0.36 – 0.49), lower annual income (OR 0.57; 95%CI, 0.47 – 0.70), not having a PCP (OR 0.77; 95%CI, 0.68 – 0.86), chemotherapy and radiotherapy outside of guidelines (OR 0.80; 95%CI, 0.66 – 0.96 and 0.69; 95%CI, 0.54 – 0.87, respectively), non-surgical specialist managing AET (OR 0.81; 95%CI, 0.67 – 0.98), older physicians (OR 0.61; 95% CI, 0.46 – 0.81), and non-adherence to AET (OR 0.69; 95%CI 0.60-0.79). The same predictors persisted in patients on any AET. Conclusions: Bone health management in seniors receiving AET is suboptimal. Factors related to underutilization of BMD can be easily identified and used to optimize chronic care of older BC survivors.

Reduced Bone Density and Vertebral Fractures in Smokers. Men and COPD Patients at Increased Risk.

Former smoking history and chronic obstructive pulmonary disease (COPD) are potential risk factors for osteoporosis and fractures. Under existing guidelines for osteoporosis screening, women are included but men are not, and only current smoking is considered. To demonstrate the impact of COPD and smoking history on the risk of osteoporosis and vertebral fracture in men and women. Characteristics of participants with low volumetric bone mineral density (vBMD) were identified and related to COPD and other risk factors. We tested associations of sex and COPD with both vBMD and fractures adjusting for age, race, body mass index (BMI), smoking, and glucocorticoid use. vBMD by calibrated quantitative computed tomography (QCT), visually scored vertebral fractures, and severity of lung disease were determined from chest CT scans of 3,321 current and ex-smokers in the COPDGene study. Low vBMD as a surrogate for osteoporosis was calculated from young adult normal values. Male smokers had a small but significantly greater risk of low vBMD (2.5 SD below young adult mean by calibrated QCT) and more fractures than female smokers. Low vBMD was present in 58% of all subjects, was more frequent in those with worse COPD, and rose to 84% among subjects with very severe COPD. Vertebral fractures were present in 37% of all subjects and were associated with lower vBMD at each Global Initiative for Chronic Obstructive Lung Disease stage of severity. Vertebral fractures were most common in the midthoracic region. COPD and especially emphysema were associated with both low vBMD and vertebral fractures after adjustment for steroid use, age, pack-years of smoking, current smoking, and exacerbations. Airway disease was associated with higher bone density after adjustment for other variables. Calibrated QCT identified more subjects with abnormal values than the standard dual-energy X-ray absorptiometry in a subset of subjects and correlated well with prevalent fractures. Male smokers, with or without COPD, have a significant risk of low vBMD and vertebral fractures. COPD was associated with low vBMD after adjusting for race, sex, BMI, smoking, steroid use, exacerbations, and age. Screening for low vBMD by using QCT in men and women who are smokers will increase opportunities to identify and treat osteoporosis in this at-risk population.

Secular trends in the incidence of primary hyperparathyroidism over five decades (1965–2010)

Introduction of automated serum calcium measurements in the 1970s resulted in a sharp rise in primary hyperparathyroidism (PHPT) incidence. However, recent investigations suggest a significant rise in PHPT incidence for unclear reasons. Our objective was to update our population-based secular trends in PHPT incidence, to determine if there has been a significant rise in PHPT incidence as suggested by others, and, if possible, to identify changes in clinical practice that might be responsible. Rochester, Minnesota, residents who met the criteria for PHPT from 2002 through 2010 were identified through the medical records-linkage system of the Rochester Epidemiology Project and added to the historical cohort beginning in 1965. Incidence rates were adjusted to the 2010 US white population. Altogether, 1142 Rochester residents have been diagnosed with PHPT since 1965, including 341 in 2002–2010. Over time, two periods of increased PHPT incidence occurred, one beginning in 1974 (121.7 per 100,000person-years) and a second peak (86.2 per 100,000person-years) starting in 1998. The median age of PHPT subjects has increased significantly from 55years in 1985–1997 to 60years of age in 1998–2010 and more patients (36%) had a parathyroidectomy in 1998–2010. Although serum calcium measurement has declined since 1996, there was a progressive increase in parathyroid hormone testing between 1994 and 2008. There was also a rise in orders for bone mineral density measurements in women since 1998, which peaked in 2003–2004. A second sharp rise in PHPT incidence occurred in our community in 1998, simultaneously with the introduction of national osteoporosis screening guidelines, Medicare coverage for bone density measurement, and new medications for the treatment of osteoporosis. Case ascertainment bias from targeted PHPT screening in patients being evaluated for osteoporosis is the most likely explanation.

Sensitivity of osteoporosis screening guidelines for eventual hip fracture in older male veterans.

This study sought to determine whether guideline-recommended clinical criteria to select men for osteoporosis screening provide significantly better sensitivity than the osteoporotic screening tool (OST) among men who later went on to have a hip fracture, and whether the sensitivity differs by race. This retrospective observational study uses data from the Department of Veterans Affairs Austin Automation Center. We identified 825 male veterans with hip fractures from 2007 to 2009. Clinical risk factors used as screening selection criteria were abstracted from five accepted guidelines. Outpatient encounters were examined for each subject to determine whether they would have met screening selection criteria for each guideline in the 5 years before their hip fracture event. Sensitivities for each guideline were compared with the OST, using McNemar's exact test. Sensitivities of Veterans Affairs Health Service Research and Development Services (VA HSR&D) and National Osteoporosis Foundation (NOF) guidelines were 77% and 82%, respectively, and were significantly better than the OST sensitivity of 72% (P<0.05). Sensitivities of American College of Physicians (ACP; 68%), VA Secretary's Letters (45%) and Center for Medicare and Medicaid Services (13%) were significantly worse than the OST sensitivity (P<0.001). The sensitivities of the VA HSR&D, ACP and NOF were significantly higher in Whites compared with non-Whites (76% vs 65%, P<0.01; 70% vs 58%, P<0.01; and 84% vs 70%, P<0.001, respectively). Only VA HSR&D and NOF clinical screening criteria are more sensitive than OST in identifying veterans who subsequently experience hip fractures, and these sensitivities vary by race.

Prevalence of osteoporosis in men aged 65-75 in a primary care setting. A practice audit after application of the Canadian 2010 guidelines for osteoporosis screening.

Current Canadian osteoporosis guidelines recommend routine bone density screening of men at age 65. The purpose of this study is to determine the prevalence of osteoporosis in men aged 65-75 in after application of screening guidelines. All males aged 65-75 years who attended a large primary care clinic were advised of the 2010 Canadian osteoporosis guidelines and advised to obtain a bone density scan at or after their 65th birthday. Those who did not have a bone density scan since their 65th birthday were advised to obtain a scan, unless there was obvious reason not to do so (i.e. known osteoporosis). A record of the results for each patient were kept and tallied to determine the prevalence of osteoporosis. Osteoporosis was defined as a T-score of ≤ -2.5 in either the hip or lumbar spine. Of 574 male subjects in this clinic, between the ages of 65-75, 557 had a bone density scan, either already having done so at the time of being informed of the guidelines or obtaining a scan in the subsequent year after being informed of the guidelines. The prevalence of osteoporosis was 1.6% (9/557, 95% confidence interval 0.8-3.1%) in this sample. The average age of subjects with osteoporosis was 70.5 ± 1.4 years (range 68-75). None of the subjects under 68 years of age were found to have osteoporosis. The prevalence of osteoporosis in unselected male cohorts aged 65 may be too low to justify the routine bone density screening recommended in the 2010 Canadian osteoporosis guidelines.

Bone Health Care for Patients With Prostate Cancer Receiving Androgen Deprivation Therapy

Patients with prostate cancer often receive androgen deprivation therapy (ADT) as part of their treatment regimen. However, treatment with ADT causes multiple side effects, including reduced bone mineral density (BMD), lower lean body mass, and a higher risk for fractures. Several organizations provide clinical practice guidelines for osteoporosis screening, prevention, and treatment in this population, but adherence to these guidelines remains low. Areas for improvement in provider adherence include baseline and follow-up BMD testing, as well as counseling regarding healthy bone behaviors such as calcium/vitamin D intake, lifestyle changes, and physical exercise. Comparison of osteoporosis care in breast cancer and non-oncology populations shows that suboptimal bone health care is not isolated to prostate cancer. A summary of the literature examining improvements in patient adherence and provider delivery of bone health care is included in this review, but high-quality studies are lacking. Patients may be the most receptive to written educational information delivered at or near the time of ADT initiation. Involvement of a primary care practitioner and oncologist in care delivery is associated with higher BMD test use. Institution-level programs that automatically initiate osteoporosis screening and management may be effective at reducing the incidence of hip fracture. Lastly, suggestions are provided for future approaches to knowledge translation and quality of care studies to improve bone health.

Adherence to the U.S. Preventive Services Task Force 2002 Osteoporosis Screening Guidelines in Academic Primary Care Settings

Osteoporosis is very common in older women in the United States. Osteoporotic fractures cause significant morbidity and mortality, as well as high healthcare costs. Since 2002, the United States Preventive Services Task Force (USPSTF) has recommended screening for osteoporosis of all women aged ≥65. Our objective was to determine adherence to osteoporosis screening guidelines by primary care internists in a large academic medical center and to assess if adherence varies based on provider gender or practice location. This was a retrospective electronic medical record (EMR) review. All women aged ≥65 who were seen in the General Internal Medicine Center (GIMC) or the Women's Health Care Center (WHCC) at the University of Washington Medical Center by internal medicine attending physicians between January 1, 2006, and February 2, 2008, were included in the study. We determined if the patient had a dual energy x-ray absorptiometry (DEXA) study in the EMR database. We calculated the percentage of patients screened per provider and also compared the rate of screening for male vs. female providers and for GIMC vs. WHCC providers. Of the 1363 women included in the study, 70% had documentation of a DEXA study. Adherence to screening recommendations for individual providers varied from 33% to 100%. Screening was more likely to occur in the WHCC than in the GIMC (79.2% vs. 66.7%, p<0.001). Although women providers were more likely to screen than their male counterparts (72.2% vs. 66.1%, p=0.023), this relationship did not hold true after excluding women providers from the WHCC. We found good adherence to the USPSTF 2002 guidelines for osteoporosis screening in women aged ≥65 years by primary care physicians in a large urban academic medical center. The practice site and not gender of the provider resulted in significantly different screening rates.

High Prevalence of Low-Trauma Fracture in Chronic Pancreatitis

Chronic pancreatitis (CP) is associated with risk factors that may negatively impact bone and mineral metabolism. The important clinical end point of osteoporosis is "low-trauma" fracture. The purpose of this study was to examine the prevalence of "low-trauma" fracture in patients with CP, compared with fracture rates in "high-risk" gastrointestinal (GI) illnesses, for which metabolic bone disease screening guidelines are in place. This is a retrospective cohort database study examining patients with CP and "high-risk" GI illnesses seen at a single tertiary care center. Time points ranged between 31 July 1998 and 31 July 2008. The main outcome measure was "low-trauma" fracture prevalence using specific International Classification of Diseases, Ninth Revision, Clinical Modification fracture codes. A total of 3,192 CP patients and 1,461,207 non-CP patients were included in the study. The fracture prevalence (patients with fracture per total patients) was as follows: controls, 1.1% (16,208/1,436,699); Crohn's disease, 3.0% (182/6057); CP, 4.8% (154/3192); cirrhosis, 4.8% (805/16,658); celiac disease, 5.0% (74/1480); and postgastrectomy, 5.4% (17/313). Prevalence for each group was statistically greater than controls (P<0.001). CP fracture prevalence was greater than controls (P<0.001) and Crohn's disease (P<0.001), and comparable with the remaining "high-risk" GI illness groups (P>0.05). The odds of fracture (odds ratio (OR), 95% confidence interval (CI)) compared with controls, adjusted for age, gender, and race was: CP 2.4 (2.1, 2.9); Crohn's disease 1.7 (1.5, 2.0); gastrectomy 2.5 (1.5, 4.1); cirrhosis 2.6 (2.4, 2.7); and celiac disease 2.7 (2.1, 3.4). The odds of fracture for each disease group were statistically greater than controls (P<0.0001). The prevalence of low-trauma fracture in CP patients is comparable with or higher than that of "high-risk" GI illnesses, for which osteoporosis screening guidelines exist.