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Bone Health Screening Prior to Medicare Eligibility—Osteoporosis Screening and Fracture Prevention After Distal Radius Fractures in Patients Aged 50–59

Current guidelines recommend bone mineral density (BMD) testing after fragility fractures in patients aged 50 years or older. This study aimed to assess BMD testing and subsequent fragility fractures after low-energy distal radius fractures (DRFs) among patients aged 50-59 years. We used the 2010-2020 MarketScan dataset to identify patients with initial DRFs with ages ranging between 50 and 59 years. We assessed the 1-year BMD testing rate and 3-year non-DRF fragility fracture rate. We created Kaplan-Meier plots to depict fragility fracture-free probabilities over time and used log-rank tests to compare the Kaplan-Meier curves. Among 78,389 patients aged 50-59 years with DRFs, 24,589 patients met our inclusion criteria, and most patients were women (N= 17,580, 71.5%). The BMD testing rate within 1 year after the initial DRF was 12.7% (95% CI, 12.3% to 13.2%). In addition, 1-year BMD testing rates for the age groups of 50-54 and 55-59 years were 10.4% (95% CI, 9.9% to 11.0%) and 14.9% (95% CI, 14.2% to 15.6%), respectively. Only 1.8% (95% CI, 1.5% to 2.1%) of men, compared with 17.1% (95% CI, 16.5% to 17.7%) of women, underwent BMD testing within 1 year after the initial fracture. The overall 3-year fragility fracture rate was 6.0% (95% CI, 5.6% to 6.3%). The subsequent fragility fracture rate was lower for those with any BMD testing (4.4%; 95% CI, 3.7% to 5.2%), compared with those without BMD testing (6.2%; 95% CI, 5.9% to 6.6%; P < .05). We report a low BMD testing rate for patients aged between 50 and 59 years after initial isolated DRFs, especially for men and patients aged between 50 and 54 years. Patients who received BMD testing had a lower rate of subsequent fracture within 3 years. We recommend that providers follow published guidelines and initiate an osteoporosis work-up for patients with low-energy DRFs to ensure early diagnosis. This provides an opportunity to initiate treatment that may prevent subsequent fractures. Prognosis II.

Utilization of screening and treatment for osteoporosis among stroke survivors.

Stroke survivors are prone to osteoporosis and fractures. However, bone mineral density (BMD) testing and osteoporosis treatment were underutilized in patients with recent stroke. We aimed to examine whether stroke has an impact on the utilization of BMD testing and osteoporosis treatment as well as the determinants of their utilization in stroke patients using nationwide population-based data in Taiwan. We identified patients aged 55 years and older who were hospitalized for hemorrhagic or ischemic stroke as the stroke cohort, and age- and sex-matched patients hospitalized for reasons other than stroke, fracture, or fall as the non-stroke cohort. We used the Fine-Gray sub-distribution hazard competing risk regression model to determine the predictors for BMD testing and osteoporosis treatment. A total of 32997 stroke patients and 32997 age- and sex-matched controls comprised the stroke and non-stroke cohorts, respectively. BMD testing and osteoporosis treatment were performed in 1.0% and 5.2% of the stroke patients, respectively, within one year after hospitalization while these measures were performed in 0.8% and 4.7% of the controls. Stroke patients were more likely to receive BMD testing (adjusted hazard ratio [HR] 1.33; 95% confidence interval [CI] 1.11-1.58) and osteoporosis treatment (adjusted HR 1.19; 95% CI 1.11-1.29). Female sex, osteoporosis, prior BMD testing, and low-trauma fractures after stroke increased the likelihood of using BMD testing and osteoporosis treatment whereas greater stroke severity reduced the likelihood of receiving both measures. Both BMD testing and osteoporosis treatment were underutilized among stroke survivors even though they had a higher chance of receiving both measures than non-stroke patients.

A retrospective observational study of osteoporosis management after a fragility fracture in primary care

SummaryIn many countries, osteoporosis is predominantly managed by primary care physicians; however, management after a fragility fracture has not been widely investigated. We describe osteoporosis care gaps in a real-world patient cohort. Our findings help inform initiatives to identify and overcome obstacles to effective management of patients after fragility fracture.PurposeA fragility fracture is a major risk factor for subsequent fracture in adults aged ≥ 50 years. This retrospective observational study aimed to characterize post-fracture management in Canadian primary care.MethodsA total of 778 patients with an index fragility fracture (low-trauma, excluding small bones) occurring between 2014 and 2016 were identified from medical records at 76 primary care centers in Canada, with follow-up until January 2018.ResultsOf 778 patients (80.5% female, median age [IQR] 73 [64–80]), 215 were on osteoporosis treatment and 269 had osteoporosis diagnosis recorded prior to their index fracture. The median follow-up was 363 (IQR 91–808) days. Of patients not on osteoporosis treatment at their index fracture, 60.2% (n = 339/563) remained untreated after their index fracture and 62.2% (n = 23/37) continued untreated after their subsequent fracture. After their index fracture, fracture risk assessment (FRAX or CAROC) was not performed in 83.2% (n = 647/778) of patients, and 59.9% (n = 466/778) of patients did not receive bone mineral density testing. Of patients without osteoporosis diagnosis recorded prior to their index date, 61.3% (n = 300/489) remained undiagnosed after their index fracture. At least one subsequent fracture occurred in 11.5% (n = 86/778) of patients.ConclusionIn the primary care setting, fragility fracture infrequently resulted in osteoporosis treatment or fracture risk assessment, even after multiple fragility fractures. These results suggest a fragility fracture is not recognized as a major risk factor for subsequent fracture and its occurrence does not prompt primary care physicians to intervene. These data urge initiatives to identify and overcome obstacles to primary care physicians’ effective management of patients after fragility fractures.

Prediction of Osteoporosis Among Vietnamese Women

Screening for osteoporosis and fracture risk in Vietnamese American women younger than 65 years is not well described. Controversy exists over who among this group should receive bone mineral density testing. This study compared the predictive value of 2 prescreening tools, the Osteoporosis Self-Assessment Tool for Asians and the Fracture Risk Assessment Tool. A 6-month retrospective health record review was completed on 149 postmenopausal Vietnamese American women, 45 to 64 years old, in a primary care setting in Southern California. Demographic and clinical risk factors were used to calculate Osteoporosis Self-Assessment Tool for Asians and Fracture Risk Assessment Tool scores. Sensitivity and specificity to predict bone mineral density results are reported.

Management of Fragility Hip Fractures: Our Institutional Experience.

Introduction:Approximately 320 000 fragility hip fractures are sustained in the United States annually, resulting in substantial morbidity and mortality as well as significant economic burden on the health-care system. Nevertheless, a majority of these patients are not screened and do not receive treatment for osteoporosis. The objective of this study was to evaluate rates of osteoporosis screening and treatment in our institution and compare them to those reported in the literature.Methods:This was a retrospective cohort study of 191 patients ages 50 and older who sustained osteoporotic hip fractures. Primary outcome measures were percentage of patients who (1) underwent bone health laboratory workup during admission, (2) were started on vitamin D, calcium, and/or a bisphosphonate, (3) received bone mineral density testing, and (4) followed up with a primary care doctor or endocrinologist. Secondary outcomes measures were (1) whether gender, race, or age influenced our primary outcomes and (2) whether obtaining in-hospital laboratory workup led to increased rates of further screening and treatment.Results:Fifty-six (29.3%) patients received full laboratory workup, 48 (25.1%) were prescribed vitamin D and calcium, 11 (5.7%) were prescribed a bisphosphonate, 13 (6.8%) underwent bone mineral density testing, and 41 (21.5%) followed up with primary care or endocrinology.Discussion:Women were more likely to be treated with vitamin D and calcium. Outcomes were similar regardless of race. Younger patients were more likely to undergo laboratory testing, bisphosphonate therapy, and bone mineral density testing. Initiating workup during admission did not lead to increased rates of outpatient treatment.Conclusion:Despite nationwide efforts to improve, rates of osteoporosis screening and treatment following hip fracture are suboptimal. Rates at our institution are similar to those reported in previous studies. There were disparities between gender and age groups. Future studies are needed to evaluate whether more recently implemented policies lead to better osteoporosis screening and management.

Healthy Bones Study: can a prescription coupled with education improve bone health for patients receiving androgen deprivation therapy?-a before/after study.

To evaluate the ability of a multimodal patient education initiative to improve adherence to healthy bone behaviors (HBBs) in men with prostate cancer receiving androgen deprivation therapy (ADT). This was a pilot prospective, single-site, before-and-after clinical trial. The control arm (n = 51) received routine care. The intervention arm (n = 52) received multimodal HBB education which included a healthy bones prescription (BoneRx), focused face-to-face education with an oncology nurse or physician, and customized educational materials. The primary endpoints were feasibility of study methods and self-reported adherence to HBBs (vitamin D intake ≥ 1000IU/day, calcium intake 1000-1500mg/day, and exercise ≥ 150min/week) at 3-month follow-up. Secondary endpoints included receipt of bone mineral density (BMD) testing. Patients were satisfied with the study intervention, found educational materials easy to understand, and felt that it increased their knowledge about osteoporosis. Although the intervention appeared to be associated with trends toward improved levels of vitamin D intake (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 0.74-4.5), calcium intake (OR 1.5, 95% CI 0.63-3.4), and exercise (OR 1.7, 0.75-3.9) as compared to the control arm, none of these were statistically significant. Patients who received the study intervention were more likely to receive BMD testing (OR 3.3, 95% CI 1.3-8.8). Although a brief, tailored educational intervention was feasible to implement and improve BMD test utilization, it did not increase HBB participation. Larger, well-designed trials are needed to clarify the effect of patient education interventions on HBB adherence. ClinicalTrials.gov ( NCT01973673 ).

Fracture prevention service to bridge the osteoporosis care gap.

BackgroundA care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive. The Fracture Prevention Service (FPS), a tailored in-hospital model of care, may effectively bridge the osteoporosis care gap for hip-fractured older persons. The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment.MethodsThis was a prospective observational study conducted in a teaching hospital with traumatology and geriatric units, and had a pre-intervention and post-intervention phase. The records of 172 participants were evaluated in the pre-intervention phase, while data from 210 participants were gathered in the post-intervention phase. All participants underwent telephone follow-up at 12 months after hospital discharge. The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture. A multidisciplinary integrated model of care was established. Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons, improve their evaluation through bone mineral density testing and blood examinations, and initiate an appropriate treatment for secondary prevention of falls and fragility fractures.ResultsCompared with the pre-intervention phase, more hip-fractured persons received bone mineral density testing (47.62% versus 14.53%, P<0.0001), specific pharmacological treatments (48.51% versus 17.16%, P<0.0001), and an appointment for evaluation at a fall and fracture clinic (52.48% versus 2.37%, P<0.0001) in the post-intervention phase. Independent of some confounders, implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge (P<0.0001) and with 1-year adherence to pharmacological treatment (P<0.0001).ConclusionThe FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture, to improve their clinical management, and to increase adherence to prescriptions.

Impact of physician visits on bone density testing in men with prostate cancer who receive androgen deprivation therapy.

291 Background: Clinical guidelines for men receiving androgen deprivation therapy (ADT) for prostate cancer (PC) recommend bone mineral density (BMD) monitoring. We examined physician visit patterns following ADT initiation and the implications for follow up BMD testing. Methods: We analyzed linked Surveillance, Epidemiology, and End Results (SEER) &amp; Medicare data for men aged 65+ with incident non-metastatic PC diagnosed during 2007-2009 and receiving ADT for at least 6 months. We examined the proportion of men who visited the following physician types after ADT initiation: urologist, medical oncologist (MO), radiation oncologist (RO), and primary care physician (PCP). Physician contact was measured during 3 time periods: 3 months pre-ADT and 3 months post-ADT (P1); 3-6 months post-ADT (P2); and 6-9 months post-ADT (P3). Multivariable logistic regression models estimated the association between physician visits and BMD testing. Results: The sample included 4,631 men (median age: 75) with non-metastatic PC who received ADT over a median duration of 12 months. During follow-up, 12% received BMD testing, and median time from ADT initiation to BMD testing was 364 days. The proportion who visited any urologist, MO, RO, and PCP during P1 was 97%, 12%, 52%, and 71%. During P2, the proportions dropped to 69%, 9%, 19%, and 53%, respectively, and remained similar in P3. Physician visits during P1 were not associated with BMD testing. During P2, the adjusted odds ratio (95% CI) for BMD testing in men who saw a MO was 1.39 (1.04-1.86). During P3, the AOR (95% CI) was 1.52 (1.15-2.01) in men who saw a MO and 1.23 (1.02-1.49) in men who saw a PCP. Conclusions: In older PC men treated with ADT, physician contact was highest during ADT initiation and decreased over time. Continued contact with physicians following ADT initiation can be beneficial.

Prevalence of fractures among men with stage IV prostate cancer (S4PC).

143 Background: Fractures (fx) are common in men with stage 4 prostate cancer (S4PC), resulting in significant clinical consequences, such as increased pain and decreased quality of life. The aim of this study was to estimate the prevalence of fx among men diagnosed with non-metastatic (M0) or metastatic (M1) S4PC and evaluate risk factors associated with fx. Methods: We estimated the prevalence of fx among men age 66 or older diagnosed with M0 or M1 S4PC using data from the U.S. SEER-Medicare datasets between 2000 to 2007. Men were followed through December 2009 or until they were lost to follow up. Codes indicating “pathologic fracture” or “fracture,” excluding codes suggesting accidents/falls in the 14 days prior to the fx, were used to identify fx. Results: Among 9,826 men with S4PC (M1 = 7301; M0 = 2525), 12.9% experienced a post-diagnosis fx based on the codes used. The prevalence of fx was nearly twice as high in men with M1 versus M0 S4PC (M1 = 14.7%; M0 = 7.5%). The median time from diagnosis of S4PC to first fx was five months for men with M1 S4PC versus 34 months for men with M0 S4PC. Compared to men with no fx, men who experienced fx were more likely to be older (20.3% vs. 17.8%), of white/non-Hispanic race (81.1% vs. 75.3%), have well (cancer grade 1) or moderately (cancer grade 2) differentiated tumors (48.7% vs. 41.7%), have a claim of osteoporosis (2.4% vs. 0.6%) or osteoarthritis (9.3% vs. 6.5%) in the year prior to S4PC diagnosis, and to have taken a bone mineral density (BMD) test (13.5% vs. 8.1%). All differences were significant at p&lt;0.05 level. Overall, 92% of men did not receive BMD testing at any time post diagnosis despite the fact that 67% of the men received ADT. Conclusions: In men with M1 S4PC at diagnosis, the prevalence of fx is higher and the time to fx is substantially shorter than in men with M0 S4PC at diagnosis. Furthermore, most men with S4PC do not receive BMD testing. A significant need remains to monitor bone health and treat fx, particularly among M1 S4PC patients.

Patterns of Bone Mineral Density Testing in Men Receiving Androgen Deprivation for Prostate Cancer

Practice guidelines recommend bone mineral density (BMD) monitoring for men on androgen deprivation therapy (ADT) for prostate cancer, but single center studies suggest this is underutilized. We examined determinants of BMD testing in men receiving ADT in a large population-based cohort of men with prostate cancer. Retrospective cohort study. We used the Surveillance, Epidemiology and End-Results (SEER)-Medicare database to identify 84,036 men with prostate cancer initiating ADT from 1996 through 2008. Rates of BMD testing within the period 12 months prior to 3 months after initiation of ADT were assessed and compared to matched controls without cancer and to men with prostate cancer not receiving ADT. A logistic regression model was performed predicting use of BMD testing, adjusted for patient demographics, indications for ADT use, year of diagnosis and specialty of the physician involved in the care of the patient. Rates of BMD testing increased steadily over time in men receiving ADT, diverging from the control groups such that by 2008, 11.5 % of men were receiving BMD testing versus 4.4 % in men with prostate cancer not on ADT and 3.8 % in the non-cancer controls. In the logistic regression model, year of diagnosis, race/ethnicity, indications for ADT use and geographic region were significant predictors of BMD testing. Patients with only a urologist involved in their care were significantly less likely to receive BMD testing as compared to those with both a urologist and a primary care physician (PCP) (odds ratio 0.71, 95 % confidence interval 0.64-0.80). There has been a sharp increase in rates of BMD testing among men receiving ADT for prostate cancer over time, beyond rates noted in contemporaneous controls. Absolute rates of BMD testing remain low, however, but are higher in men who have a PCP involved in their care.

Effect of Reimbursement Reductions on Bone Mineral Density Testing for Female Medicare Beneficiaries

We examined whether the recent reimbursement reductions on the bone mineral density (BMD) test affected BMD testing in female Medicare beneficiaries with or without supplemental private health insurance. Retrospectively analyzing hospital administrative and clinical data on female Medicare beneficiaries (n=1320), we reviewed whether participants received BMD testing before (January 2004-December 2006) or after (January 2007-December 2009) reimbursement reductions for BMD testing. After adjusting for demographics and clinical characteristics, we performed Cox proportional hazard regression analyses of the BMD test including data from all study participants; we then performed separate regression analyses using data with or without supplemental private health insurance. In those without supplemental private health insurance (n=421), less frequent BMD testing occurred after reimbursement reductions for BMD testing (hazard ratio [HR] 0.67, 95% confidence intervals [CI] 0.34-0.98; p=0.03). By contrast, in the overall participants (n=1320) and those with supplemental private health insurance (n=899), the number of BMD tests did not change significantly after reimbursement reductions for BMD testing. We found a significant association between reimbursement reductions and decrease in BMD tests in female Medicare beneficiaries without supplemental private health insurance.

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial

SummaryWe conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.IntroductionTo determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).MethodsA cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was ‘appropriate’ management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.ResultsThirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3–4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0–7.0).ConclusionsA centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.

Physician Follow-up Care for Osteoporosis After Fragility Fractures

Osteoporosis affects > 10 million Americans each year. The disease is characterized by low bone mass and decreased bone strength, and patients often sustain fragility fractures. Previous research highlights low rates of identification and treatment of the disease after a fragility fracture, yet patients are still overlooked. This study identified patients who did not receive proper osteoporosis care after a fragility fracture in Southeastern Pennsylvania. In a telephone interview, we asked patients who had sustained a fragility fracture in 2008 and were treated at one orthopedic practice about information on events before and after their fractures. We concluded that a patient's bone health had suboptimal care if, after the fracture, the patient had no doctor interview, did not receive bone mineral density testing, and did not begin or change medications. Of the 224 patients who participated in our study, we determined that 149 (67%) patients received insufficient osteoporosis care. One hundred fourteen (63%) women and 35 (80%) men received inadequate osteoporosis care. The high incidence of unsatisfactory care, particularly in men, indicates that osteoporosis care continues to be a problem. We believe that one contributing factor is physician accountability for care. Our study indicates that no specific specialist takes responsibility for follow-up care, possibly signifying the lack of an adequate system for identifying and treating the disease. The opportunity to address this issue should be a high priority for both primary care physicians and orthopedic surgeons.

A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial

In a cluster randomized trial, we evaluated the effect of a multifaceted intervention (directed at both patient and primary care physician) on the rates of testing and treatment of osteoporosis in postmenopausal women within six months of their wrist fracture. Compared to usual care, women in the intervention practices were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments. Postmenopausal women with wrist fractures are at increased risk of future fragility fractures, yet they frequently do not receive evaluation and treatment for osteoporosis. We set out to evaluate a multifaceted intervention designed to improve management of osteoporosis in older women with recent wrist fractures. Cluster randomized trial of 270 women cared for in 119 primary care practices. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario, Canada. Family practices were randomly assigned to either the intervention or usual care. The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician, in addition to an educational package and letter to the women. The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture. The mean age of women was 69(10.9) years. The intervention increased the proportion of women started on osteoporosis medications (28% vs. 10%) of controls, adjusted OR 3.45, 95% CI, 1.58-7.56, p = 0.002) and the proportion who had a bone mineral density (BMD) test (53.3% vs. 26%) of controls, OR 3.38, 95% CI, 1.83-6.26, p < 0.001). In addition to the intervention, having a female physician was a predictor of increased testing and treatment rates. A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures.