Search

There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed., Introduction: Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture., Methods: Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables., Results: We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses., Conclusions: QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.

Unlabelled: We estimate the current burden of illness of osteoporosis in Canada is double ($4.6 billion) our previous estimates ($2.3 billion) due to improved data capture of the multiple encounters and services that accompany a fracture: emergency room, admissions to acute and step-down non-acute institutions, rehabilitation, home-assisted or long-term residency support., Introduction: We previously estimated the economic burden of illness of osteoporosis-attributable fractures in Canada for the year 2008 to be $2.3 billion in the base case and as much as $3.9 billion. The aim of this study is to update the estimate of the economic burden of illness for osteoporosis-attributable fractures for Canada based on newly available home care and long-term care (LTC) data., Methods: Multiple national databases were used for the fiscal-year ending March 31, 2011 (FY 2010/2011) for acute institutional care, emergency visits, day surgery, secondary admissions for rehabilitation, and complex continuing care, as well as national dispensing data for osteoporosis medications. Gaps in national data were supplemented by provincial and community survey data. Osteoporosis-attributable fractures for Canadians age 50+ were identified by ICD-10-CA codes. Costs were expressed in 2014 dollars., Results: In FY 2010/2011, the number of osteoporosis-attributable fractures was 131,443 resulting in 64,884 acute care admissions and 983,074 acute hospital days. Acute care costs were $1.5 billion, an 18 % increase since 2008. The cost of LTC was 33.4 times the previous estimate ($31 million versus $1.03 billion) because of improved data capture. The cost for rehabilitation and secondary admissions increased 3.4 fold, while drug costs decreased 19 %. The overall cost of osteoporosis was over $4.6 billion, an increase of 83 % from the 2008 estimate., Conclusion: Since the 2008 estimate, new Canadian data on home care and LTC are available which provided a better estimate of the burden of osteoporosis in Canada. This suggests that our previous estimates were seriously underestimated.

Unlabelled: The aim of this review is to compare the efficacy and safety of denosumab over other treatments for osteoporosis. The results of this study suggest that the safety of denosumab and its efficacy in reducing fractures is not significantly different from bisphosphonates. Denosumab was, however, more effective in increasing bone mineral density., Introduction: This study was conducted to compare the efficacy and safety of denosumab over other pharmacological treatments for osteoporosis in individuals at risk of fracture., Methods: Randomised controlled trials comparing denosumab with another pharmacological treatment for osteoporosis were searched in MEDLINE, EMBASE and CENTRAL. Identified articles were screened by two independent reviewers and assessed for inclusion. Data from included studies were extracted and meta-analyses were conducted using random effects models., Results: Nine studies including a total of 4890 postmenopausal women were identified. The follow-up period varied from 12 to 24 months. In all studies except one, the comparator treatment was a bisphosphonate. There was no statistically significant difference between patients receiving denosumab and those receiving a bisphosphonate in terms of fracture risk (RR[95 % CI] = 1.15 [0.84-1.58]), adverse events (RR[95 % CI] = 0.99 [0.96-1.02]) or deaths (OR[95 % CI] = 0.58 [0.12-2.71]). Withdrawals due to adverse events were less frequent in denosumab than in other treatment groups but the difference did not reach statistical significance (OR[95 % CI] = 0.68 [0.45-1.04]). The percent change in bone mineral density at the total hip, lumbar spine, femoral neck and one-third radius was significantly higher in participants who received denosumab (e.g. mean difference [95 % CI] at the total hip: 1.06 [0.86-1.25])., Conclusions: These results suggest that, after 12 to 24 months, the safety and efficacy of denosumab for reducing fracture risk is not significantly different from bisphosphonates despite higher gains in bone mineral density. In a clinical setting, denosumab may demonstrate greater effectiveness.

The purpose of this study was to investigate the impact of two educational interventions on the intake of calcium and vitamin D supplements and modifiable risk factors for osteoporosis in women ≥50 years with a fragility fracture (FF). Within 6-8 months of fracture, women were randomized to one of three intervention groups: usual care (UC), written materials (WM), or videocassette and written materials (VC). The written materials for patients and their physician provided information on osteoporosis, FF, and available treatments; written materials for physician were provided through patients. The videocassette presented similar information as the written material, but in greater depth. Twelve months after randomization, the effectiveness of the interventions was assessed. The study cohort consisted of 1,175 women undiagnosed and untreated for osteoporosis. After 12 months, the mean intake of Ca supplements increased by 33, 93, and 91 mg/day for the UC, WM, and VC groups, respectively (p value, WM vs UC = 0.163; VC vs UC = 0.026); the corresponding mean increases for vitamin D were 58, 105, and 118 IU/day (p value, WM vs UC = 0.214; VC vs UC = 0.012). The proportion of women who increased their Ca and vitamin D intake by supplements was similar in all three groups. The intervention had a greater impact in those not taking supplements at randomization and had no impact on modifiable risk factors. In women without diagnosis and treatment for osteoporosis, the interventions seem effective at increasing the amounts of Ca and vitamin D supplements, but not effective at inciting more women to increase their consumption. Therefore, the clinical significance of the impact of the intervention is difficult to evaluate.

Unlabelled: We used data from a large, prospective Canadian cohort to assess the association between selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) and fracture. We found an increased risk of fractures in individuals who used SSRI or SNRI, even after controlling for multiple risk factors., Introduction: Previous studies have suggested an association between SSRIs and increasing risk of fragility fractures. However, the majority of these studies were not long-term analyses or were performed using administrative data and, thus, could not fully control for potential confounders. We sought to determine whether the use of SSRIs and SNRIs is associated with increased risk of fragility fracture, in adults aged 50 + ., Methods: We used data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective randomly selected population-based community cohort; our analyses focused on subjects aged 50+. Time to event methodology was used to assess the association between SSRI/SNRI use, modeled time-dependently, and fragility fracture., Results: Among 6,645 subjects, 192 (2.9%) were using SSRIs or/and SNRIs at baseline. During the 10-year study period, 978 (14.7%) participants experienced at least one fragility fracture. In our main analysis, SSRI/SNRI use was associated with increased risk of fragility fracture (hazard ratio (HR), 1.88; 95% confidence intervals (CI), 1.48-2.39). After controlling for multiple risk factors, including Charlson score, previous falls, and bone mineral density hip and lumbar bone density, the adjusted HR for current SSRI/SNRI use remained elevated (HR, 1.68; 95% CI, 1.32-2.14)., Conclusions: Our results lend additional support to an association between SSRI/SNRI use and fragility fractures. Given the high prevalence of antidepressants use, and the impact of fractures on health, our findings may have a significant clinical impact., Competing Interests: Lisa-Ann Fraser has been on the speaker’s bureau for Amgen. Jonathan D. Adachi has been a consultant/speaker for Amgen, Eli Lilly, Merck, Novartis, and Warner Chilcot, and has conducted clinical trials for Amgen, Eli Lilly, Merck, and Novartis. David Goltzman has been an advisory board member or consultant for Amgen, Eli Lilly, Merck Frosst, and Novartis. William Leslie has received speaker fees from Amgen, Eli Lilly, and Novartis and research grants from Amgen and Genzyme.

Unlabelled: Prevention of bone mineral density loss in rheumatoid arthritis (RA) has been associated with use of biologic disease-modifying anti-rheumatic drugs (DMARDs). However, in this study, we could not demonstrate a reduction in the risk of non-vertebral fractures. Additional research is required to clarify the impact of biologic DMARDs on fracture risk in RA., Introduction: Small studies have suggested biologic DMARDs preserve bone mineral density at 6-12 months. Our objective was to determine the association between biologic DMARD use and the risk of non-vertebral osteoporotic fractures in RA subjects aged ≥50 years., Methods: A nested case-control study was conducted using Quebec physician billing and hospital discharge data. RA subjects were identified from International Classification of Disease-9/10 codes in billing and hospitalisation data and followed from cohort entry until the earliest of non-vertebral osteoporotic fracture, death, or end of study period. Controls were matched to cases (4:1 ratio) on age, sex, and date of cohort entry. Biologic DMARD exposure was defined as being on treatment for ≥180 days pre-fracture (index). Conditional logistic regression was used, adjusting for indicators of RA severity, comorbidity, drugs influencing fracture risk, and measures of health care utilisation., Results: Over the study period, 1,515 cases were identified (6,023 controls). The most frequent fracture site was hip/femur (42.3%). In total, 172 subjects (49 cases and 123 controls) were exposed to biologic DMARDs. The median duration of exposure was 735 (interquartile range (IQR), 564) and 645 (IQR, 903) days in cases and controls, respectively. We were unable to demonstrate an association between biologic DMARDs and fracture risk (odds ratio, 1.03; 95% confidence interval, 0.42-2.53). RA duration significantly increased the fracture risk., Conclusions: Despite the positive impact of biologic DMARDs on bone remodelling observed in small studies, we were unable to demonstrate a reduction in the risk of non-vertebral osteoporotic fractures in older adults with RA.

Disease-modifying anti-rheumatic drugs (DMARDs) are the cornerstone of rheumatoid arthritis (RA) pharmacotherapy and should be initiated promptly after RA diagnosis. We examined trends in use of traditional and biologic DMARDs, and non-DMARD treatments, among overall RA patients, and factors associated with DMARD initiation in the newly diagnosed RA. RA subjects identified with the Quebec administrative databases were followed between January 1, 2002, and December 31, 2008. DMARD use was characterized on November 1 of each year using cross-sectional analyses. For a subgroup of newly diagnosed subjects, we used multivariable logistic regressions to identify predictors of DMARD initiation within 12 months of diagnosis and survival analyses to appraise time to DMARD initiation. A total of 37,399 subjects were included (65.8 % ≥65 years; 70.5 % female). The percentage of subjects using any DMARDs increased over the study period from 41.4 % [95 % confidence interval (CI) 40.8-42.0] to 43.3 % (95 % CI 42.7-43.9). Among newly diagnosed RA, being followed by a rheumatologist was the strongest predictor of DMARD initiation (odds ratio 4.31; 95 % CI 3.73-4.97). Care by an internist, increasing calendar year, use of NSAIDs, corticosteroids, or opioids, and a history of hospitalization increased the likelihood of DMARD initiation. Older age, female, higher comorbidity score, number of medical visits pre-diagnosis, care by other specialists, and the use of acetaminophen were inversely associated with DMARD initiation. The probability of any DMARD initiation at 12 months was 38.5 %. Despite the clinical practice guideline recommendations for earlier aggressive RA management, DMARD use appears to be suboptimal in Quebec.

Evidence supports early use of non-biologic DMARDs to prevent irreversible damage in inflammatory arthritides, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and possibly ankylosing spondylitis (AS). However, there is a paucity of data exploring their effects on pain as a primary outcome in these conditions. This systematic literature review investigated the effect of non-biologic DMARDs on pain levels in IA and examined whether disease duration impacted efficacy. We searched Medline, Embase, Cochrane Central, and Cochrane Database of Systematic Reviews, abstracts from the 2008 to 2010 American College of Rheumatology annual congresses, and citation lists of retrieved publications. Only randomized, double-blind controlled trials were analyzed. Quality was assessed with the Risk of Bias tool. Descriptive statistics were used in meta-analysis. 9,860 articles were identified, with 33 eligible for inclusion: 8 in AS, 6 in PsA, 9 in early RA (ERA), and 10 in established RA. In ERA and established RA, all studies of DMARDs (monotherapy and combination therapies) consistently revealed statistically significant reductions in pain except three oral gold studies. In AS, sulfasalazine studies showed significant pain reduction, whereas use of other DMARDs did not. In PsA, 5 of 6 studies reported VAS-pain improvement. From the studies included, we were unable to assess the influence of disease duration on pain outcomes in these rheumatic conditions. DMARDs improve pain in early and established RA. Sulfasalazine may improve pain in AS and PsA. Further study is needed to assess the relationship between disease duration and DMARD efficacy in reducing pain in these conditions.

Unlabelled: To update the 1993 burden of illness of osteoporosis in Canada, administrative and community data were used to calculate the 2010 costs of osteoporosis at $2.3 billion in Canada or 1.3% of Canada's healthcare expenditures. Prevention of fractures in high-risk individuals is key to decrease the financial burden of osteoporosis., Introduction: Since the 1996 publication of the burden of osteoporosis in 1993 in Canada, the population has aged and the management of osteoporosis has changed. The study purpose was to estimate the current burden of illness due to osteoporosis in Canadians aged 50 and over., Methods: Analyses were conducted using five national administrative databases from the Canadian Institute for Health Information for the fiscal-year ending March 31 2008 (FY 2007/2008). Gaps in national data were supplemented by provincial and community data extrapolated to national levels. Osteoporosis-related fractures were identified using a combination of most responsible diagnosis at discharge and intervention codes. Fractures associated with severe trauma codes were excluded. Costs, expressed in 2010 dollars, were calculated for osteoporosis-related hospitalizations, emergency care, same day surgeries, rehabilitation, continuing care, homecare, long-term care, prescription drugs, physician visits, and productivity losses. Sensitivity analyses were conducted to measure the impact on the results of key assumptions., Results: Osteoporosis-related fractures were responsible for 57,413 acute care admissions and 832,594 hospitalized days in FY 2007/2008. Acute care costs were estimated at $1.2 billion. When outpatient care, prescription drugs, and indirect costs were added, the overall yearly cost of osteoporosis was over $2.3 billion for the base case analysis and as much as $3.9 billion if a proportion of Canadians were assumed to be living in long-term care facilities due to osteoporosis., Conclusions: Osteoporosis is a chronic disease that affects a large segment of the adult population and results in a substantial economic burden to the Canadian society.

Unlabelled: This study determined the cost of treating fractures at osteoporotic sites (except spine fractures) for the year following fracture. While the average cost of treating a hip fracture was the highest of all fractures ($46,664 CAD per fracture), treating other fractures also accounted for significant expenditures ($5,253 to $10,410 CAD per fracture)., Introduction: This study aims to determine the mean direct medical cost of treating fractures at peripheral osteoporotic sites in the year post-fracture (through 2 years post-hip fracture)., Methods: Health administrative databases from the province of Quebec, Canada were used to estimate the cost of treating peripheral fractures at osteoporotic sites for the year following fracture (through 2 years for hip fractures). Included in costs analyses were physician claims, emergency and outpatient clinic costs, hospitalization costs, and subsequent costs for treatment of complications., Results: A total of 15,827 patients (mean age 72 years) who suffered one fracture at an osteoporotic site had data for analyses. Hip/femur fractures had the highest rate of hospital stays related to fracture (91%) and the highest rate of hospital stays associated with a post-fracture complication (8%). In the year following fracture, the mean (SD) costs (2009 Canadian dollars) of treating acute fractures and post-fracture complications were: hip/femur fracture $46,664 ($43,198), wrist fracture $5,253 ($18,982), and fractures at other peripheral sites $10,410 ($27,641). The average (SD) cost of treating post-fracture complications at the hip/femur in the second year post-fracture was $1,698 ($12,462). Hospitalizations associated with the fracture accounted for 88% of the total cost of fracture treatment., Conclusions: The treatment of hip fractures accounts for a significant proportion of the costs associated with the treatment of peripheral osteoporotic fractures. Interventions to reduce the incidence of fractures, particularly hip fractures, would result in significant cost savings to the health care system and would preserve quality of life in many patients.

Summary: Physician-billing claims databases can be used to determine the incidence of fractures in the community. This study tested three algorithms designed to accurately and reliably identify fractures from a physician-billing claims database and concluded that they were useful for identifying all types of fractures, except vertebral, sacral, and coccyx fractures., Introduction: To develop and validate algorithms that identify fracture events from a physician-billing claims database (PCDs)., Methods: Three algorithms were developed using physician's specialty, diagnostic, and medical service codes used in a PCD from the province of Quebec. Algorithm validity was assessed via calculation of positive predictive values (PPV; via verification of a sample of algorithm-identified cases with hospitalization files) and sensitivities (via cross-referencing respective algorithm-identified fracture cases with a well-characterized fracture cohort)., Results: PPV and sensitivity varied across fracture sites. For most fracture sites, the PPV with algorithm 3 was higher than with algorithms 1 or 2. Except for knee fracture, the PPVs ranged from 0.81 to 0.96. Sensitivities were low at the vertebral, sacral, and coccyx sites (0.40-0.50), but high at all other fracture sites. For 95% of fractures, the fracture site identified by algorithm agreed with the fracture site from patients' medical records. Fracture dates identified by algorithm were within 2 days of the actual fracture date in 88% of fracture cases. Among cases identified by algorithm 3 to have had an open reduction (N = 461), 95% underwent surgery according to their respective medical charts., Conclusion: Algorithms using PCDs are accurate and reliable for identifying incident fractures associated with osteoporosis-related fracture sites. The identification of these fractures in the community is important for helping to estimate the burden associated with osteoporosis and the utility of programs designed to reduce the rates of fragility fracture.

Unlabelled: This study assessed whether osteoporosis diagnosis and treatment after an osteoporotic fracture can be increased by providing osteoporosis reading material to patients and family doctors or by watching a videocassette about osteoporosis. Educating patients about osteoporosis had little impact on whether a woman received an osteoporosis diagnosis or treatment., Introduction: The purpose of this study was to investigate the impact of two education-based interventions on osteoporosis diagnosis and treatment in women ≥ 50 years of age after fragility fracture., Methods: Six to eight months after fracture, women were randomized into three groups: (1) control, (2) written materials, or (3) videocassette and written materials. Written materials for both the patient and physician detailed osteoporosis, fragility fracture, and available treatments; written materials for physicians were provided through patients. The educational videocassette presented similar information as the written material, but in greater depth. Rates of osteoporosis diagnosis and treatment following intervention were compared among groups using survival analysis methods. Statistical significance was set at p < 0.0167., Results: At randomization, 1,174 women were without osteoporosis diagnosis and treatment, and after follow-up, 12% of the control group, 15% of the written materials group (p = 0.073), and 16% (p = 0.036) of the videocassette and written materials group were diagnosed with osteoporosis (statistical comparisons to control). Treatment rates were 8% for the control group, 12% for the written materials group (p = 0.052), and 11% for the videocassette and written materials group (p = 0.157). At randomization, 1,314 women were without treatment and after follow-up therapy was initiated in 10% of the control group, 13% of the written materials group (p = 0.107), and 13% of the videocassette and written materials group (p = 0.238)., Conclusions: The educational interventions assessed in this trial were not satisfactory to increase osteoporosis diagnosis or treatment in recently fractured women to a clinically meaningful degree.

Unlabelled: The Preference and Satisfaction Questionnaire (PSQ) compares patient preference and satisfaction between a 6-month subcutaneous injection and weekly oral tablet for treatment of bone loss. Patients preferred and were more satisfied with a treatment that was administered less frequently, suggesting the acceptability of the 6-month injection for treatment of bone loss., Introduction: The PSQ compares patient preference and satisfaction between a 6-month subcutaneous injection and a weekly oral tablet for treatment of bone loss., Methods: Postmenopausal women with low bone mass who enrolled in two separate randomized phase 3 double-blind, double-dummy studies received a 6-month subcutaneous denosumab injection (60 mg) plus a weekly oral placebo or a weekly alendronate tablet (70 mg) plus a 6-month subcutaneous placebo injection. After 12 months, patients completed the PSQ to rate their preference, satisfaction, and degree of bother with each regimen., Results: Most enrolled patients (1,583 out of 1,693; 93.5%) answered >or=1 item of the PSQ. Significantly more patients preferred and were more satisfied with the 6-month injection versus the weekly tablet (P < 0.001). More patients reported no bother with the 6-month injection (90%) than the weekly tablet (62%)., Conclusion: Patients preferred, were more satisfied, and less bothered with a 6-month injection regimen for osteoporosis.

Unlabelled: Treatment rates of osteoporosis after fracture are very low. Women who suffer a fragility fracture have a greater chance of receiving anti-fracture treatment if they had low bone mineral density (BMD), a fracture at the hip, femur or pelvis, administration of calcium and vitamin D supplements and/or an age > or =60 years., Introduction: This investigation identifies the predictors of osteoporosis treatment 6 to 8 months following fragility fracture in women >50 years of age., Methods: In this prospective cohort study, women were recruited 0 to 16 weeks following fracture and classified as having experienced fragility or traumatic fractures (phase 1). Six to 8 months following fracture, women completed a questionnaire on demographic features, clinical characteristics and risk factors for osteoporosis (phase 2). Osteoporosis treatment was defined as initiating anti-fracture therapy (bisphosphonate, raloxifene, nasal calcitonin and teriparatide) after fracture in those previously untreated., Results: Of the 1,273 women completing phase 1, 1,001 (79%) sustained a fragility fracture, and of these women, 738 were untreated for osteoporosis at phase 1 and completed the phase 2 questionnaire. Significant predictors of treatment included BMD result, fracture site, administration of calcium and vitamin D supplements at the time of fracture and age > or =60 years. All other risk factors for osteoporosis, such as fracture history after the age of 40 years, family history of osteoporosis and comorbidities did not significantly influence the treatment rate., Conclusions: Physicians largely based their decision to treat on BMD results and not on the clinical event-fragility fracture.

Unlabelled: In women aged 50 years or more who experienced a fracture, 81% suffered a fragility fracture. Six to eight months after fragility fracture, 79% had either not been investigated for osteoporosis or prescribed anti-fracture therapy. Despite fragility fractures being common in this population osteoporosis is under-diagnosed and under-treated., Introduction: The objective of this study was to evaluate the diagnostic and treatment rates for osteoporosis six months following fragility fracture., Methods: This prospective cohort study was set in the general community from the Province of Quebec, Canada. Women at least 50 years of age who suffered a fracture were recruited during their initial visit to the hospital and had their fracture type classified as either fragility or traumatic. Six-to-eight months after fragility fracture, women were again contacted to evaluate the diagnostic and treatment rates of osteoporosis., Results: Of the 2,075 women recruited over a 25 month period 1,688 (81%) sustained a fragility fracture and 387 (19%) sustained a traumatic fracture. Nine hundred and three participants with a fragility fracture were again contacted six-to-eight months after fracture. For the 739 women not on treatment on the recruitment day, only 15.4% initiated pharmacological therapy in the six-to-eight-month period following fracture and 79.0% had either not been investigated for osteoporosis or prescribed anti-fracture treatment., Conclusions: The proportion of fragility fractures to total fractures is higher than previously reported. Despite the availability of diagnostic modalities, effective treatments, and adequate health care assessments, there is a substantial care gap in the management of osteoporosis.