Assessment	
  of	
  vertebral	
  fractures	
  in	
  
pa3ents	
  older	
  than	
  50	
  years	
  with	
  a	
  
recent	
  no...
Disclosures	
  
This	
  study	
  was	
  supported	
  by	
  an	
  unrestricted	
  
educaKonal	
  grant	
  from	
  Eli	
  Li...
Background	
  
•  Prevalence	
  of	
  vertebral	
  fractures	
  in	
  paKents	
  
presenKng	
  with	
  a	
  non-­‐vertebra...
Recent	
  non-­‐
vertebral	
  
fracture,	
  
including	
  hip	
  
fracture	
  >50	
  yr	
  
	
  
	
  
	
  
	
  	
  	
  	
 ...
Vertebral	
  fracture	
  assessment	
  (VFA)	
  using	
  DXA	
  
5
Mw. Drs. S.P.G. Bours
Purpose	
  
To	
  study	
  the	
  effect	
  of	
  implementaKon	
  of	
  VFA	
  
according	
  to	
  the	
  Dutch	
  guideli...
Pa3ents	
  and	
  methods	
  
•  PaKents	
  aged	
  ≥	
  50	
  years	
  with	
  a	
  recent	
  non-­‐vertebral	
  
fractur...
•  ClassificaKon	
  of	
  baseline	
  non-­‐vertebral	
  fractures1	
  
-­‐  hip	
  
-­‐  major:	
  pelvis,	
  distal	
  fe...
NA:	
  not	
  applicable	
  
Before	
  implementa3on	
  
of	
  VFA	
  
A;er	
  implementa3on	
  
of	
  VFA	
  
VU	
   NA	
...
Before	
  
implementa3on	
  
of	
  VFA	
  
A;er	
  
implementa3on	
  
of	
  VFA	
  
p-­‐value	
  
Women	
  (%)*	
   450/63...
Percentage	
  of	
  paKents	
  with	
  VFA	
  and	
  with	
  ≥1	
  newly	
  
diagnosed	
  vertebral	
  fracture	
  before	...
Percentage	
  of	
  paKents	
  with	
  a	
  newly	
  diagnosed	
  vertebral	
  
fracture	
  grade	
  1,	
  2	
  or	
  3	
 ...
Percentage	
  of	
  paKents	
  with	
  ≥1	
  newly	
  diagnosed	
  vertebral	
  
fracture	
  according	
  to	
  baseline	
...
Normal	
  BMD	
  –	
  osteoporosis:	
  p	
  =	
  0.01	
  
137	
   385	
   210	
  
14
%	
  of	
  paKents	
  
Percentage	
  ...
137	
   385	
   210	
  
15
%	
  of	
  paKents	
  
Clinical	
  implicaKons	
  
Mw. Drs. S.P.G. Bours
137	
   385	
   210	
  
16
%	
  of	
  paKents	
  
Clinical	
  implicaKons	
  
Mw. Drs. S.P.G. Bours
Clinical	
  implicaKons	
  in	
  paKents	
  with	
  osteopenia	
  
%	
  of	
  paKents	
  
In	
  13,2%	
  of	
  pa3ents	
  ...
Limita3ons	
  
•  Different	
  hospitals	
  
•  Different	
  paKent	
  selecKon	
  criteria	
  
•  Different	
  devices	
  
•...
Conclusion	
  
ImplementaKon	
  of	
  VFA	
  results	
  in	
  
•  20-­‐fold	
  increase	
  in	
  imaging	
  of	
  the	
  s...
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Seminar 30 11-2013 assessment of vertebral fractures

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Assessment of vertebral fractures in patients older than 50 years with a recent non vertebral fracture before and after introduction of systematic vertebral fracture assessment (VFA) door Mw. Drs. S.P.G. Bours, internist-endocrinoloog, MUMC

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Seminar 30 11-2013 assessment of vertebral fractures

  1. 1. Assessment  of  vertebral  fractures  in   pa3ents  older  than  50  years  with  a   recent  non-­‐vertebral  fracture  before   and  a;er  introduc3on  of  systema3c   vertebral  fracture  assessment  (VFA)   S.P.G.  Bours,  P.P.  Geusens,  W.F.  Lems,  R.Y.  van  der  Velde,     T.A.C.M.  van  Geel,  J.P.W.  van  den  Bergh   Internal  Medicine/Rheumatology   Maastricht  UMC,  Viecuri  MC  Venlo,  VU  MC  Amsterdam   The  Netherlands     Mw. Drs. S.P.G. Bours
  2. 2. Disclosures   This  study  was  supported  by  an  unrestricted   educaKonal  grant  from  Eli  Lilly  ®     Authors  do  not  have  personal  disclosures  with   regard  to  this  study   2 Mw. Drs. S.P.G. Bours
  3. 3. Background   •  Prevalence  of  vertebral  fractures  in  paKents   presenKng  with  a  non-­‐vertebral  fracture:  20-­‐30%1,2   •  Presence  of  vertebral  fractures  in  postmenopausal   women  and  men  older  than  50  years  increases  risk   for  a  new  fracture   -­‐  3-­‐5x  for  a  new  vertebral  fracture3   -­‐  2x  for  a  new  non-­‐vertebral  fracture4   •  2011:  new  Dutch  guidelines  for  Osteoporosis  and   Fracture  prevenKon5   -­‐  importance  of  diagnosing  vertebral  fractures   1.  Howat,  Clinical  endocrinology  2007    2.  Gallacher,  Osteop  Int  2007    3.  Lindsay,  JAMA  2001   4.  Klotzbuecher,  JBMR  2000  5.  CBO  2011  www.richtlijnonline.nl  3 Mw. Drs. S.P.G. Bours
  4. 4. Recent  non-­‐ vertebral   fracture,   including  hip   fracture  >50  yr                         DXA                       T  ≤-­‐2.5   T  >-­‐2.5    and     <-­‐1.0     T  ≥-­‐1.0   Vertebral  fracture   Imaging  spine     Low  risk:   -­‐  Life  style   -­‐  No  medica3on   Inves3ga3on   &   correc3on  of   new   secondary   osteoporosis       Medical   treatment             Follow-­‐up           High  risk:   -­‐  Therapy  or  follow  up   -­‐  Life  style   Recommended         Strongly  recommended     Can  be  useful   No  vertebral  fracture   or  no  imaging,  but   other  risk  factors*   Dutch  guidelines  for  fracture  prevenKon     in  women  and  men  older  than  50  years   Imaging  spine   *Other  risk  factors:  recent  hip  fracture,  recent  fracture  and  T<-­‐2.0,   diseases/medica3ons  with  possible  bone  loss,  repeat  recent  falls,  FRAX   CBO  2011  www.richtlijnonline.nl   4   Mw. Drs. S.P.G. Bours
  5. 5. Vertebral  fracture  assessment  (VFA)  using  DXA   5 Mw. Drs. S.P.G. Bours
  6. 6. Purpose   To  study  the  effect  of  implementaKon  of  VFA   according  to  the  Dutch  guideline*  in  paKents                 50  years  and  older  with  a  recent  non-­‐vertebral   fracture,  with  regard  to:   1.  the  number  of  paKents  who  did  get  a  VFA     2.  the  number  of  newly  diagnosed  vertebral   fractures   *Dutch  guidelines  for  Osteoporosis  and  Fracture  PrevenKon  CBO  2011  www.richtlijnonline.nl     6 Mw. Drs. S.P.G. Bours
  7. 7. Pa3ents  and  methods   •  PaKents  aged  ≥  50  years  with  a  recent  non-­‐vertebral   fracture   •  3  hospitals  in  the  Netherlands:   •  PaKents  before  implementaKon  of  VFA  (black)  were   compared  to  paKents  aher  implementaKon  of  VFA  (green)   Before  guideline   A;er  guideline   Viecuri  MC  Venlo   FLS,  no  VFA   FLS  +  VFA   Maastricht  UMC   No  FLS,  VFA  available   FLS  +  VFA   VU  MC  Amsterdam   FLS  +  VFA   FLS  +  VFA   7 Mw. Drs. S.P.G. Bours
  8. 8. •  ClassificaKon  of  baseline  non-­‐vertebral  fractures1   -­‐  hip   -­‐  major:  pelvis,  distal  femur,  proximal  Kbia,  mulKple  rib,   humerus   -­‐  minor   -­‐  finger/toe  fractures   •  Semi-­‐quanKtaKve  scoring  of  vertebral  fractures2     -­‐  grade  0  (<20%),  grade  1  (20-­‐25%),  grade  2  (25-­‐40%),  grade  3   (>40%)   -­‐  by  an  experienced  local  invesKgator   1.Center,  JAMA  2007   2.Genant,  Bone  2003   Mw. Drs. S.P.G. Bours
  9. 9. NA:  not  applicable   Before  implementa3on   of  VFA   A;er  implementa3on   of  VFA   VU   NA   174   VC   630   254   MUMC   300   320   Total   930   748   Results   9 Number  of  included  paKents  per  hospital  before   and  aher  implementaKon  of  VFA   Mw. Drs. S.P.G. Bours
  10. 10. Before   implementa3on   of  VFA   A;er   implementa3on   of  VFA   p-­‐value   Women  (%)*   450/630  (71.4%)   549/748  (73.5%)   0.415   Age  in  years  (SD)   67.0  (10.6)   66.6  (9.4)   0.358   Baseline  fracture   (%)   0.285   Hip   97  (10.4%)   60  (8.0%)   Major   190  (20.5%)   165  (22.1%)   Minor   562  (60.5%)   465  (62.2%)   Finger  &  toe   80  (8.6%)   57  (7.6%)   *  Only  available  in  FLS  paKents    10 Baseline  characterisKcs   Mw. Drs. S.P.G. Bours
  11. 11. Percentage  of  paKents  with  VFA  and  with  ≥1  newly   diagnosed  vertebral  fracture  before  and  aher  systemaKc   implementaKon  of  VFA   %  of  paKents   *   *   *  p  <  0.001     11 Mw. Drs. S.P.G. Bours
  12. 12. Percentage  of  paKents  with  a  newly  diagnosed  vertebral   fracture  grade  1,  2  or  3  before  and  aher  implementaKon   of  VFA   %  of  paKents   57,4% of all newly diagnosed vertebral fractures on VFA Total   p  <  0.001   Grade  1   p  <  0.001   Grade  2   p  <  0.001   Grade  3   p  <  0.001   Mw. Drs. S.P.G. Bours
  13. 13. Percentage  of  paKents  with  ≥1  newly  diagnosed  vertebral   fracture  according  to  baseline  fracture  (only  paKents  aher   implementaKon  of  VFA)   56   163   455   57     Major-­‐minor:  p  =  0.003   Hip-­‐minor:    p  =  0.001   Hip-­‐finger/toe:    p  =  0.04   %  of  paKents   Mw. Drs. S.P.G. Bours
  14. 14. Normal  BMD  –  osteoporosis:  p  =  0.01   137   385   210   14 %  of  paKents   Percentage  of  paKents  with  ≥1  newly  diagnosed   vertebral  fracture  (≥  grade  1)  according  to  BMD   Mw. Drs. S.P.G. Bours
  15. 15. 137   385   210   15 %  of  paKents   Clinical  implicaKons   Mw. Drs. S.P.G. Bours
  16. 16. 137   385   210   16 %  of  paKents   Clinical  implicaKons   Mw. Drs. S.P.G. Bours
  17. 17. Clinical  implicaKons  in  paKents  with  osteopenia   %  of  paKents   In  13,2%  of  pa3ents  with  osteopenia   indica3on  for  therapy  in  the  Netherlands   CBO  2011  www.richtlijnonline.nl  17 Mw. Drs. S.P.G. Bours
  18. 18. Limita3ons   •  Different  hospitals   •  Different  paKent  selecKon  criteria   •  Different  devices   •  Different  readers   18 Mw. Drs. S.P.G. Bours
  19. 19. Conclusion   ImplementaKon  of  VFA  results  in   •  20-­‐fold  increase  in  imaging  of  the  spine   •  10-­‐fold  increase  in  the  diagnosis  of  a   previously  unknown  vertebral  fracture   •  IdenKfying  paKents  in  the  osteopenic  range,   with  non-­‐clinical  vertebral  fractures,  who   have  an  indicaKon  for  treatment   19 Mw. Drs. S.P.G. Bours
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