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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
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
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
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
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	
  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
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
•  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
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
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
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
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
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
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
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	
  with	
  osteopenia	
  
indica3on	
  for	
  therapy	
  in	
  the	
  Netherlands	
  
CBO	
  2011	
  www.richtlijnonline.nl	
  17
Mw. Drs. S.P.G. Bours
Limita3ons	
  
•  Different	
  hospitals	
  
•  Different	
  paKent	
  selecKon	
  criteria	
  
•  Different	
  devices	
  
•  Different	
  readers	
  
18
Mw. Drs. S.P.G. Bours
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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Seminar 30 11-2013 assessment of vertebral fractures

  • 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. 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. 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. 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. Vertebral  fracture  assessment  (VFA)  using  DXA   5 Mw. Drs. S.P.G. Bours
  • 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. 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. •  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. 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. 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. 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. 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. 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. 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. 137   385   210   15 %  of  paKents   Clinical  implicaKons   Mw. Drs. S.P.G. Bours
  • 16. 137   385   210   16 %  of  paKents   Clinical  implicaKons   Mw. Drs. S.P.G. Bours
  • 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. Limita3ons   •  Different  hospitals   •  Different  paKent  selecKon  criteria   •  Different  devices   •  Different  readers   18 Mw. Drs. S.P.G. Bours
  • 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