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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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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. B
ours
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. D
rs. 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. D
rs. 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. B
ours
Vertebral fracture assessment (VFA) using DXA
5 Mw. D
rs. 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. D
rs. 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. D
rs. 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. B
ours
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. B
ours
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. B
ours
Percentage of paKents with VFA and with ≥1 newly diagnosed vertebral fracture before and aher systemaKc implementaKon of VFA
% of p
aKen
ts
*
*
* p < 0.001
11 Mw. D
rs. 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 p
aKen
ts
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. B
ours
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 p
aKen
ts
Mw. Drs. S.P.G. B
ours
Normal BMD – osteoporosis: p = 0.01
137 385 210
14
% of p
aKen
ts
Percentage of paKents with ≥1 newly diagnosed vertebral fracture (≥ grade 1) according to BMD
Mw. Drs. S.P.G. B
ours
137 385 210
15
% of p
aKen
ts
Clinical implicaKons
Mw. Drs. S.P.G. B
ours
137 385 210
16
% of p
aKen
ts
Clinical implicaKons
Mw. Drs. S.P.G. B
ours
Clinical implicaKons in paKents with osteopenia % of p
aKen
ts
In 13,2% of pa3ents with osteopenia indica3on for therapy in the Netherlands
CBO 2011 www.richtlijnonline.nl 17 Mw. D
rs. S.P.G. Bours
Limita3ons
• Different hospitals • Different paKent selecKon criteria • Different devices • Different readers
18 Mw. D
rs. 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. D
rs. S.P.G. Bours
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