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
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
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
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
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