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International Osteoporosis Foundation & European Society of Musculoskeletal Radiology VERTEBRAL FRACTURE INITIATIVE Slide Kit Part 1: Osteoporosis and Related Fractures: An Under-diagnosed and Under-treated Public Health Issue Why is the Vertebral Fracture Initiative needed? Most vertebral fractures are a complication of osteoporosis and increase the likelihood of subsequent fractures
Currently mild and moderate vertebral fractures are often not being recognised and reported, leading to under-diagnosis and under-treatment
Radiographic diagnosis is considered the best way to identify and confirm the presence of vertebral fractures in clinical practice
All vertebral fractures identified should be reported as FRACTURED to avoid ambiguity caused by other terminology
Early radiographic diagnosis followed by appropriate therapy will help prevent subsequent fractures What is the Vertebral Fracture Initiative? An educational initiative to improve recognition and reporting of vertebral fractures: Pilot phase in five European countries Teaching Faculty Initiative Leaders: Harry K. Genant & Pierre D. Delmas
France: Jean-Denis Larédo & Pierre D. Delmas
Germany: Helmut Minne & Michael Jergas / Dieter Felsenberg
Italy: Silvano Adami & Giuseppe Guglielmi
Spain: Jorge Cannata & Francisco Aparisi
UK: David Reid & Judith Adams
A clinician and radiologist team taking the lead in each country What does the Vertebral Fracture Initiative include? 1. Presentations at radiology conferences
2. Articles in radiology & related publications
3. A resource document and a slide kit including:
Part 1. Osteoporosis and Related Fractures: An Under-diagnosed and Under-Treated Public Health Issue
Part 2. Recognition and Reporting of Vertebral Fractures
4. Summary handout
5. Interactive teaching programme on CD-ROM
Teaching tools available from: www.osteofound.org Definition of Osteoporosis A disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk.
World Health Organization (WHO) , 1994 Normal bone Osteoporosis OSTEOPOROSIS: THE SIZE OF THE PROBLEM Osteoporosis is a Prevalent Disease Affects 200 million women worldwide1
- 1/3 of women aged 60 to 70
- 2/3 of women aged 80 or older
Approximately 20-25% of women over the age of 50 have one or more vertebral fractures2
- United States: 25%3
- Australia: 20%4
- Western Europe: 19%5
- Scandinavia: 26%5
- Denmark: 21%6 1. International Osteoporosis Foundation 4. Jones G et al., Osteoporos Int 1996, 6:233
2. Melton LJ 3rd et al., Spine 1997, 22:2S 5. O'Neill et al., J Bone Miner Res 1996, 11:1010
3. Ettinger B et al., J Bone Miner Res 1992,7:449 6. Jensen GF et al., Clin Orthop 1982,166:75 Incidence Rates for Vertebral, Wrist & Hip Fractures in Women after Age 50 Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999 Osteoporotic Fractures in Women: Comparison with Other Diseases Riggs BL, Melton LJ. Bone 1995
Heart and Stroke Facts, 1996, American Heart Association
Cancer Facts & Figures, 1996, American Cancer Society Projected Burden of Osteoporotic Hip Fractures Worldwide Total no. hip fractures 1990 = 1.66 million 2050 = 6.26 million Adapted from Cooper C., Melton LJ, Osteoporos Int 1992, 2:285 OSTEOPOROSIS: MORTALITY & MORBIDITY Hip Fracture vs. Stroke Mortality: Death Rates per 100,000 in Older Women Hip Fracture Stroke
Sweden 177 154
Denmark 154 180
Germany 131 190 Hip fracture data: age 80; Kanis JA, J Bone Miner Res 2002, 17:1237
Stroke data: ages 65-74; Sans et al., Eur Heart J 1997, 18:1231 Relative Risk of Death Following Clinical Fractures Fracture Intervention Trial (FIT)* *6459 postmenopausal women ages 55-81 years followed for an average of 3.8 years Any Symptomatic Age-Adjusted Relative Risk (95% CI) 0 1 2 5 16 Non-spine Other Forearm Spine Hip 10 6.7 8.6 Cauley JA et al., Osteoporos Int 2000, 11:556 Cumulative Survival Probability Center JR et al., Lancet 1999, 353:878 Age MEN Survival probability 0.2 0.4 0.6 0.8 0 1.0 60 65 70 75 80 85 Dubbo Population Vertebral/Major Fractures Proximal Femur Fractures Age WOMEN Survival probability 1.0 0 0.2 0.4 0.6 0.8 60 65 70 75 80 85 Mortality Rates by Number of Prevalent Vertebral Fractures Kado DM et al., Arch Intern Med 1999,159:1215 P for trend < 0.001 Mortality
(per 1000 person-years) 0 5 10 15 20 25 30 35 40 0 1 2 3 4 5+ Number of Vertebral Fractures 45 Clinical Consequences Kyphosis
Loss of height
Bulging abdomen Acute and chronic pain
Breathing difficulties, reflux and other GI symptoms
Depression REDUCED QUALITY OF LIFE Vertebral Fractures Substantially Increase the Risk of New Fragility Fractures Women with vertebral fractures have a 5-fold increased risk of a new vertebral fracture and a 2-fold increased risk of hip fracture
Black et al., J Bone Miner Res 1999
Melton et al, Osteoporos Int 1999
One woman in five will suffer from another vertebral fracture within a year
Lindsay et al., JAMA, 2001 Effect of Prior Vertebral Fracture on Risk of Subsequent Vertebral Fracture Adapted from Lindsay R et al., JAMA 2001, 285:320 First Year of Study
2725 postmenopausal women randomised to placebo Incidence of New Vertebral Fracture (%) No. of Vertebral Fractures at Baseline 0 1 1 2 0 5 10 RR=5.1 (3.1, 8.4) RR=2.6 (1.4, 4.9) 15 RR=7.3 (4.4, 12.3) All Types of Vertebral Fractures are Associated With Morbidity Nevitt MC et al., Arch Intern Med.2000, 160:77 Limited Activity Bed Rest 0 25 50 75 100 Patients (%) No Incident
Fracture Radiographic
Fracture Clinical
Fracture 36.8 3.9 76.2 26.9 93.2 52.7 Due to back pain Vertebral Fractures in Summary Are the most common osteoporotic fractures
Are associated with excess mortality
Are associated with significant morbidity, even if they do not come to clinical attention
Increase the risk of subsequent vertebral fracture(s) by 5 fold and of other fragility fractures (including hip) by 2 fold COST OF OSTEOPOROSIS Some Costs of Osteoporosis in Europe In Europe the total direct costs of osteoporotic fractures are over €31 billion and are expected to increase to more that €76 billion in 2050. Kanis JA & Johnell O. - Osteoporos Int 2005 (in press)
In France osteoporotic hip fractures are estimated to cost about €1 billion every year*
In Spain the total direct hospital cost of osteoporotic fractures in 1995 was approximately €222 million*
In England & Wales the total direct hospital cost of osteoporotic fractures in 1999 was approximately €847 million* *Osteoporosis in the European Community: A Call to Action. IOF Nov, 2001 Osteoporosis Results in More Disability & Direct Hospital Cost Than Many Other Diseases 8% of vertebral fractures are hospitalised and 2% require long-term nursing care
Ross et al., Am Journal of Medicine 1997, 103(2A):30S – 42S
Annual cost of acute hospitalisation in Switzerland in 1992: 600 million Swiss francs (US$350 million)
Lippuner et al., Osteoporosis Int 1997, 7:414-25
– Number of bed days (men & women)
891,000 for COPD
701,000 for osteoporosis
533,000 for stroke
328,000 for myocardial infarction
201,000 for breast cancer Osteoporosis # 1 when looking at women only UNDER-DIAGNOSIS OF VERTEBRAL FRACTURES: WHAT IS THE SIZE OF THE PROBLEM? A Retrospective Study Suggests that Vertebral Fractures are Under-Diagnosed Gehlbach et al.,Osteoporos Int 2000, 11:577 934 hospitalised women with a lateral chest x-ray 0 20 40 60 80 100 120 140 Patients (n) 132 65 23 25 Fracture
identified
by study
radiologists Fracture
noted in
radiology
report Fracture
noted in
medical
record Received
osteoporosis
treatment A Large Prospective Study Demonstrates Under-Diagnosis of Vertebral Fractures is a Worldwide Problem Vertebral fractures were markedly under-diagnosed in radiology reports in a multicenter, multinational study population of osteoporotic women (n=2451) in which 789 (32%) women had 1 vertebral fracture at baseline.
Adjudicated discrepancies (n=350) between local and central readings due to undetected vertebral fracture (68%) or equivocal terminology in the local radiology report (32%) yielded a false-negative rate of 34%.
Under-diagnosis of vertebral fractures was observed in all geographic regions (false-negative rates: North America 45.2%, Latin America 46.5%, Europe/South Africa/Australia 29.5%). The false-positive rate was 5% globally.
Under-diagnosis of vertebral fracture is a worldwide problem attributable in part to a lack of radiographic detection or use of ambiguous terminology in the radiology report, or both. Delmas et al., J Bone Miner Res 2005, in press. Awareness & Treatment of Vertebral Fractures in Europe is Low Despite… Known disability associated with all fractures
Excess mortality associated with vertebral and hip fractures
€31 billion total direct hospital costs in Europe
A validated radiographic diagnosis technique
Effective and safe treatments
Evidence based guidelines for diagnosis and management Effective therapies are widely available and can reduce vertebral, hip and other fractures by 30% to 65%. Updated from Delmas, Lancet 2002 Antifracture Efficacy of Antiosteoporotic Agents Incident vertebral fractures - Relative risk RR ± 95% CI RLX 60 (MORE)* RLX 60 (MORE)** ALN 5/10 (FIT1)* ALN 5/10 (FIT2)** RIS 5 (VERT - NA)* RIS 5 (VERT - MN)* CT 200 (PROOF)* Teriparatide 20µg Strontium ranelate (SOTI)* Strontium ranelate (SOTI + TROPOS)** 0.2 0.6 1.0 * with prev vert fracture(s)
** without prev vert fractures 0.8 0.4 RECOGNITION & REPORTING OF VERTEBRAL FRACTURES Vertebral Fractures Semi-quantitative reading / visual scoring Genant et al., J Bone Miner Res 1993, 8:137 SQ Mild FX SQ Severe FX 1 1 3 3 Single Energy Fan-beam DXA Imaging a Potential Alternative to Conventional Radiographs Single energy imaging
Fast (10 sec) scanning / breath hold
Simple visual evaluation
Low dose (1/100 of radiographs)
Available at point of care Lateral Vertebral Assessment: …Point-of-Care tools Combining BMD & Vertebral Fracture Assessment: A New Approach to Improve the Diagnosis Rate of Vertebral Fractures Improve risk assessment
Identify many (~30%) of “missed” fractures
Improve targeting of therapy
May improve patient understanding, acceptance and compliance Conclusions Most vertebral fractures are a complication of osteoporosis and increase the likelihood of subsequent fractures
Currently mild and moderate vertebral fractures are often not being recognised and reported, leading to under-diagnosis and under-treatment
Radiographic diagnosis is considered the best way to identify and confirm the presence of vertebral fractures in clinical practice
All vertebral fractures identified should be reported as FRACTURED to avoid ambiguity caused by other terminology
Early radiographic diagnosis followed by appropriate therapy will help prevent subsequent fractures
– Effective therapies are widely available and can reduce vertebral, hip and other fragility fractures by 30% to 65%.
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