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A Vertebral Fracture Assessment (VFA) Performance Algorithm Improves Appropriate Utilization Among Those Referred for DXA
504
Abstracts
erythematosus) were reviewed. Fifty one had bone mineral density (BMD) assessed by dual absorbtiometry scan (DXA) and their charts were reviewed in detail. Age, body mass index (BMI) and disease duration were recorded. Disease activity was assessed by the SLEDAI (SLE disease activity index) score. Laboratory test results were reviewed, including erythrocyte sedimentation rate (ESR), presence of double stranded DNA antibodies (DsDNA), complement levels, complete blood counts and presence of proteinuria. Vitamin D levels were included when available. Medications were recorded, including glucocorticoids, immunosupressants, osteoporosis medications, calcium and vitamin D. The patients’ age ranged from 21 to 76, with a median of 44 years. 33 patients (64.7%) were premenopausal and 18 (35.3%) were postmenopausal. In the premenopausal group, the patients had moderate disease activity, as opposed to the postmenopausal group, where the disease activity was low. There were 11(21.5%) patients with osteoporosis, 23 (45%) patients with osteopenia and 17 (33.3%) patients had normal bone density. The majority of patients were on chronic low dose glucocorticoids, however only approximately half were taking osteoporosis-preventing medications. The patients with BMD within normal and osteopenic ranges were younger and had moderate disease activity scores. A higher prevalence of fragility fractures was observed in the osteoporotic group. The patients with osteoporosis were older, had longer disease duration and low disease activity scores. ESR and vitamin D levels were not significantly different in the three groups. Body mass index was higher, in the overweight range, for the patients with normal BMD, and normal in the osteoporotic and osteopenic groups. In conclusion, in our study, the main determinants for osteoporosis were disease duration and menopausal status. Disease activity and inflammation at the time of obtaining the DXA did not seem to play a major role in bone density. Higher BMI seemed to have a protective effect. Fragility fractures increased in the osteoporotic group but did not correlate with the disease activity or vitamin D level. Larger, prospective trials are needed to establish definite risk factors associated with bone loss in lupus patients.
care delivery organizations. However, uptake of the algorithm is likely to be a gradual process requiring sustained effort for full success.
151 150
Risk Assessment and Epidemiology: Osteoporosis and Other Conditions
A VERTEBRAL FRACTURE ASSESSMENT (VFA) PERFORMANCE ALGORITHM IMPROVES APPROPRIATE UTILIZATION AMONG THOSE REFERRED FOR DXA John Schousboe, Park Nicollet Institute for Research and Education Fergus McKiernan, Marshfield Clinic; Neil Binkley, University of Wisconsin Osteoporosis Clinical Research Program; Jay Fuehrer, Marshfield Clinic Research Foundation; Derek Fuerbringer, University of Wisconsin Background: Vertebral fracture assessment (VFA) identifies prevalent vertebral fracture and improves fracture risk estimation. However, VFA is under-utilized in clinical practice. VFA should be performed in those with sufficient pre-test probability of finding a prevalent vertebral fracture to warrant the additional resource utilization. A performance algorithm implemented by DXA technologists at one of our three institutions (Park Nicollet) for the last 7 years has increased appropriate VFA utilization. The objectives of this study are to a) assess how well DXA technologists implemented a performance algorithm over a five year period and b) assess VFA utilization following similar implementation of this performance algorithm at a large rural multispecialty community health care organization and a university academic health center. Methods: We devised a physician order option simplified from the ISCD 2007 Position Statement for VFA indications to specify that VFA is appropriate for those patients whose worst T-score (lumbar spine, femoral neck, total hip) is 5 -1.5 and PLUS age 5 65 years OR height loss 5 1.5 inches OR current glucocorticoid use. The association between indications for VFA and actual utilization of VFA at Park Nicollet was assessed by cross tabulation and chi2 statistic. The order option was introduced at the other two institutions in January 2011 with slight revision in that the T-score criterion was changed to 5 -1.5 and O -2.5. VFA utilization among those with these bone density and age/height loss/glucocorticoid criteria for the 8-month period following introduction of this order option was compared to the three preceding 8 month periods by chi2 statistic. Results: At Park Nicollet, 72% of those referred for DXA who meet criteria for a VFA had the test, whereas 92% of those who lack the indication noted above do not have the test done. Following introduction of the order option, 23% and 44%, respectively, of those meeting the criteria at the other two institutions had VFA performed (figure). Conclusions: Using a performance algorithm for VFA, DXA technologists successfully can identify those for whom VFA is indicated and perform the test. This performance algorithm can be successfully introduced in a variety of health
Journal of Clinical Densitometry: Assessment of Skeletal Health
Risk Assessment and Epidemiology: Osteoporosis and Other Conditions
TWO METHODS TO PREDICT FRACTURES CLAVICLE: 3D MODELISATION AND BONE DENSITOMETRY Sophie Abrassart, Hopital Universitaire de Geneve Christophe Barea, HUG; Pierre Hoffmeyer, HUG Introduction: Fractures of clavicles account for 5 to 10% off all fractures, with injuries of the middle third of the clavicle accounting for 80 % of these cases. The aim of this study was to compare one 3D finite element model of clavicle with mCT analysis. One finite element model of a normal clavicle was created. Six paired clavicles were analyzed with normal CT and with mCT. Changes in stress distribution were visualized in the bone in order to quantify the stress shielding effect compared to real bone quality. Materials and Methods: 1) CT-images of a normal clavicle were processed in order to build the clavicle geometry and to get bone properties with Mimics (Materialise, BE). In ABAQUS-Pre software (HKS, Inc., Pawtucket, RI, USA), the 3D finite element model of the bone (including cortical and cancellous bone) was generated. The model consisted of 113’135 hexahedral elements Axial loads of 800N and boundary conditions reproduced the main forces acting on the shoulder
Volume 15, 2012
Abstracts
erythematosus) were reviewed. Fifty one had bone mineral density (BMD) assessed by dual absorbtiometry scan (DXA) and their charts were reviewed in detail. Age, body mass index (BMI) and disease duration were recorded. Disease activity was assessed by the SLEDAI (SLE disease activity index) score. Laboratory test results were reviewed, including erythrocyte sedimentation rate (ESR), presence of double stranded DNA antibodies (DsDNA), complement levels, complete blood counts and presence of proteinuria. Vitamin D levels were included when available. Medications were recorded, including glucocorticoids, immunosupressants, osteoporosis medications, calcium and vitamin D. The patients’ age ranged from 21 to 76, with a median of 44 years. 33 patients (64.7%) were premenopausal and 18 (35.3%) were postmenopausal. In the premenopausal group, the patients had moderate disease activity, as opposed to the postmenopausal group, where the disease activity was low. There were 11(21.5%) patients with osteoporosis, 23 (45%) patients with osteopenia and 17 (33.3%) patients had normal bone density. The majority of patients were on chronic low dose glucocorticoids, however only approximately half were taking osteoporosis-preventing medications. The patients with BMD within normal and osteopenic ranges were younger and had moderate disease activity scores. A higher prevalence of fragility fractures was observed in the osteoporotic group. The patients with osteoporosis were older, had longer disease duration and low disease activity scores. ESR and vitamin D levels were not significantly different in the three groups. Body mass index was higher, in the overweight range, for the patients with normal BMD, and normal in the osteoporotic and osteopenic groups. In conclusion, in our study, the main determinants for osteoporosis were disease duration and menopausal status. Disease activity and inflammation at the time of obtaining the DXA did not seem to play a major role in bone density. Higher BMI seemed to have a protective effect. Fragility fractures increased in the osteoporotic group but did not correlate with the disease activity or vitamin D level. Larger, prospective trials are needed to establish definite risk factors associated with bone loss in lupus patients.
care delivery organizations. However, uptake of the algorithm is likely to be a gradual process requiring sustained effort for full success.
151 150
Risk Assessment and Epidemiology: Osteoporosis and Other Conditions
A VERTEBRAL FRACTURE ASSESSMENT (VFA) PERFORMANCE ALGORITHM IMPROVES APPROPRIATE UTILIZATION AMONG THOSE REFERRED FOR DXA John Schousboe, Park Nicollet Institute for Research and Education Fergus McKiernan, Marshfield Clinic; Neil Binkley, University of Wisconsin Osteoporosis Clinical Research Program; Jay Fuehrer, Marshfield Clinic Research Foundation; Derek Fuerbringer, University of Wisconsin Background: Vertebral fracture assessment (VFA) identifies prevalent vertebral fracture and improves fracture risk estimation. However, VFA is under-utilized in clinical practice. VFA should be performed in those with sufficient pre-test probability of finding a prevalent vertebral fracture to warrant the additional resource utilization. A performance algorithm implemented by DXA technologists at one of our three institutions (Park Nicollet) for the last 7 years has increased appropriate VFA utilization. The objectives of this study are to a) assess how well DXA technologists implemented a performance algorithm over a five year period and b) assess VFA utilization following similar implementation of this performance algorithm at a large rural multispecialty community health care organization and a university academic health center. Methods: We devised a physician order option simplified from the ISCD 2007 Position Statement for VFA indications to specify that VFA is appropriate for those patients whose worst T-score (lumbar spine, femoral neck, total hip) is 5 -1.5 and PLUS age 5 65 years OR height loss 5 1.5 inches OR current glucocorticoid use. The association between indications for VFA and actual utilization of VFA at Park Nicollet was assessed by cross tabulation and chi2 statistic. The order option was introduced at the other two institutions in January 2011 with slight revision in that the T-score criterion was changed to 5 -1.5 and O -2.5. VFA utilization among those with these bone density and age/height loss/glucocorticoid criteria for the 8-month period following introduction of this order option was compared to the three preceding 8 month periods by chi2 statistic. Results: At Park Nicollet, 72% of those referred for DXA who meet criteria for a VFA had the test, whereas 92% of those who lack the indication noted above do not have the test done. Following introduction of the order option, 23% and 44%, respectively, of those meeting the criteria at the other two institutions had VFA performed (figure). Conclusions: Using a performance algorithm for VFA, DXA technologists successfully can identify those for whom VFA is indicated and perform the test. This performance algorithm can be successfully introduced in a variety of health
Journal of Clinical Densitometry: Assessment of Skeletal Health
Risk Assessment and Epidemiology: Osteoporosis and Other Conditions
TWO METHODS TO PREDICT FRACTURES CLAVICLE: 3D MODELISATION AND BONE DENSITOMETRY Sophie Abrassart, Hopital Universitaire de Geneve Christophe Barea, HUG; Pierre Hoffmeyer, HUG Introduction: Fractures of clavicles account for 5 to 10% off all fractures, with injuries of the middle third of the clavicle accounting for 80 % of these cases. The aim of this study was to compare one 3D finite element model of clavicle with mCT analysis. One finite element model of a normal clavicle was created. Six paired clavicles were analyzed with normal CT and with mCT. Changes in stress distribution were visualized in the bone in order to quantify the stress shielding effect compared to real bone quality. Materials and Methods: 1) CT-images of a normal clavicle were processed in order to build the clavicle geometry and to get bone properties with Mimics (Materialise, BE). In ABAQUS-Pre software (HKS, Inc., Pawtucket, RI, USA), the 3D finite element model of the bone (including cortical and cancellous bone) was generated. The model consisted of 113’135 hexahedral elements Axial loads of 800N and boundary conditions reproduced the main forces acting on the shoulder
Volume 15, 2012