Bone densitometry Medicare claims suggest inadequate testing for Australian men and rural men and women

Abstracts / Bone 44 (2009) S68–S98

Results: Charts for 203 patients (101 MMH, 102 NSH) were reviewed. The two groups were similar in age (mean age = 83.2 years), gender (80% female), and other casemix factors. Median time from admission to theatre was shorter in NSH, (21 vs. 44 h, p-value< 0.0001). Length of stay was significantly shorter at NSH (mean difference 4.4 days 95% CI 1.1–7.6 when adjusted for casemix factors). Significantly more NSH patients were transferred for rehabilitation than MMH patients (75% vs. 51%). At discharge, significantly more MMH patients (34% vs. 14%) were treated with alendronate. Of 126 patients admitted from home, 81% returned home, 4% went to rest homes, 13% to private hospitals and 2% died; differences between centres were not significant. Overall inpatient mortality was 3.9%. Conclusions: The orthogeriatric model of care at NSH was associated with a shorter overall length of stay, earlier transfer to the AT&R setting, and a higher proportion rehabilitated in AT&R. Outcomes in terms of discharge destination and six month mortality were similar at both centres. Keywords: Hip fracture, Orthogeriatrics, Rehabilitation, Elderly, Osteoporosis. doi:10.1016/j.bone.2009.01.203

288 Can we use the nitric oxide donor, nitroglycerine for prevention of postmenopausal bone loss? S.J. Wimalawansaa, A. Wilsona, F. Chena, J. Grimesa, D. Hooverb Endocrinology and Metabolism, UMDNJ-RWJMS, New Brunswick, NJ, USA Department of Bio-Statistics, Rutgers University, New Brunswick, NJ, USA Since medications are expensive, cost-effective therapies are welcome for the management of osteoporosis. The use of HRT declined after a Women's Health-Initiative study that showed increased risks with HRT. The beneficial effects of estrogen on bone maintenance are at least in part mediated via the nitric oxide (NO)/ cGMP pathway. At appropriate doses, nitroglycerine as a NO donor was shown to favorably affect both osteoblasts and osteoclasts (i.e., uncoupling these two cell types). A three-year randomized, doubled-blind, controlled clinical trial was conducted to assess the efficacy of nitroglycerin in preventing bone loss in early postmenopausal women. This study, Nitroglycerin as an Option: Value in Early Bone Loss (NOVEL), was funded by NIAMS. Over 200,000 women were contacted, 1400 were interviewed, 215 were screened, and 186 were recruited. Women were

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randomized to receive either nitroglycerine ointment or placebo ointment. All women received calcium and vitamin D supplementation. There were no differences in the treatment arms in key baseline characteristics including BMD, BMI, smoking status, time since menopause, etc. Taking compliance (∼75%) into consideration, the actual dose used by the study participants is only ∼50% (14 mg/day) of that originally intended to be used in this study. The intent to treat analysis did not reveal differences between the two treatment groups on the primary outcome of lumbar spine BMD. The change of BMD from the baseline in each group was only − 0.023 (2.1% change over the three-year study period; was not significant). Except for the increased headaches in the active arm, all other adverse events had similar profiles compared to placebo. Some of the secondary outcomes including biochemical markers of bone turnover have not been completed. These results suggest that the nitroglycerin dose used in this NOVEL clinical study was not effective. However, the NOVEL study subjects used only ∼half the effective dose of nitroglycerin, in preventing bone loss. Taken the narrow therapeutic margin for beneficial effects of nitroglycerin on bone, this is likely to be the main reason for not having any positive outcome. Therefore, we believe that an additional study using the correct dose of nitroglycerin is warranted before eliminating NO donor nitroglycerin as a novel, costeffective therapy for prevention of osteoporosis. doi:10.1016/j.bone.2009.01.204

289 Bone densitometry Medicare claims suggest inadequate testing for Australian men and rural men and women D.P. Ewaldb, J. Eismanc, B. Ewaldd, T.M. Winzenberga, M.J. Seibele, P.R. Ebelingf, L. Flickerg, P. Nashh Menzies Research Institute, Hobart, TAS, Australia Northern Rivers General Practice Network, NSW, Australia Garvan Institute, Sydney, NSW, Australia Centre for Clinical Epidemiology and Biostatistics, Newcastle, NSW, Australia Bone Research Program, ANZAC Research Institute, The University of Sydney, Sydney, NSW, Australia University of Melbourne, Footscray, VIC, Australia Western Australian Centre for Health and Ageing, University of Western Australia, Perth, WA, Australia Rheumatology Research Unit, University of Queensland, QLD, Australia Introduction: There is a substantial gap between evidence-based best practice and actual practice for the detection and treatment of

Fig. 1. Age-adjusted BMD utilisation by RRMA location, sex and year.

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Abstracts / Bone 44 (2009) S68–S98

osteoporosis. As part of the preparation of national guidelines for the management of osteoporosis in primary health care, we identified an evidence gap in that equity issues surrounding access to osteoporosis diagnostic and treatment services were under-explored, particularly in the Australian context. Bone densitometry (BMD) utilisation is a key marker of osteoporosis diagnosis and care activity and BMD is the current gold standard for diagnosing osteoporosis. We therefore aimed to analyse sex and geographical differences in BMD utilisation to identify possible access and equity issues in the availability and uptake of BMD. Methods: We analysed the Medicare claims data for BMD from 2001 to 2005 inclusive. In that time period, Medicare claims covered BMD performed in Australian men and women who had had a minimal trauma fracture, had certain diseases/treatments known to predispose to osteoporosis or who were having BMD to monitor osteoporosis. Age-adjusted BMD rates were derived from Medicare Australia claims and 2001 Australian Bureau of Statistics population data. These were analysed by age, sex and rural, remote and metropolitan areas (RRMA) classification. Results: Utilisation of BMD increased by 26% over the six years. However rates were lower for rural and remote populations, with people in capital cities about three times as likely to have BMD performed as the remote population (Fig. 1). Sex ratios for men remain low, but have improved from >6:1 female to male to 4:1 over the six years. Discussion: Our results show that there is a relative underutilisation of BMD in males regardless of location, and in rural and remote areas in both sexes. The former is consistent with the known under-diagnosis and under-treatment of osteoporosis in men. The latter likely reflects reduced access to BMD services in these areas. Sex and rural inequities in BMD need to be addressed as part of a national approach to reduce the incidence of minimal trauma fractures and improve ‘second-fracture’ prevention. doi:10.1016/j.bone.2009.01.205

290 Undercarboxylated osteocalcin/osteocalcin ratio is negatively associated with hyperglycemic conditions, but not with the presence of vertebral fractures, in patients with type 2 diabetes M. Yamamoto, T. Yamaguchi, M. Yamauchi, S. Yano, T. Sugimoto Internal Medicine 1, Shimane University Faculty of Medicine, Enya-cho, Izumo, Shimane, Japan Bone fragility of patients with type 2 diabetes (T2DM) depends on bone quality rather than bone mineral density (BMD). A ratio of undercarboxylated osteocalcin level to osteocalcin (ucOC/OC) as well as ucOC level itself is considered as one of candidate index for bone quality. Indeed, ucOC/OC ratio is correlated with sound of speed measured by calcaneal ultrasound, which reflects bone strength independent of BMD. It is well known that OC level is negatively associated with hyperglycemia. However, the associations between bone fragility and ucOC/OC ratio as well as ucOC level in T2DM were still unknown. In this study, to examine this issue, 99 male patients older than 50 years old and 101 postmenopausal female with 2DM within normal creatinine levels were examined by BMD at the lumbar spine, femoral neck and one-third of radius as well as spine radiographs, and by measurement of biochemical parameters including ucOC/OC. Serum level of OC and ucOC as well as ucOC/OC ratio in T2DM women were significantly and negatively associated with HbA1c (r = −0.24, P < 0.01, r = −0.27, P < 0.01, and r = −0.20, P < 0.05, respectively). Serum ucOC level in T2DM men were also significantly and negatively associated with HbA1c (r = −0.20, P < 0.05). Multiple regression analysis was performed with each of OC, ucOC, and ucOC/OC

ratio as a dependent variable, and age, body weight, body height, HbA1c, creatinine, BAP, urinary NTX, duration of diabetes, and femoral neck BMD as independent variables. OC, ucOC, and ucOC/OC ratio were negatively correlated with HbA1c in both gender (men: r = −0.22, P < 0.05, r = −0.28, P < 0.01 and r = −0.23, P < 0.05; women: r = −0.24, P < 0.01, r = −0.29, P < 0.01 and r = −0.22, P < 0.05, respectively). These values, however, were not associated with the presence of prevalent vertebral fractures by logistic regression analysis. These results suggest that undercarboxylated OC may not be a predictor of vertebral fractures, although it is decreased by hyperglycemia. doi:10.1016/j.bone.2009.01.206

291 Postmenopausal women with mild to moderate renal dysfunction are at increased risk for bone loss and vertebral fractures M. Yamauchia, T. Yamaguchia, H. Kajib, T. Sugimotoa Internal Medicine 1, Shimane University Faculty of Medicine, Izumo, Japan Division of Diabetes, Metabolism, Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan Background: An increased rate of hip fractures has been reported in patients with end-stage renal disease, but the effect of less severe renal dysfunction on bone loss and fracture risk is uncertain. We therefore evaluated whether or not mild to moderate renal dysfunction affects bone mineral density (BMD) and the risk of vertebral fractures (VFs) in postmenopausal women. Methods: We enrolled 659 postmenopausal women who had examination of osteoporosis (mean age 65 years). Serum creatinine level was measured and creatinine clearance (CCr) was calculated using the Cockcroft–Gault formula. Estimated glomerular filtration rate (eGFR) was calculated using the formula presented by the MDRD study. BMD values of the lumbar (L), femoral neck (FN), and radius (Rad) were measured by DXA. Results: Renal function was categorized by the criteria from the Kidney Disease Outcomes Quality Initiative (K/DOQI) committee. At baseline, 22.3% of participants had chronic kidney disease (CKD) stage1 (eGFR90 ≦ ml/min/1.73 m2), 64.8% had CKD stage2 (60–89), and 12.9% had stage3 or more (< 60). Based on CCr, these percentages were 46.3%, 46.9%, and 6.8%, respectively. One hundred eighty women had one or more VFs. Comparison of fracture prevalence by CKD stages revealed that the stage3 or more group by eGFR had a significantly higher rate of VFs (45.3%) than the stage1 (23.8%) and 2 (25.3%) groups (p < 0.01), suggesting that lower eGFR was associated with increasing risk for VFs. In the stage2 group, there were significant positive correlations between eGFR and BMD values at FN and Rad, as well as between CCr and BMD values at all sites. Moreover, postmenopausal women with VFs had lower eGFR (p < 0.05) and CCr (p < 0.01) values than those without VFs in stage2. When multivariable logistic regression analysis was performed with the presence of VFs as a dependent variable and CCr levels adjusted for years after menopause, smoking habit, alcohol intake, as well as BMD as an independent variable. CCr levels were identified as a factor associated with the presence of VFs in postmenopausal women (odds ratio 0.38, 95% confidential interval 0.18–0.79 per SD increase, p < 0.01). Conclusion: The present results suggest that postmenopausal women with mild to moderate renal dysfunction are at increased risk for bone loss and VFs. doi:10.1016/j.bone.2009.01.207