Fracture risk and antiresorptive medication use in older women in the USA.

UNLABELLED: Risk of fragility fractures in older women appears to be under-recognized and under treated. Analysis of a national sample of older US women reveals that over 5 million are at high risk of fracture; only one third of these report being told they have osteoporosis and one quarter are receiving appropriate treatment. INTRODUCTION: Substantial numbers of older women in the United States suffer fragility fractures each year. Although risk for these fractures can be readily identified from clinical characteristics, many women may not be receiving treatments demonstrated to reduce risk. Our objective was to estimate the extent of fracture risk among older white US women and assess patterns of use of pharmacologic agents in response to that risk. METHODS: Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) for 1999-2000 and 2001-2002 were combined to enumerate risk factors for fracture and use of antiresorptive prescription medications for all white women 65 years of age and older. The FRACTURE Index (FI), developed from the Study of Osteoporotic Fractures (SOF), which combines subjects' characteristics to estimate five-year fracture risk, was applied to these national data. RESULTS: Of more than 15 million US women in this age group almost 40% have one risk factor in addition to age that predisposes to fracture; 20% have two or more. More than 5 million women are in the highest category of FI risk; 26% of these will have a nonvertebral fracture and 10% will have a vertebral fracture in the next five years. Antiresorptive medications are being taken by less than 50% of women in most risk categories when all antiresorptives, including estrogen replacement, are included; only 17% of older women who have sustained a prior fracture and 13% in the highest category of FI risk are receiving agents specifically intended to reduce bone loss. CONCLUSIONS: Millions of older US women are at high risk for fragility fractures. Levels of treatment with antiresorptive medications are low and are not commensurate with fracture risk.

Trends in hospital care for hip fractures.

UNLABELLED: To assess the impact of the aging population on the occurrence of fragility fractures, we examined hospital discharges for hip fracture among U.S. women and men aged 45 years and older from 1993 through to 2003. The number of hospitalizations declined by 5%, and age-adjusted rates fell by over 20% for both women and men during this period. INTRODUCTION: Although the aging of the population should mean an increasing burden of fragility fractures, several recently published reports suggest regional declines in the incidence of hip fracture. We investigated trends in hospital discharges and utilization for hip fractures across the USA from 1993 to 2003. METHODS: Hospital discharges from the Nationwide Inpatient Sample from 1993 through to 2003 were analyzed for numbers of primary diagnosis of hip fracture and associated average length of stay (LOS) and charges among women and men aged 45 years and older. Age-specific rates were constructed using national census data. RESULTS: Over the 11-year study period the number of hospitalizations for hip fractures decreased by 5%, from 296,000 to 281,000. The numbers of discharges declined by 16,600 (7.4%) for women and increased by 1900 (2.6%) among men. However, age-adjusted rates for both women and men fell by about 20%. Average hospital LOS was reduced by about 35% for both sexes, resulting in decreases in days of care of 42 and 33% for women and men, respectively. At the same time, average inflation-adjusted charges for each hospitalization grew by 35% for women and 38% for men, and increasing proportions of patients were discharged to continuing institutional care. During the study interval the total number of prescriptions per year for bisphosphonate anti-resorptive agents grew from under 0.5 to 30 million. CONCLUSIONS: Despite the increasing size of the older segment of the U.S. population, hospitalizations for hip fractures are not increasing. With declining lengths of stay there has been a reduced demand on hospital resources, although with average charges per hospitalization rising and more patients being discharged to other institutions for continuing care the economic consequences of hip fracture continue to increase.

Hospital care of osteoporosis-related vertebral fractures.

Resource implications of hospitalization for osteoporosis-related vertebral fracture are sparsely documented. This study utilized data abstracted from a national sample of hospitalized patients to identify characteristics of patients who are hospitalized with vertebral fracture and their patterns of resource utilization. These were compared with patterns observed for hip fracture hospitalizations. Data from the Nationwide Inpatient Sample (NIS) for 1997 were used to identify men and women age 45 years and above who had a primary diagnosis of vertebral fracture. After patients whose fractures might have been due to metastatic cancer or severe trauma were excluded, 68,901 individuals hospitalized for vertebral fracture were identified. Seventy-seven percent of these were women, most were white, 75 years and older, and had multiple comorbid diagnoses. Total charges averaged 8000-10,000 US dollars per hospitalization and were higher in men. Mean length of stay was just under 6 days and more than 50% of discharged patients required some form of continuing care. Hospitalizations for vertebral fracture occurred at only one-fourth the rate of those for hip fracture, and created only half the hospital charges per admission. Vertebral fracture accounted for over 400,000 total hospital days and generated charges in excess of 500 million US dollars. This resource impact is considerably higher than has been described in prior studies.

Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening.

OBJECTIVES: The relation of personal characteristics, health and lifestyle behaviors, and cancer screening practices to current colorectal cancer (CRC) screening was assessed and compared with those factors' relation to current mammography screening in women and prostate-specific antigen (PSA) screening in men. METHODS: A cross-sectional random-digit-dialed telephone survey of 954 Massachusetts residents aged 50 and older was conducted. RESULTS: The overall prevalence of current CRC screening was 55.3%. Logistic regression results indicated that family history of CRC (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.02, 3.86), receiving a regular medical checkup (OR = 3.07; 95% CI = 2.00, 4.71), current screening by mammography in women and PSA in men (OR = 4.40; 95% CI = 2.94, 6.58), and vitamin supplement use (OR = 1.87; 95% CI = 1.27, 2.77) were significant predictors of CRC screening. CONCLUSIONS: Health and lifestyle behaviors were related to increased current CRC, mammography, and PSA screening. Personal factors independently related to CRC screening were not consistent with those related to mammography and PSA screening. This lack of consistency may reflect different stages of adoption of each type of screening by clinicians and the public.

Colorectal cancer screening in Massachusetts: measuring compliance with current guidelines.

CONTEXT: Professional organizations have published guidelines for colorectal cancer screening. Defining which patients are currently, or should be, screened is an important clinical and public health issue. OBJECTIVE: To document the prevalence of colorectal cancer screening and profile the tests patients have had. DESIGN/POPULATION: A random-digit telephone survey of Massachusetts adults, 50 years of age and older. OUTCOME MEASURES: Percentage of persons ever and currently tested by fecal occult blood tests, flexible sigmoidoscopy, barium enema, colonoscopy, or some combination of these tests. RESULTS: Sixty-five percent of those contacted agreed to the telephone interview. Approximately 29% of the 1119 respondents had never had any currently accepted test, including 10% who reported having only a fecal occult blood test done in a provider's office and 19% who reported having no tests. At least 51% were currently tested by one or more tests for screening, diagnosis, or both. Another 10% were possibly current by colonoscopy or barium enema, both of which can be ordered for screening but are more commonly used to evaluate a problem, such as rectal bleeding, or for surveillance after identification of a polyp or other abnormality. An additional 11% had been tested at some point but were not current according to guidelines. CONCLUSIONS: Accurate assessment of rates of colorectal cancer screening is complex because of the multiple acceptable screening methods, the fact that patients may be tested for screening or diagnostic purposes, and the lack of adequate systems for tracking such testing. For accurate measurement, all methods must be assessed regardless of whether tests were ordered for screening, diagnosis, or surveillance.

Understanding the diverse needs of the Medicare population: implications for Medicare reform.

Meeting the health care needs of millions of elderly and disabled Americans is central to the debate over Medicare's future. Using data from a nationally representative survey of 3,309 beneficiaries, Medicare's most vulnerable beneficiaries were profiled, examining variations in coverage, satisfaction, access, and financial difficulties. A substantial portion of the Medicare population--two thirds--were found to have health problems or low incomes. The analysis found that about 40% of beneficiaries with incomes below the poverty level, in fair or poor health, or with ADL limitations, have difficulties paying their medical bills or getting needed health care. Medicare's disabled, under-65 beneficiaries are at even higher risk: nearly half (47%) have health care access problems or deal with financial hardship due to medical bills. The diverse needs and experiences of the Medicare population are underscored, providing new insights into the challenge of maintaining or improving protection for those with greatest need while assuring the long-term fiscal viability of the program.

Insurance matters for low-income adults: results from a five-state survey.

Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality.

Chronic psychological effects of exercise and exercise plus cognitive strategies.

Psychological changes associated with 16-wk moderate and low intensity exercise training programs, two of which possessed a cognitive component, were evaluated. Subjects were healthy, sedentary adults, 69 women (mean age = 54.8 +/- 8.3 yr) and 66 men (mean age = 50.6 +/- 8.0 yr). Participants were randomly assigned to a control group (C), moderate intensity walking group (MW), low intensity walking group (LW), low intensity walking plus relaxation response group (LWR), or mindful exercise (ME) group-a Tai Chi type program. Women in the ME group experienced reductions in mood disturbance (tension, P < 0.01; depression, P < 0.05; anger, P < 0.008; confusion, P < 0.02; and total mood disturbance, P < 0.006) and an improvement in general mood (P < 0.04). Women in the MW group noted greater satisfaction with physical attributes (body cathexis, P < 0.03), and men in MW reported increased positive affect (P < 0.006). No other differences were observed between groups on measures of mood, self-esteem, personality, or life satisfaction. Equivocal support is provided for the hypothesis that exercise plus cognitive strategy training programs are more effective than exercise programs lacking a structured cognitive component in promoting psychological benefits.

Estimates of blood pressure variability in adolescents using an automatic blood pressure measuring device.

Knowledge of BP variability is important for BP screening and for the design of studies with BP as an outcome. We calculated estimates of the between-visit and within-visit variances from data obtained using an automated BP.device (Dinamap) in 776 students, aged 13-17 years, in the Exeter-Andover Project. Each subject had his or her BP measured three times per visit at up to 24 weekly visits. We compared these estimates of variance with those published for adolescents using a standard mercury sphygmomanometer. For subjects measured using the Dinamap, the between-visit variance was greater for SBP and the within-visit variance for both pressures was almost three times greater than for subjects measured with the standard instrument.

Effects of alterations in fatty acid intake on the blood pressure of adolescents: the Exeter-Andover Project.

To judge the effect on blood pressure, the ratio of polyunsaturated to saturated fatty acids (P:S) of foods served to students at two boarding high schools was modified alternately at each school for one school year. The average P:S of the diet of males increased from 0.53 to 0.93 during the intervention whereas among females it increased from 0.64 to 0.98. Comparison of repeated systolic and diastolic blood pressure measurements near the end of the school year did not demonstrate a beneficial effect of the dietary fat changes on the blood pressure of these normotensive adolescents. Compared with the blood pressure patterns during control years, the dietary intervention resulted in slightly higher systolic (+0.88 mm Hg; 95% CI -0.66, +2.42) and diastolic (+1.23 mm Hg; 95% CI = +0.04, +2.42) blood pressure readings among males. Among females the intervention resulted in slightly lower systolic (-0.54 mm Hg; 95% CI = -1.95, +0.88) and diastolic (-0.80 mm Hg (95% CI -2.18, +0.58) blood pressure readings.

Development of a single-stage submaximal treadmill walking test.

An equation was developed to estimate maximal oxygen uptake (VO2max, ml.kg-1.min-1) based on a single submaximal stage of a treadmill walking test. Subjects (67 males, 72 females) aged 20-59 yr completed 4-min stages at 0, 5, and 10% grades walking at a constant speed (2.0-4.5 mph) and then performed a VO2max test. Heart rate and respiratory gas exchange variables were measured during the test. Multiple regression analysis (N = 117) to estimate VO2max from the 4-min stage at 5% grade yielded the following model (R2 = 0.86; SEE = 4.85 ml.kg-1.min-1): VO2max = 15.1 + 21.8*SPEED (mph) -0.327*HEART RATE (bpm) -0.263*SPEED*AGE (yr) + 0.00504*HEART RATE*AGE + 5.98*GENDER (0 = Female; 1 = Male). The constant and all coefficients were highly significant (P less than 0.01). To assess the accuracy of the model in a cross-validation group (N = 22), an estimated VO2max value was obtained using the above model. Estimated VO2max then was regressed on observed VO2max yielding the following equation (R2 = 0.92): ESTIMATED VO2max = 0.15 + 1.03*OBSERVED VO2max. The intercept and slope of this equation were not significantly different from 0 and 1, respectively. For 90.9% of the subjects in the cross-validation group, residual scores were within the range of +/- 5 ml.kg-1.min-1. In conclusion, this submaximal walking test based on a single stage of a treadmill protocol provides a valid and time-efficient method for estimating VO2max.

Use of fat-modified food products to change dietary fat intake of young people.

Food purchasing and preparation practices were modified in two boarding high schools to increase the polyunsaturated-to-saturated fat ratio (P/S) of the diet of students by changing food products rather than attempting to change eating behaviors. During years when fat-modified products were served, the P/S of males increased by 75 percent, versus a decrease of 6 percent during control years. For females, P/S increased by 53 percent during intervention years, versus an increase of 6 percent during control years.

Study of secretory component in patients with metastatic breast cancer.

A radioimmunoassay was developed for secretory component, a glandular epithelial cell product secreted as an accessory protein with dimeric immunoglobulins A and M. Forty-four normal women between the ages of 40 and 70 had plasma concentrations of secretory component of 7.195 microgram/ml +/- 3.590 (+/-2 SD). Of the patients with metastic breast cancer of epithelial origin, 34 (91.9%) had plasma concentrations greater than 8.990 microgram/ml; 29 (78.1%) had plasma concentrations greater than 10.785 microgram/ml; 10 (27%) had concentrations greater than 15.000 microgram/ml; and 3 (8.1%) had concentrations greater than 22.710 microgram/ml. Serial plasma concentrations (averaging 3.48 per patient) of 35 (94.6%) of these patients reflected the clinical course of the disease. All patients had some combination of surgery, radiation therapy, and chemotherapy. No direct correlation was noted between the type of therapy and concentration of secretory component. However, plasma secretory component served as a marker in the systemic circulation of a change in the status of the metastatic breast cancer. The impact of this research may lie in its incorporation into clinical management.