Our expert panel used the RAND/UCLA appropriateness method, which includes elements of the nominal and Delphi methods, to score the likelihood of fractures being due to osteoporosis. Because of the possibility that some clinical risk factors might modify the relationship between having osteoporosis and sustaining a fracture, the evidence report also included estimates of the association of fractures with age, sex, race, trauma, glucocorticoid use, and chronic kidney disease.Įxpert Panel Process using the RAND/UCLA appropriateness method A summary of the data available in the current literature, which was provided to the expert panel members within an evidence report, is found in Appendix 1. As evidence that a fracture at a given site was most likely due to osteoporosis, we used an association with either low bone mineral density or a subsequent fracture. The evidence report described the published estimates of fracture risk associated with osteoporosis for each anatomic bone site. The remaining 68 articles underwent detailed review and abstraction of data elements for an evidence report. We retrieved full text of the remaining 168 potentially relevant articles and excluded 100 additional articles for the same reason. Two reviewers (AW, NP) independently reviewed the abstracts of these articles and excluded 3,848 articles that were irrelevant to fracture epidemiology. The search strategy initially yielded 4,016 articles. To identify articles linking osteoporosis with fractures overall and by particular anatomic site, we limited our search to the exploded Medical Subject Headings (MeSH) ‘osteoporosis’ and ‘fracture’. A meta-analysis published in 2000 was used as reference for earlier studies. To conduct the systematic review and develop the evidence report, we used PubMed restricted to English language articles with abstracts indicating the use of human subjects and retrieved articles published in the ten years from Januto February 13, 2008. A multi-disciplinary expert panel used this evidence and their collective expertise to grade the strength of the association between osteoporosis and different fracture sites. To allow our findings to be useful for future investigations using administrative databases, we further grouped fractures based on ICD-9-CM. To assess the attribution to osteoporosis of fractures at different anatomic sites among persons with different osteoporosis risk factors, we used a modification of the Research and Development/University of California at Los Angeles (RAND/UCLA) Appropriateness Method to assemble the published evidence for the relationship between osteoporosis and fractures at all anatomic sites. These databases may be particularly helpful to study populations in which fracture epidemiology has been less well characterized, such as in non-Caucasians and older adults. The relationship of these codes to osteoporosis is very useful to determine fracture epidemiology at a population level. These databases identify fractures based on ICD-CM diagnosis codes and Current Procedural Terminology (CPT) procedure codes. and other countries in using large administrative databases, such as Medicare data, to examine the epidemiology of osteoporosis and fractures. Our approach sought to broaden the understanding of osteoporosis attribution at all fracture sites and to specify these fractures through the use of the International Classification of Diseases Clinical Modification (ICD-CM) fracture codes that are often used in epidemiologic studies to define events of interest. Most prior efforts to synthesize fracture literature have included only osteoporotic fractures at the typical sites (hip, spine, wrist, and humerus). However, increasing data on fracture epidemiology and newer approaches to utilizing formal group processes to define consensus motivated a careful reconsideration of the attribution of specific fracture sites to osteoporosis. Past efforts to define the fractures that are most strongly associated with osteoporosis have utilized formal group processes during which experts reviewed available evidence. In addition, the inconsistent use of the terms “fragility fracture” or “osteoporotic fracture” in clinical trials leads to varying reports of efficacy for osteoporosis therapies. Without an evidence-based consensus on what constitutes an osteoporosis-related fracture, the epidemiology and public health burden of osteoporosis cannot be accurately determined. Determining anatomic sites and circumstances under which a fracture may be a consequence of osteoporosis has been a topic of ongoing controversy. Based on current guidelines, a diagnosis of osteoporosis relies on a history of fragility fracture or the result of bone mineral density (BMD) evaluation.
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