Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Geriatric Research, Education and Clinical Center, Durham, NC.
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC.
Mayo Clin Proc. 2018 Dec;93(12):1749-1759. doi: 10.1016/j.mayocp.2018.06.024.
To determine the association between dual-energy x-ray absorptiometry (DXA) testing for osteoporosis and subsequent fractures in US male veterans without a previous fracture.
This is a propensity score-matched observational study using Centers for Medicare and Medicaid Services and Veterans Affairs (VA) data from January 1, 2000, through December 31, 2010, with a mean follow-up time of 4.7 years (range, 0-10 years). Men receiving VA primary care aged 65 to 99 years without a previous fracture (N=2,539,812) were included. Men undergoing DXA testing were propensity score matched with untested controls in a 1:3 ratio, indicating the probability of DXA testing within the next year. Time to first clinical fracture was the primary outcome. Comorbidities, demographic characteristics, medications, DXA results, and osteoporosis treatment were defined using administrative data and natural language processing. A landmark analysis contingent on surviving to 12 months after screening was completed, accounting for competing risk of mortality.
During follow-up of 153,311 men tested by DXA and 390,158 controls, 56,083 (10.3%) had sustained a fracture and 111,774 (20.6%) died. Overall, DXA testing was not associated with a decrease in fractures; conclusions are limited by unmeasured confounders and low medication initiation and adherence in those meeting treatment thresholds (12% of follow-up time). In contrast, DXA testing in prespecified subgroups was associated with a lower risk of fracture in comparison to the overall population who underwent DXA testing: androgen deprivation therapy (hazard ratio [HR], 0.77; 95% CI, 0.66-0.89), glucocorticoids (HR, 0.77; 95% CI, 0.72-0.84), age 80 years and older (HR, 0.85; 0.81-0.90), 1 or more VA guideline risk factors (HR, 0.91; 95% CI, 0.87-0.95), and high Fracture Risk Assessment Tool using body mass index score (HR, 0.90; 95% CI, 0.86-0.95).
Current VA DXA testing practices are ineffective overall; interventions to improve treatment adherence are needed. Targeted DXA testing in higher-risk men was associated with a lower fracture risk.
确定在美国无既往骨折的男性退伍军人中，双能 X 射线吸收法（DXA）骨质疏松检测与随后骨折之间的关联。
这是一项使用医疗保险和医疗补助服务中心以及退伍军人事务部（VA）数据的倾向评分匹配观察性研究，从 2000 年 1 月 1 日至 2010 年 12 月 31 日，平均随访时间为 4.7 年（范围，0-10 年）。纳入了年龄在 65 至 99 岁、无既往骨折（N=2539812）且接受 VA 初级保健的男性。对 DXA 检测者进行倾向评分匹配，以未检测者为对照，比例为 1:3，表明下一年进行 DXA 检测的可能性。首次临床骨折时间为主要结局。共病、人口统计学特征、药物、DXA 结果和骨质疏松症治疗均采用行政数据和自然语言处理进行定义。在完成筛选后 12 个月进行了基于生存的 landmark 分析，以考虑死亡的竞争风险。
在对 153311 名接受 DXA 检测的男性和 390158 名对照者进行随访期间，有 56083 名（10.3%）发生了骨折，有 111774 名（20.6%）死亡。总体而言，DXA 检测并未降低骨折风险；由于存在无法测量的混杂因素以及在符合治疗阈值的患者中药物起始和依从性较低（占随访时间的 12%），结论受到限制。相比之下，在预先指定的亚组中，DXA 检测与接受 DXA 检测的总体人群相比，骨折风险较低：雄激素剥夺治疗（HR，0.77；95%CI，0.66-0.89）、糖皮质激素（HR，0.77；95%CI，0.72-0.84）、年龄 80 岁及以上（HR，0.85；0.81-0.90）、1 个或更多 VA 指南风险因素（HR，0.91；95%CI，0.87-0.95）和使用体重指数评分的高骨折风险评估工具（HR，0.90；95%CI，0.86-0.95）。
目前 VA 的 DXA 检测实践总体上无效；需要采取干预措施提高治疗依从性。对高风险男性进行有针对性的 DXA 检测与较低的骨折风险相关。
