Modeling fracture prediction in spinal cord injury and disease

描述（由申请人提供）： 对退伍军人医疗保健的预期影响：本项目的目的是创建一个工作工具来估计SCI/D退伍军人的骨折风险。该工具将有助于指导临床医生决定哪些SCI/D患者应接受药物治疗以预防骨折。项目背景：超过10%的SCI/D患者通过VA接受护理，SCI/D退伍军人的护理是VA的核心问题。我们已经发现，严重的发病率发生在脊髓损伤/脊髓损伤的退伍军人骨折。然而，关于SCI/D患者发生椎体骨折的危险因素知之甚少。更好地了解SCI/D骨折的危险因素将使现有的骨质疏松症治疗方法具有适当的针对性。最近，骨质疏松症药物治疗的严重副作用，包括颌骨骨坏死和非典型股骨骨折的报道。因此，避免对骨折风险低的患者进行过度治疗变得至关重要。 结合临床因素和骨矿物质密度（BMD）测量来估计骨折风险的工具最近已经为非SCI/D的人开发出来。然而，由于SCI/D后骨丢失的病理生理学与年龄相关的、绝经后的、甚至简单的废用性骨质疏松症的病理生理学有很大不同，因此需要开发一种不同的模型来预测SCI/D中的骨折。作为开发预测SCI/D骨折的工作模型的第一步，确定双能X射线吸收测定法（DXA）衍生的BMD是否确实可用于预测骨折至关重要。开发预测SCI/D骨折的工作模型的第二步是确定哪些临床风险因素可以预测偶发骨折。一个最终的模型，明确和容易地确定哪些SCI/D患者骨折的风险最高，可以直接在诊所使用，将有助于临床医生的决策。这种工具可以避免过度治疗和骨质疏松症治疗对骨折风险低的人的潜在伤害，并将这种治疗的好处赋予那些最有可能骨折的人。在这种情况下，我们的工作假设是临床因素，而不是DXA衍生的BMD将最好地预测SCI/D患者的骨折。我们的假设将在以下具体目标中进行检验。具体目标1：确定DXA预测SCI/D退伍军人骨折的实用性。我们假设DXA衍生的BMD不能预测SCI/D中的骨折事件。为了验证我们的假设，我们将使用回顾性队列设计，在2002 - 2012财年的SCD登记研究中纳入退伍军人，并确定DXA衍生的BMD是否能够预测研究期间发生的骨折。具体目标2：确定预测SCI/D退伍军人非轴性骨折的最佳模型。我们假设一组临床因素可以预测SCI/D中的骨折事件。为了检验我们的假设，在回顾性队列设计中，我们将纳入2002 - 2012财年SCD登记研究中的退伍军人，并确定哪些临床因素可以预测2012财年发生非轴向骨折的风险。我们最终的骨折预测模型将包括BMD（仅当BMD可以预测骨折时）和那些确定用于预测偶发骨折的临床风险因素。本研究的直接目标是确定DXA衍生的BMD是否是预测SCI/D骨折的有用工具，并建立预测SCI/D骨折的模型。长期目标是使用该模型指导SCI/D患者预防骨折的治疗决策。项目方法：本项目将利用管理数据集和图表审查数据。VA的资源，包括VA脊髓疾病（SCD）登记处、DSS药房和放射学系统、企业数据仓库和奥斯汀国家患者护理数据库，将为本项目提供管理数据。

DESCRIPTION (provided by applicant): Anticipated Impacts on Veteran's Healthcare: The purpose of this project is to create a working tool to estimate fracture risk in Veterans with SCI/D. This tool will help guide clinicians in decision making for which patients with SCI/D should be treated with pharmacological agents to prevent fracture. Project Background: More than 10% of all persons with a SCI/D receive care through the VA and care of Veterans with SCI/D is of central concern to the VA. We have identified that serious morbidities occur following osteoporotic fractures in Veterans with SCI/D. However, there is very little known concerning risk factors for osteoporotic fractures in SCI/D. A better understanding of risk factors for fractures in SCI/D would allow appropriate targeting of existing treatments for osteoporosis. Recently, serious side effects from pharmacological therapies for osteoporosis including osteonecrosis of the jaw and atypical femoral fractures have been reported. Thus, it has now become critically important to avoid overtreatment of patients at low risk for fracture. Tools which incorporate clinical factors and bone mineral density (BMD) measurements to estimate fracture risk have recently been developed for persons without SCI/D. However, since the pathophysiology of bone loss following SCI/D differs substantially from that of age related, postmenopausal, or even simple disuse osteoporosis, there is a need to develop a distinct model to predict fractures in SCI/D. As a first step towards developing a working model to predict fractures in SCI/D, it is critical to determine whether Dual Energy X-ray Absorptiometry (DXA)-derived BMD is indeed useful for predicting fractures. A second step in developing a working model to predict fractures in SCI/D is to determine which clinical risk factors can predict incident fractures. A final model that clearly and easily identifes which patients with SCI/D are at highest risk for fracture that can be used directly in the clinics would facilitate decision making for clinicians. Such a tool could avoid overtreatment and potential harm to those at low risk for fracture by treatments for osteoporosis, and confer the benefits of such treatments to those who are most likely to fracture. In this context, our working hypothesis is that clinical factors but not DXA-derived BMD will best predict fractures in persons with SCI/D. Our hypothesis will be examined in the following specific objectives. Specific Objective 1: Determine the utility of DXA to predict fractures in Veterans with SCI/D. We hypothesize that DXA-derived BMD will not be able to predict incident fractures in SCI/D. To test our hypothesis, using a retrospective cohort design, we will include Veterans in the SCD Registry in FY2002-2012 and determine whether DXA-derived BMD is able to predict incident fractures during the study period. Specific Objective 2: Determine the best model for non-axial fracture prediction in Veterans with SCI/D. We hypothesize that a set of clinical factors will predict incident fractures in SCI/D. To test our hypothesis, in a retrospective cohort design, we will include Veterans in the SCD Registry in FY2002-2012 and determine which clinical factors can predict risk for incident non-axial fractures through FY2012. Our final fracture prediction model will include BMD (only if BMD can predict fractures) and those clinical risk factors identified to predict incident fractures. The immediate objectives of this research are to determine whether DXA-derived BMD is a useful tool in predicting fractures in SCI/D and to develop a model to predict fractures in SCI/D. The long-term objectives are to use this model to guide treatment decisions for fracture prevention in persons with SCI/D. Project Methods: This project will utilize administrative datasets and chart review data. The resources at the VA including the VA Spinal Cord Disorders (SCD) Registry, the DSS Pharmacy and Radiology Systems, the Corporate Data Warehouse and the Austin National Patient Care Databases will provide the administrative data for this project.