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：该项目的目的是创建一个工作工具来评估患有脊髓损伤/D的退伍军人的骨折风险。该工具将帮助指导临床医生决策哪些脊髓损伤/D患者应该接受药物治疗以防止骨折。项目背景：超过10%的SCI/D患者通过退伍军人管理局接受护理，退伍军人SCI/D患者的护理是退伍军人管理局关注的核心问题。我们已经发现，患有SCI/D的退伍军人发生骨质疏松性骨折后会发生严重的并发症。然而，关于SCI/D中骨质疏松性骨折的危险因素知之甚少。更好地了解SCI/D中的骨折危险因素将有助于对现有的骨质疏松治疗进行适当的靶向治疗。最近，药物治疗骨质疏松症的严重副作用已有报道，包括颌骨骨坏死和不典型股骨骨折。因此，现在避免过度治疗低风险骨折的患者变得至关重要。结合临床因素和骨密度(BMD)测量来评估无SCI/D人群的骨折风险的工具最近已被开发出来。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、甚至单纯的废用性骨质疏松有很大的不同，因此需要开发一种独特的模型来预测SCI/D中的骨折。作为开发预测SCI/D中骨折的工作模型的第一步，关键是确定双能X射线吸收法(DXA)得出的BMD是否真的对预测骨折有用。在SCI/D中开发预测骨折的工作模型的第二步是确定哪些临床危险因素可以预测发生的骨折。一个可以直接在临床上使用的最终模型将有助于临床医生的决策，该模型可以清楚且容易地识别哪些SCI/D患者是骨折风险最高的患者。这种工具可以通过治疗骨质疏松症避免过度治疗和对低风险骨折者的潜在伤害，并将这种治疗的好处赋予那些最有可能骨折的人。在此背景下，我们的工作假设是，临床因素而不是DXA来源的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在预测患有SCI/D的退伍军人中的骨折的有效性。我们假设DXA来源的BMD将不能预测SCI/D中发生的骨折。为了验证我们的假设，使用回溯性队列设计，我们将在2002-2012财年将退伍军人纳入SCD登记，并确定在研究期间DXA来源的BMD是否能够预测发生的骨折。具体目标2：确定SCI/D退伍军人中非轴性骨折预测的最佳模型。我们假设一组临床因素将预测SCI/D中发生的骨折。为了验证我们的假设，我们将在2002-2012财年将退伍军人纳入SCD登记，并确定哪些临床因素可以预测2012财年发生非轴性骨折的风险。我们最终的骨折预测模型将包括BMD(只有在BMD可以预测骨折的情况下)和那些被确定为预测骨折发生的临床危险因素。这项研究的近期目标是确定DXA来源的BMD是否是预测SCI/D骨折的有用工具，并开发一个预测SCI/D骨折的模型。长期目标是使用该模型来指导SCI/D患者预防骨折的治疗决策。项目方法：该项目将利用管理数据集和图表审查数据。退伍军人管理局的资源包括退伍军人管理局脊髓疾病(SCD)登记处、DSS药房和放射系统、企业数据仓库和奥斯汀国家患者护理数据库，将为该项目提供管理数据。

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.