Osteoporotic fractures are a significant public health problem, resulting in substantial morbidity and mortality. Previous estimates of the economic burden of osteoporosis, however, have not fully accounted for the costs associated with treatment of nonhip fractures, minority populations, or men. Accordingly, the 1995 total direct medical expenditures for the treatment of osteoporotic fractures were estimated for all persons aged 45 years or older in the United States by age group, sex, race, type of fracture, and site of service (inpatient hospital, nursing home, and outpatient). Osteoporosis attribution probabilities were used to estimate the proportion of health service utilization and expenditures for fractures that resulted from osteoporosis. Health care expenditures attributable to osteoporotic fractures in 1995 were estimated at $13.8 billion, of which $10.3 billion (75.1%) was for the treatment of white women, $2.5 billion (18.4%) for white men, $0.7 billion (5.3%) for nonwhite women, and $0.2 billion (1.3%) for nonwhite men. Although the majority of U.S. health care expenditures for the treatment of osteoporotic fractures were for white women, one-fourth of the total was borne by other population subgroups. By site-of-service, $8.6 billion (62.4%) was spent for inpatient care, $3.9 billion (28.2%) for nursing home care, and $1.3 billion (9.4%) for outpatient services. Importantly, fractures at skeletal sites other than the hip accounted for 36.9% of the total attributed health care expenditures nationally. The contribution of nonhip fractures to the substantial morbidity and expenditures associated with osteoporosis has been underestimated by previous researchers. (J Bone Miner Res 1997;12:24-35)

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To assess the cost-effectiveness of interventions to prevent osteoporosis, it is necessary to estimate total health care expenditures for the treatment of osteoporotic fractures. Resources utilized for the treatment of many diseases can be estimated from secondary databases using relevant diagnosis codes, but such codes do not indicate which fractures are osteoporotic in nature. Therefore, a panel of experts was convened to make judgments about the probabilities that fractures of different types might be related to osteoporosis according to patient age, gender, and race. A three-round Delphi process was applied to estimate the proportion of fractures related to osteoporosis (i.e., the osteoporosis attribution probabilities) in 72 categories comprised of four specific fracture types (hip, spine, forearm, all other sites combined) stratified by three age groups (45-64 years, 65-84 years, 85 years and older), three racial groups (white, black, all others), and both genders (female, male). It was estimated that at least 90% of all hip and spine fractures among elderly white women should be attributed to osteoporosis. Much smaller proportions of the other fractures were attributed to osteoporosis. Regardless of fracture type, attribution probabilities were less for men than women and generally less for non-whites than whites. These probabilities will be used to estimate the total direct medical costs associated with osteoporosis-related fractures in the United States. (J Bone Miner Res 1997;12:16-23)

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Background A shared decision-making tool could help elderly advanced chronic kidney disease (CKD) patients decide about initiating dialysis. Since mortality may be high in the first few months after initiating dialysis, incorporating early mortality predictors in such a tool would be important for an informed decision. Our objective is to derive and validate a predictive risk score for early mortality after initiating dialysis. Study Design Retrospective observational cohort, with development and validation cohorts. Setting & Participants US Renal Data System (USRDS) and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) end-stage renal disease (ESRD) patients with previous 2-year Medicare history who initiated dialysis January 1, 2009–December 31, 2010. Candidate Predictors Demographics, predialysis care, laboratory data, functional limitations and medical history. Outcomes All-cause mortality in the first 3 and 6 months. Analytical Approach Predicted mortality via logistic regression. Results The simple risk score (total score, 0–9) included age (0–3 points); low albumin, assistance with daily living, nursing home residence, cancer, heart failure, and hospitalization (1 point each), and showed area under the receiver operating characteristic curve (AUROC) =0.69 in the validation sample. A comprehensive risk score with additional predictors was also developed (with AUROC=0.72, high concordance between predicted vs. observed risk). Mortality probabilities were estimated from these models: the median score of 3 indicating 12% risk in 3 months and 20% in 6 months, and the highest scores (≥8) indicating 39% risk in 3 months and 55% in 6 months. Limitations Patients who did not choose dialysis and who did not have 2 year Medicare history were excluded. Conclusions Routinely available information can be used by CKD patients, families and their nephrologists to estimate risk of early mortality after dialysis initiation, which may facilitate informed decision-making regarding treatment options.

Background Corticosteroids are the mainstay for treatment of systemic lupus erythematosus (SLE). The potential role of corticosteroid use on the pathogenesis of permanent organ damage requires appropriate adjustment for confounding by disease activity. We estimate the effect of corticosteroids (prednisone dose) on permanent organ damage among persons with SLE. Methods We identified 525 incident SLE patients in the Hopkins Lupus Cohort. At each visit, clinical activity indices, laboratory data, and treatment were recorded. The study population was followed from the month after the first visit until June 29 2006, irreversible organ damage, death, loss to follow-up, or receipt of pulse methylprednisolone therapy. We estimated the effect of cumulative average dose of prednisone on organ damage using a marginal structural model to adjust for time-dependent confounding by indication due to SLE disease activity. Findings Compared with non prednisone use, the hazard ratio (95% confidence interval) of organ damage for prednisone was 1.16 (0.59, 2.20) for cumulative average doses >0–180 mg/month, 1.50 (0.67, 3.39) for >180–360 mg/month, 1.64 (0.67, 4.06) for >360–540 mg/month, and 2.51 (1.02, 6.19) for >540 mg/month. In contrast, standard Cox regression models estimated higher hazard ratios at all dose levels. Interpretation Our results suggest that low doses of prednisone do not result in a substantially increased risk of irreversible organ damage.

Epoetin dose requirement is an independent predictor of total mortality in hemodialysis patients after adjustment for hematocrit. Poor responders who continue to have low hematocrit values despite the administration of high epoetin doses may not necessarily benefit from more epoetin, but perhaps should be considered for other adjunctive therapies. In contrast to conventional wisdom, this study suggests that epoetin dosing requirements could provide important prognostic information beyond that predicted by hematocrit alone.