LOMA LINDA, CA — A pair of new studies shows a very high prevalence of bone disease among male veterans with chronic obstructive pulmonary disease (COPD) and other pulmonary illnesses, raising the question of whether more screening is needed.
In the first study, presented at the American Thoracic Society International Conference, nearly 60% of 46 veterans referred to a pulmonary clinic at the VA Loma Linda Healthcare System in Loma Linda, CA, had positive dual-emission X-ray absorptiometry (DXA) scans. Of the 27 patients with bone disease, 78% had osteopenia (21), and 22% (6) had osteoporosis. Forty-five of the patients were male.1
Of the patients referred to the pulmonary rehabilitation clinic, 80% had diagnoses of COPD, 16% had idiopathic pulmonary fibrosis, and 4% had asthma. The researchers noted that those patients with more severe lung disease also were more likely to have osteoporosis or osteopenia.
For the VA, understanding this correlation between pulmonary disease and bone disease could have widespread implications. “COPD has bypassed stroke to become the third-leading cause of death in the U.S. and fifth most prevalent disease in the veteran population, affecting approximately 15% of VA healthcare users,” according to Christine Freeman, PhD, research biologist at VA Medical Center, Ann Arbor, MI, and research investigator in Internal Medicine at the University of Michigan Health System.
The VA currently routinely screens female veterans over the age of 65 for osteoporosis but recommends men for bone assessments only on a case-by-case basis.
“The high prevalence of bone disease we found in male patients referred to our pulmonary rehabilitation program suggests that routine screening should also be performed in men with pulmonary disease,” said lead investigator Kathleen Ellstrom, PhD, RN, APRN-BC, Pulmonary Clinical Nurse Specialist and Director of the Pulmonary Rehabilitation Program at the Veterans Administration Loma Linda Healthcare System.
National guidelines do not yet recommend such screening. “The VA follows the guidelines issued by the U.S. Preventive Task Force, and there is not a national screening program for osteoporosis in COPD,” said a VA spokesperson. “A review in UpToDate published this January also does not recommend routine screening for osteoporosis in men.”
However, national guidelines do “suggest screening in men for those with radiographic osteopenia, history of low trauma fractures and loss of more than 1.5 inches in height, as well as in those with risk factors for fracture, such as long-term glucocorticoid therapy and androgen deprivation therapy for prostate,” the VA spokesperson told U.S. Medicine.
Risk Independent of Steroids
Veterans who take steroids, often prescribed for exacerbations of pulmonary disease, often are monitored for osteoporosis and osteopenia. But this study and other “recent evidence suggests that COPD itself may be associated with an increased risk secondary to an inflammatory process independent of steroid use,” Ellstrom said.
“Our findings suggest that routine screening for osteopenia/osteoporosis in male patients with pulmonary disease may help reduce the occurrence of fractures in these patients by identifying at-risk individuals that might otherwise not be evaluated and treated,” she added.
“Osteoporotic fractures may be particularly devastating in the veteran population, as post-fracture inpatient mortality rates for veterans are more than double that of the general population,” according to the HSR&D “Evidence Synthesis Pilot Program — Screening Men for Osteoporosis: Who & How.”
In the general population, about 20% of older hip-fracture patients die within one year of their fracture, with men having twice the mortality rate of women in the first six months after a fracture, according to the International Osteoporosis Foundation. About half of patients who suffer hip fractures and previously lived independently are unable to so afterward.
The second study, published online recently in COPD: the Journal of Chronic Obstructive Pulmonary Disease, looked at the correlation between COPD and osteoporosis from the reverse perspective. That study focused on records of patients with these potentially catastrophic hip fractures and found very high rates of COPD. 2
The research team led by Elizabeth Regan, MD, PhD, of the VA Eastern Colorado Healthcare System in Denver and National Jewish Health, used the VA Surgical Quality Improvement Program (VASQUIP) and administrative databases to analyze 12,646 records of men undergoing hip-fracture surgery within the VHA from 1998 to 2005. They evaluated the COPD status, type of comorbid conditions and surgical factors against surgical outcomes.2
Nearly half (47%) of the hip-fracture surgery patients in this period had COPD. More than a quarter (26%) had severe pulmonary disease characterized by functional disability, previous hospitalizations or chronic drug treatment. Twenty-one percent had mild disease.
Severe COPD patients had one-year mortality rates of 40.2%, while mild COPD patients had 31% mortality, and non-COPD patients had 28.8% one-year mortality rates. Only 3% of patients had previous diagnoses of osteoporosis.
The researchers concluded that “COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications.” In addition, “osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.”
In a written response to U.S. Medicine, VA healthcare experts noted that evidence for screening for osteoporosis in pulmonary disease patients is not entirely consistent.
“In a multivariable analysis of 714 patients with COPD and asthma, only those on corticosteroids (inhaled or oral) were shown to have an increased risk of reduced hip and spine bone mineral densities, despite higher rates of spine fractures,” they wrote.3
“In contrast, the TORCH [TOwards a Revolution in COPD Health] study did not find a reduction in bone mineral density associated with use of inhaled corticosteroids over three years. Others suggest that the low-grade systemic inflammation found in patients with chronic lung disease may play a role in the increased fractures reported by some in COPD,” noted the VA source. In addition, “hypercapnea in the COPD patients with severe disease has been associated with increased bone resorption leading to the reduced bone mineral density,” said the VA experts. 4
1. Abstract 32409 High Prevalence Of Osteopenia/Osteoporosis In Patients Referred For Pulmonary Rehabilitation Type: Scientific Abstract Category: 15.06 – Pulmonary Rehabilitation: Patient Assessment (PR) Authors: K. Ellstrom, N.L. Specht; VA Loma Linda Healthcare System – Loma Linda, CA/US
2. Regan EA, Radcliff TA, Henderson WG, Cowper Ripley DC, Maciejewski ML, et al. Improving hip fractures outcomes for COPD patients. COPD. Published online Dec 28, 2012.
3. Dam TT, Harrison S, Fink HA, Ramsdell J, Barrett-Connor E. and the Osteoporotic Fractures in Men (MrOS) Research Group. Bone mineral density and fractures in older men with chronic obstructive pulmonary disease or asthma. Osteoporos Int. 2010;21(8):134-49.
4. Ferguson GT, Claverley PM, Anderson JA, Jenkins CR, Jones PW, et al. Prevalence and progression of osteoporosis in patients with COPD: results from the Towards a Revolution in COPD Health study. Chest. 2009;136(6):1456-65.
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.