JAGS
MAY 2014–VOL. 62, NO. 5
ability and functional performance in PAD. We combined the participants from the three groups because of the smaller numbers and to examine relationships over the broader spectrum of possible changes. If muscle endurance decreased or stayed the same, we wanted to see whether walking would be similarly affected. This strengthened the relationships and gave us a clearer idea of what was happening, adding to the rationale for strength training interventions. Figure 1 showed changes in muscular endurance, with Figure 1B specifically showing change in hip extensor endurance. Because of comorbidities such as chronic lower back pain, stroke, and amputation, only 10 subjects were able to complete the hip extension endurance testing. The relationship is highly significant despite the small number of subjects, highlighting the robustness of the association. The subject who experienced the adverse event was not excluded from the study; he continued the training protocol without the leg press exercise and completed the trial. The leg press exercise was subsequently excluded from the study protocol. The authors felt that the high intensity of the exercise on the leg press may have led to the problem and that the use of the leg press is clinically appropriate for most patients and is not contraindicated in future trials, although it should be avoided for individuals with heel cracks or fissures and poorer circulation, based on our single adverse event. Belinda J. Parmenter, PhD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, Exercise Physiology Unit, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Jacqueline Raymond, PhD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia Paul Dinnen, MD Gold Coast Vascular Centre, Benowa, Queensland Australia Robert J. Lusby, MD Sydney Medical School, University of Sydney, Sydney New South Wales, Australia Maria A. Fiatarone Singh, MD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney New South Wales, Australia Hebrew SeniorLife and Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University Boston, Massachusetts
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
LETTERS TO THE EDITOR
997
Author Contributions: Belinda J. Parmenter is the primary author of this paper. All other authors approved of this paper. Sponsor’s Role: None.
REFERENCES 1. Parmenter BJ, Raymond J, Dinnen P et al. High-intensity progressive resistance training improves flat-ground walking in older adults with symptomatic peripheral arterial disease. J Am Geriatr Soc 2013;61:1964–1970. 2. Hiatt WR, Wolfel EE, Meier RH et al. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Circulation 1994;90:1866–1874. 3. McGuigan MR, Bronks R, Newton RU et al. Resistance training in patients with peripheral arterial disease: Effects on myosin isoforms, fiber type distribution, and capillary supply to skeletal muscle. J Gerontol A Biol Sci Med Sci 2001;56A:B302–B310. 4. McDermott M, Ades P, Guralnik JM et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: A randomized controlled trial. JAMA 2009;301:165–174. 5. Parr B, Noakes T, Derman E. Peripheral arterial disease and intermittent claudication: Efficacy of short-term upper body strength training, dynamic exercise training, and advice to exercise at home. S Afr Med J 2009;99:800–804. 6. Ritti-Dias R, Wolosker N, Forjaz L et al. Strength training increases walking tolerance in intermittent claudication patients: Randomized trial. J Vasc Surg 2010;51:89–95. 7. Singh N, Stavrinos T, Scarbek Y et al. A randomized controlled trial of high vs. low intensity weight training versus general practitioner care for clinical depression in older adults. J Gerontol A Biol Sci Med Sci 2005;60A:768–776. 8. Fiatarone M, Marks E, Ryan N et al. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990;263:3029–3034. 9. Fiatarone M, O’Neill E, Doyle N et al. The Boston FICSIT study: The effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatr Soc 1993;41:333–337. 10. Mavros Y, Rooney K, Kay S et al. Changes in insulin resistance and HbA1c are related to exercise-mediated changes in body composition in older adults with type 2 diabetes: Interim outcomes from the GREAT2DO trial. Diabetes Care 2013;36:2372–2379. 11. Cheema B, Abas H, Smith B et al. Effect of resistance training during hemodialysis on circulating cytokines: A randomized controlled trial. Eur J Appl Physiol 2011;111:1437. 12. Pu C, Johnson M, Forman D et al. Randomized trial of progressive resistance training to counteract the myopathy of chronic heart failure. J Appl Physiol 2001;90:2341–2350. 13. Parmenter BJ, Raymond J, Dinnen PJ et al. Preliminary evidence that low ankle brachial index is associated with reduced bilateral hip extensor strength and functional mobility in peripheral arterial disease. J Vasc Surg 2013;57:963–973.
GUIDELINES FOR OSTEOPOROSIS CARE FOR FRAGILITY FRACTURES To the Editor: Dr. Stephen Liu’s article1 regarding the deficiency in postfragility fracture care for older Medicare recipients was enlightening, but he has overstated the quality-of-care measures from the National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF).2,3 Dr. Liu indicates they measure whether an individual has a bone mineral density test (dual-energy X-ray absorptiometry (DXA)) after a fragility fracture and a prescription to treat osteoporosis within 6 months of the fracture. Both organizations indicate it is an “or” measure and not an “and” measure. Although the distinction may
998
LETTERS TO THE EDITOR
seem minor, to use healthcare resources most efficiently, these individuals could be treated with medication and not have a DXA scan. The scan has not been shown to be necessary for determining the need for therapy or the type of therapy after a fragility fracture. Herbert L. Muncie, Jr., MD Department of Family Medicine, School of Medicine, Louisiana State University, New Orleans, Louisiana
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contribution: HLM is responsible for the entire content of this paper. Sponsor’s Role: None.
REFERENCES 1. Liu SK, Munson JC, Bell J-E et al. Quality of osteoporosis care of older Medicare recipients with fragility fractures: 2006 to 2010. J Am Geriatr Soc 2013;61:1855–1862. 2. National Quality Forum, Osteoporosis management in women who had a fracture. STEWARD: National Committee for Quality Assurance [on-line]. Available at http://www.qualityforum.org/QPS/0053 Accessed October 22, 2012. 3. That State of Health Care Quality, The National Committee for Quality Assurance. Washington, DC: The National Committee for Quality Assurance, 2004 [on-line]. Available at www.ncqa.org/communications/SOMC/ SOHC2004.pdf Accessed December 21, 2012.
RESPONSE LETTER TO HERBERT L. MUNCIE, JR. To the Editor: We thank Dr. Muncie for identifying the need for clarification of the quality measure: “Osteoporosis Management in Women Who Had a Fracture.”1 The National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF) endorse this measure. Although the article stated that the measure assesses “receipt of appropriate bone density testing and pharmacotherapy within 6 months of a fragility fracture for women aged 67 and older,” we agree that this phrasing is not consistent with the official measure wording. An “or” should replace the “and” in the sentence describing the quality measure. The phrase “and” was not meant to suggest that both were recommended but that receipt of bone density testing and pharmacotherapy after a fracture were each assessed in this quality metric. The primary outcome for this study was the receipt of bone density testing or prescription pharmacotherapy within 6 months after fracture,2 which is consistent with the NCQA/NQF quality metric. Therefore this clarification of quality measure wording does not change the care measured, the findings, or the conclusion drawn in this study. We appreciate the importance of providing cost-sensitive care and avoiding unnecessary care, but the study
MAY 2014–VOL. 62, NO. 5
JAGS
shows that an overwhelming majority of participants received neither a bone density test nor a prescription for pharmacotherapy after a fracture. Stephen K. Liu, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Department of Community and Family Medicine, Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Jeffrey C. Munson, MD, MSCE Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Veterans Affairs Medical Center, White River Junction, VT John-Erik Bell, MD, MS Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Orthopedics, Geisel School of Medicine, Dartmouth College, Hanover, NH Rebecca L. Zaha, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH John N. Mecchella, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Anna N. A. Tosteson, ScD Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Department of Community and Family Medicine, Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Nancy E. Morden, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH
MAY 2014–VOL. 62, NO. 5
ability and functional performance in PAD. We combined the participants from the three groups because of the smaller numbers and to examine relationships over the broader spectrum of possible changes. If muscle endurance decreased or stayed the same, we wanted to see whether walking would be similarly affected. This strengthened the relationships and gave us a clearer idea of what was happening, adding to the rationale for strength training interventions. Figure 1 showed changes in muscular endurance, with Figure 1B specifically showing change in hip extensor endurance. Because of comorbidities such as chronic lower back pain, stroke, and amputation, only 10 subjects were able to complete the hip extension endurance testing. The relationship is highly significant despite the small number of subjects, highlighting the robustness of the association. The subject who experienced the adverse event was not excluded from the study; he continued the training protocol without the leg press exercise and completed the trial. The leg press exercise was subsequently excluded from the study protocol. The authors felt that the high intensity of the exercise on the leg press may have led to the problem and that the use of the leg press is clinically appropriate for most patients and is not contraindicated in future trials, although it should be avoided for individuals with heel cracks or fissures and poorer circulation, based on our single adverse event. Belinda J. Parmenter, PhD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, Exercise Physiology Unit, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Jacqueline Raymond, PhD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia Paul Dinnen, MD Gold Coast Vascular Centre, Benowa, Queensland Australia Robert J. Lusby, MD Sydney Medical School, University of Sydney, Sydney New South Wales, Australia Maria A. Fiatarone Singh, MD Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney New South Wales, Australia Hebrew SeniorLife and Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University Boston, Massachusetts
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
LETTERS TO THE EDITOR
997
Author Contributions: Belinda J. Parmenter is the primary author of this paper. All other authors approved of this paper. Sponsor’s Role: None.
REFERENCES 1. Parmenter BJ, Raymond J, Dinnen P et al. High-intensity progressive resistance training improves flat-ground walking in older adults with symptomatic peripheral arterial disease. J Am Geriatr Soc 2013;61:1964–1970. 2. Hiatt WR, Wolfel EE, Meier RH et al. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Circulation 1994;90:1866–1874. 3. McGuigan MR, Bronks R, Newton RU et al. Resistance training in patients with peripheral arterial disease: Effects on myosin isoforms, fiber type distribution, and capillary supply to skeletal muscle. J Gerontol A Biol Sci Med Sci 2001;56A:B302–B310. 4. McDermott M, Ades P, Guralnik JM et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: A randomized controlled trial. JAMA 2009;301:165–174. 5. Parr B, Noakes T, Derman E. Peripheral arterial disease and intermittent claudication: Efficacy of short-term upper body strength training, dynamic exercise training, and advice to exercise at home. S Afr Med J 2009;99:800–804. 6. Ritti-Dias R, Wolosker N, Forjaz L et al. Strength training increases walking tolerance in intermittent claudication patients: Randomized trial. J Vasc Surg 2010;51:89–95. 7. Singh N, Stavrinos T, Scarbek Y et al. A randomized controlled trial of high vs. low intensity weight training versus general practitioner care for clinical depression in older adults. J Gerontol A Biol Sci Med Sci 2005;60A:768–776. 8. Fiatarone M, Marks E, Ryan N et al. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990;263:3029–3034. 9. Fiatarone M, O’Neill E, Doyle N et al. The Boston FICSIT study: The effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatr Soc 1993;41:333–337. 10. Mavros Y, Rooney K, Kay S et al. Changes in insulin resistance and HbA1c are related to exercise-mediated changes in body composition in older adults with type 2 diabetes: Interim outcomes from the GREAT2DO trial. Diabetes Care 2013;36:2372–2379. 11. Cheema B, Abas H, Smith B et al. Effect of resistance training during hemodialysis on circulating cytokines: A randomized controlled trial. Eur J Appl Physiol 2011;111:1437. 12. Pu C, Johnson M, Forman D et al. Randomized trial of progressive resistance training to counteract the myopathy of chronic heart failure. J Appl Physiol 2001;90:2341–2350. 13. Parmenter BJ, Raymond J, Dinnen PJ et al. Preliminary evidence that low ankle brachial index is associated with reduced bilateral hip extensor strength and functional mobility in peripheral arterial disease. J Vasc Surg 2013;57:963–973.
GUIDELINES FOR OSTEOPOROSIS CARE FOR FRAGILITY FRACTURES To the Editor: Dr. Stephen Liu’s article1 regarding the deficiency in postfragility fracture care for older Medicare recipients was enlightening, but he has overstated the quality-of-care measures from the National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF).2,3 Dr. Liu indicates they measure whether an individual has a bone mineral density test (dual-energy X-ray absorptiometry (DXA)) after a fragility fracture and a prescription to treat osteoporosis within 6 months of the fracture. Both organizations indicate it is an “or” measure and not an “and” measure. Although the distinction may
998
LETTERS TO THE EDITOR
seem minor, to use healthcare resources most efficiently, these individuals could be treated with medication and not have a DXA scan. The scan has not been shown to be necessary for determining the need for therapy or the type of therapy after a fragility fracture. Herbert L. Muncie, Jr., MD Department of Family Medicine, School of Medicine, Louisiana State University, New Orleans, Louisiana
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contribution: HLM is responsible for the entire content of this paper. Sponsor’s Role: None.
REFERENCES 1. Liu SK, Munson JC, Bell J-E et al. Quality of osteoporosis care of older Medicare recipients with fragility fractures: 2006 to 2010. J Am Geriatr Soc 2013;61:1855–1862. 2. National Quality Forum, Osteoporosis management in women who had a fracture. STEWARD: National Committee for Quality Assurance [on-line]. Available at http://www.qualityforum.org/QPS/0053 Accessed October 22, 2012. 3. That State of Health Care Quality, The National Committee for Quality Assurance. Washington, DC: The National Committee for Quality Assurance, 2004 [on-line]. Available at www.ncqa.org/communications/SOMC/ SOHC2004.pdf Accessed December 21, 2012.
RESPONSE LETTER TO HERBERT L. MUNCIE, JR. To the Editor: We thank Dr. Muncie for identifying the need for clarification of the quality measure: “Osteoporosis Management in Women Who Had a Fracture.”1 The National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF) endorse this measure. Although the article stated that the measure assesses “receipt of appropriate bone density testing and pharmacotherapy within 6 months of a fragility fracture for women aged 67 and older,” we agree that this phrasing is not consistent with the official measure wording. An “or” should replace the “and” in the sentence describing the quality measure. The phrase “and” was not meant to suggest that both were recommended but that receipt of bone density testing and pharmacotherapy after a fracture were each assessed in this quality metric. The primary outcome for this study was the receipt of bone density testing or prescription pharmacotherapy within 6 months after fracture,2 which is consistent with the NCQA/NQF quality metric. Therefore this clarification of quality measure wording does not change the care measured, the findings, or the conclusion drawn in this study. We appreciate the importance of providing cost-sensitive care and avoiding unnecessary care, but the study
MAY 2014–VOL. 62, NO. 5
JAGS
shows that an overwhelming majority of participants received neither a bone density test nor a prescription for pharmacotherapy after a fracture. Stephen K. Liu, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Department of Community and Family Medicine, Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Jeffrey C. Munson, MD, MSCE Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Veterans Affairs Medical Center, White River Junction, VT John-Erik Bell, MD, MS Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Orthopedics, Geisel School of Medicine, Dartmouth College, Hanover, NH Rebecca L. Zaha, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH John N. Mecchella, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Anna N. A. Tosteson, ScD Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Department of Community and Family Medicine, Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Nancy E. Morden, MD, MPH Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Lebanon, NH Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH
