S M Ott

University of Washington Seattle, Seattle, WA, United States

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Publications (99)653.43 Total impact

  • Susan M Ott
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    ABSTRACT: Patients with chronic kidney disease (CKD) have a high risk of bone fracture owing to their low bone mineral density, which resembles that of postmenopausal osteoporosis. However, the mineral and bone disorder associated with CKD (CKD-MBD) is more complex than osteoporosis and the same treatments might not be appropriate. In particular, vascular calcifications are strongly associated with CKD-MBD, and must be taken into consideration. Post hoc analyses of data from pivotal osteoporosis studies suggest that in patients with mild stage 3 CKD and normal parathyroid hormone (PTH), calcium and phosphate measurements, conventional medications for osteoporosis (such as raloxifene, bisphosphonates, teriparatide and denosumab) are effective at reducing fracture rates. However, for patients with stage 4-5 CKD, or those with abnormal PTH and mineral values, the available data are insufficient to determine whether these commonly used medications are effective against fractures. Moreover, all medications used to treat osteoporosis have known or potential adverse effects in patients with CKD. Medicines that increase bone formation by upregulating Wnt signalling have shown promise in patients with osteoporosis and might be used to treat CKD-MBD in the future, but off-target effects could limit their use in in this setting.
    Nature Reviews Nephrology 10/2013; · 7.94 Impact Factor
  • Susan M Ott
    JAAPA: official journal of the American Academy of Physician Assistants 08/2013; 26(8):64-5.
  • Susan M Ott
    Cleveland Clinic Journal of Medicine 04/2013; 80(4):240-1. · 3.40 Impact Factor
  • Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 11/2012; · 6.04 Impact Factor
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    ABSTRACT: OBJECTIVE: To evaluate the accuracy of using ICD-9 codes to identify nonunions (NU) and malunions (MU) among adults with a prior fracture code and to explore case-finding algorithms. STUDY DESIGN: Medical chart review of potential NU (N=300) and MU (N=288) cases. True NU cases had evidence of NU and no evidence of MU in the chart (and vice versa for MUs) or were confirmed by the study clinician. Positive predictive values (PPV) were calculated for ICD-9 codes. Case-finding algorithms were developed by a classification and regression tree analysis using additional automated data, and these algorithms were compared to true case status. SETTING: Group Health Cooperative. RESULTS: Compared to true cases as determined from chart review, the PPV of ICD-9 codes for NU and MU were 89% (95% CI, 85-92%) and 47% (95% CI, 41-53%), respectively. A higher proportion of true cases (NU: 95%; 95% CI, 90-98%; MU: 56%; 95% CI, 47-66%) were found among subjects with 1+ additional codes occurring in the 12months following the initial code. There was no case-finding algorithm for NU developed given the high PPV of ICD-9 codes. For MU, the best case-finding algorithm classified people as an MU case if they had a fracture in the forearm, hand, or skull and had no visit with an NU diagnosis code in the 12-months post MU diagnosis. PPV for this MU case-finding algorithm increased to 84%. CONCLUSIONS: Identifying NUs with its ICD-9 code is reasonable. Identifying MUs with automated data can be improved by using a case-finding algorithm that uses additional information. Further validation of the MU algorithms in different populations is needed, as well as exploration of its performance in a larger sample.
    Bone 11/2012; · 3.82 Impact Factor
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    ABSTRACT: Bisphosphonates are a class of drugs commonly prescribed to treat osteoporosis. They act by decreasing the resorption of bone. Since tooth movement depends on bone remodeling, these drugs can impact orthodontic treatment. The purpose of this study was to evaluate the extent to which bisphosphonate therapy is a risk factor for poor orthodontic outcomes. Orthodontists were invited to participate in the study by performing case reviews of women over age 50 who were treated from 2002 through 2008. Women who used bisphosphonates were compared with women who did not have a history of bisphosphonate use. Outcomes assessed included treatment time, osteonecrosis of the jaws, incisor alignment, incomplete space closure, and root parallelism. The records for 20 subjects with bisphosphonate exposure were collected, as well as records for 93 subjects without bisphosphonate exposure. In patients undergoing extractions, treatment times were significantly longer if they had a history of bisphosphonate use. No occurrences of osteonecrosis of the jaws were reported, nor did patients end treatment with incisor alignment discrepancies greater than 1 mm, regardless of bisphosphonate exposure. Among patients with extractions or initial spacing, there were higher odds of incomplete space closure (odds ratio, 13) and poor root parallelism (odds ratio, 26) at the end of treatment for patients using bisphosphonates. Bisphosphonate use is associated with longer treatment times among extraction patients, increased odds of poor space closure, and increased odds of poor root parallelism.
    American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 11/2012; 142(5):625-634.e3. · 1.33 Impact Factor
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    Susan M Ott
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    ABSTRACT: A new population-based study of elderly patients hospitalized for a fracture and treated with an oral bisphosphonate finds no increased risk of acute kidney injury. The safety and efficacy of bisphosphonates may be different in patients with chronic kidney disease (CKD). The effects on vascular calcifications need further study, because low bone turnover might exacerbate vascular calcifications in patients with CKD. Even if bisphosphonates prove safe, their efficacy in this population is uncertain.
    Kidney International 10/2012; 82(8):833-5. · 7.92 Impact Factor
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    ABSTRACT: Background/Aims In an era of increasing openness in health plans, use of electronic medical records (EMR) for detailed chart abstraction for all enrollees poses challenges. At Group Health Cooperative (GH), EMR data are most complete for enrollees in the Group Practice Division (GPD). However, all GH enrollees (from both the GPD and the Contracted Network Division (CND) have EMRs. CND providers do not have access to patients' GH EMR. Information for CND enrollees is only entered when the patient or provider interacts with the GPD, such as a patient receiving GPD specialty care while receiving CND primary care. In the interest of achieving a larger sample size for an ongoing GH-based case-control study (FOCUS), we evaluated the feasibility of including CND enrollees by determining the proportion with sufficient EMR information for fracture adjudication. Methods The FOCUS study is adjudicating and recruiting incident osteoporotic fracture cases in women across the menopausal transition using the GPD. We used identical automated sampling methods to identify, via ICD-9 codes, a pool of potential adjudicable fracture cases among CND enrollees. Results For the GPD, from a denominator of 58,328 age-eligible women, 2,310 (4%) were identified with fractures January 2008-March 2011. For the CND, among 38,041 age-eligible women, 1,040 (3%) were identified with fractures. Following automated exclusions, 944 CND potential cases remained. Initial review of these 944 EMRs found that 685 charts had no data; 54 had data unrelated to fracture; 145 had sufficient fracture-related data to adjudicate; and 60 had some fracture-related data. Preliminary chart adjudication of these last two groups found that 88% (127/145) of the "complete" EMR group and 10% (6/60) of the "partially complete" group had qualifying fractures. Discussion About 23% of GH network enrollees with automated fracture codes had evaluable EMR data. Preliminary adjudication has identified 65% (133/205) as additional potential FOCUS cases to contact for interviews. It appears that, even for a study requiring sufficient chart information to adjudicate a health outcome, the CND can contribute cases for study inclusion. We also have developed network control selection methods. Still to be ascertained at the survey step are continued eligibility and study participation.
    Clinical Medicine &amp Research 08/2012; 10(3):165.
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    ABSTRACT: Background/Aims Hormonal contraception is a popular contraceptive choice among sexually-active women. Yet, its association with body composition in younger women is not well understood. We compared body composition measures by duration of Depo-Provera (DMPA) use and dose and duration of oral contraceptive (OC) use in adolescent and young adult women. Methods Study participants were Group Health Cooperative members. DMPA use (new, prevalent, or none) was collected in 170 adolescents aged 14-18 years, and in 440 women aged 18-39 years. OC use was gathered in 301 adolescents aged 14-18 years, and 305 women aged 19-30 years. Among OC users, ethinyl estradiol (EE) dose (=30mcg vs. <30mcg) and months of use were also collected. For all participants, weight, BMI, and truncal and total fat and lean mass were estimated using DEXA. Mean differences in baseline body composition by dose and duration of hormone contraception use were compared cross-sectionally using ANOVA. Results Adolescents who were prevalent DMPA users had higher baseline truncal and total fat mass compared to adolescent non-DMPA users. For example, baseline mean (SE) total fat mass was 23.3 (1.2) kilograms for prevalent DMPA users, but was 19.9 (0.9) kilograms for non-DMPA users (p<0.05). No mean differences in the body composition measures were observed between new DMPA vs. non- DMPA adolescent users or among young women, regardless of DMPA use. With OC use, baseline BMI and truncal and total fat mass differed by EE dose in young adult women. Baseline mean (SE) total fat mass, in kilograms, for women using =30mcg EE doses, <30mcg EE doses, and for non-OC users was 20.8 (0.9), 19.0 (0.9), and 22.2 (0.9), respectively (p=0.02). No differences were noted between EE dose and body composition indices in adolescents. For both adolescents and young women, baseline body composition was not associated with duration of OC use. Conclusions Our results suggest that DMPA use is associated with fat mass in adolescents and that EE dose in OCs is associated with fat mass in young adult women. Analysis of follow-up data to determine if these relationships continue to be seen longitudinally is needed.
    Clinical Medicine &amp Research 08/2012; 10(3):186.
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    ABSTRACT: Background/Aims Self-reported use of oral contraceptives (OCs) may be subject to recall bias. Previous reports comparing self-report OC use and computerized pharmacy data have focused on current use or longer-term use in younger women and have found (adjusted) kappa statistics of 79-85%. The objective of the current analysis was to evaluate the reliability of self-reported OC use obtained from a sample of peri- and early post-menopausal women. Methods Participants were 45-59 year-old women eligible for an ongoing population-based case-control study assessing the association between OC use and incident fractures around the menopausal transition. Cases were all women enrolled in Group Health with an ICD9 osteoporotic fracture code in 2008-2009; age-matched non-fracture controls were randomly selected. Eligible cases and controls (n=535) who reported at interview that they always/usually filled prescriptions at GH pharmacies and agreed to record review were included. Respondents who reported ever using OCs before the reference date (fracture date for cases; randomly assigned dates based on distribution of case dates for controls) were asked, for each episode of use, their age and length of use. A life events- calendar tool was available to interviewers. Computerized pharmacy information was obtained on OC fills back to 1977. OC use was based on GH pharmacy and First Data Bank OC class, key ingredients [e.g. ethinyl estradiol, levonorgestrel], and name. OC use was evaluated using >1 fill or >2 fills within a 1-year period. Ever use, use since ages 35, 38, and 40, and 5 years before reference date were examined. Women were required to be enrolled for the designated time period except for the ever-use category. We calculated kappa (K), the chance-corrected measure of agreement, and the prevalence-adjusted bias-adjusted kappa (PABAK). Results The agreement between self-reported OC use and OC fills was highest for more recent use (PABAK=92% for OC use within 5 years of reference date and 55% for use at ages >38). Conclusion In women around the menopausal transition, agreement between self-reported OC use and computerized OC prescription fills was moderate for use after age 38 and excellent for OC use within 5 years of the reference date.
    Clinical Medicine &amp Research 08/2012; 10(3):186-7.
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    ABSTRACT: Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. "Atypical" non-traumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from 1/1/2007 until 12/31/2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T-score -2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age-adjusted incidence rates for an atypical fracture were 1.78/100,000/yr (95% confidence interval 1.5,2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/yr (69.3, 156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond five years. © 2012 American Society for Bone and Mineral Research.
    Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 07/2012; · 6.04 Impact Factor
  • Susan M Ott
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    ABSTRACT: What are the benefits and harms of vitamin D supplementation, with or without calcium, in adults? REVIEW SCOPE: Included studies compared oral vitamin D, with or without calcium, with placebo or no supplementation in healthy adults (< 20% had major chronic disease) or in ambulatory adults ≥ 65 years of age who did not have cancer (but may have had other diseases). Studies that included pregnant women only, measured vitamin D status only during pregnancy, compared vitamin D dosages without a control group that did not receive vitamin D, used synthetic vitamin D analogues, or had follow-up < 1 month were excluded. Outcomes were cancer, fracture, and adverse events. MEDLINE and Cochrane Central Register of Controlled Trials (to Jul 2011) were searched for English-language, randomized, controlled trials (RCTs). Eligible articles from a broader search done in 2009 were also included. 63 RCTs met the selection criteria. 18 of these RCTs (n = 104,959, mean age 53 to 85 y, 24% to 100% women) reported cancer and fracture outcomes; vitamin D doses ranged from 300 IU/d to 1100 IU/d. Of the 18 RCTs, 4 were of good quality, 9 were of fair quality, and 5 were of poor quality. Mean follow-up ranged from 7 months to 7 years. Meta-analyses were not done for the 3 trials (n = 40,147) that provided data for cancer outcomes. Of 4 comparisons, 1 (n = 734) found a reduction in cancer with vitamin D plus calcium compared with placebo; the results of the other 3 comparisons were not statistically significant. The findings for fracture are in the Table. 1 RCT found an increase in renal and urinary tract stones with vitamin D plus calcium (hazard ratio 1.2, 95% CI 1.0 to 1.3 for both outcomes), but there were too few data to assess other adverse events. Oral vitamin D with--but not without--calcium reduces fracture risk in adults. Limited data are available to evaluate the effect of vitamin D on cancer or adverse events.
    Annals of internal medicine 06/2012; 156(12):JC6-7. · 13.98 Impact Factor
  • Susan M Ott
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    ABSTRACT: Fractures are a common problem in chronic kidney disease (CKD). The 2009 KDIGO (Kidney Disease: Improving Global Outcomes) review of the bone and mineral disorders highlighted areas of uncertainty and stressed the importance of further research. This review includes studies published since that report with a focus on the bone. Bone biopsies have shown a shift toward more adynamic bone, which may be associated with vascular calcifications. There are important racial differences in skeletal metabolism. Bone density may be helpful in identifying patients who have fractures, but neuromuscular tests perform better than radiographic ones. Even if bone density can predict fractures, it is still not clear what can be done in patients who have advanced stages of CKD. New data show interrelationships of fibroblast growth factor 23 (FGF23) secretion, parathyroid hormone, and wnt-signaling pathways. High FGF23 could have a negative impact on the bone. These advances suggest that caution must be used prior to treatment with medications that inhibit bone turnover. Racial differences in response to vitamin D therapy need more careful delineation. Medications which inhibit wnt-signaling offer hope but development of new therapies to treat the bone disease will rely on further understanding of bone and vascular physiology.
    Current opinion in nephrology and hypertension 04/2012; 21(4):376-81. · 3.96 Impact Factor
  • Kidney International 09/2011; 80(5):554. · 7.92 Impact Factor
  • Susan M Ott
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    ABSTRACT: It is reasonable to stop bisphosphonates after 5 years of use and then to follow patients with markers of bone turnover. As long as the levels of these markers remain reduced, adding an antiresorptive drug does not make physiologic sense.
    Cleveland Clinic Journal of Medicine 09/2011; 78(9):619-30. · 3.40 Impact Factor
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    ABSTRACT: Oral contraceptive (OC) use is common, but bone changes associated with use of contemporary OC remain unclear. The objective of the study was to compare bone mineral density (BMD) change in adolescent and young adult OC users and discontinuers of two estrogen doses, relative to nonusers. This was a prospective cohort study, Group Health Cooperative. Participants included 606 women aged 14-30 yr (50% adolescents aged 14-18 yr): 389 OC users [62% 30-35 μg ethinyl estradiol (EE)] and 217 age-similar nonusers; there were 172 OC discontinuers. The 24-month retention was 78%. The main outcome measure was BMD measured at 6-month intervals for 24-36 months. After 24 months, adolescents using 30-35 μg EE OCs, but not those using lower-dose OCs, had significantly smaller adjusted mean percentage BMD gains than nonusers at the spine [group means (95% confidence interval for between group differences) 1.32 vs. 2.26% (-1.89, -0.13%)] and whole body [1.45 vs. 2.03% (-1.29%, -0.13%)]. Adolescents who discontinued 30-35 μg EE OC showed significantly smaller gains than nonusers at the spine after 12 months [0.51 vs. 1.72% (-2.38%, -0.30%)]. Young adult OC users did not differ from nonusers. However, OC discontinuers of both doses differed significantly from nonusers at the spine 12 months after discontinuation [-1.32% < 30 μg EE, -0.92% 30-35 μg EE vs. +0.27% nonusers (-2.48, -0.54, and -1.94%, -0.55%, respectively)]. Results were similar for mean absolute BMD change (grams per square centimeter). Both OC use and discontinuation were associated with BMD losses/smaller gains relative to nonusers (differences < 2% after 12-24 months for all skeletal sites). The clinical significance of these results regarding future fracture risk is unknown. Study of longer-term trends after discontinuation is needed.
    The Journal of clinical endocrinology and metabolism 07/2011; 96(9):E1380-7. · 6.50 Impact Factor
  • Kidney International 12/2010; 78(11):1186. · 7.92 Impact Factor
  • L Spangler, S M Ott, D Scholes
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    ABSTRACT: In women age 45 years and older, enrolled in an integrated group practice in 2007, use of ICD9 diagnostic codes, including the "not otherwise specified" code (821.00) resulted in a high false-positive rate for identifying femoral diaphyseal fractures. Restriction to more specific site-codes missed 36% of these rare fractures. The aim of this study was to assess the utility of automated data in identifying the occurrence of femoral diaphyseal fractures. We identified all women age 45 years and older enrolled in a Pacific Northwest integrated group practice during 2007. Using the computerized database we selected all ICD9 codes that could be related to a femur fracture occurring in the diaphyseal region. We then quantified the percent of codes confirmed by medical record review to have occurred in the correct anatomic location during the year of interest (positive predictive value). Of the 95,765 eligible women, 161 (0.17%) had an ICD9 diagnostic code potentially related to a femoral diaphyseal fracture in 2007; of these 58 (36%) had a fracture of the femoral diaphysis, and 38 (24%) of the fractures occurred in 2007. The most frequent code was 821.00, described as "femur fracture not otherwise specified", applied to 107 women; 21 of the 58 diaphyseal fractures had this code. In this study, use of ICD9 codes that included the "not otherwise specified" code (821.00) resulted in a high false-positive rate for identifying diaphyseal fractures. However, restriction to more specific site codes would have missed at least 36% of the diaphyseal fractures. Furthermore, the codes did not provide any information about the characteristics of the fracture. Our findings support validating cases selected using ICD codes before they are used as a surrogate for the occurrence of femoral diaphyseal fractures.
    Osteoporosis International 12/2010; 22(9):2523-7. · 4.04 Impact Factor
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    ABSTRACT: The range of protein intakes for optimizing bone health among premenopausal women is unclear. Protein is a major constituent of bone, but acidic amino acids may promote bone resorption. The objective was to examine cross-sectional and longitudinal associations between baseline dietary protein and bone mineral density (BMD) among 560 females aged 14-40 y at baseline enrolled in a Pacific Northwest managed-care organization. The role of protein source (animal or vegetable) and participant characteristics were considered. Dietary protein intake was assessed by using a semiquantitative food-frequency questionnaire in participants enrolled in a study investigating associations between hormonal contraceptive use and bone health. Annual changes in hip, spine, and whole-body BMD were measured by using dual-energy X-ray absorptiometry. Cross-sectional and longitudinal associations between baseline protein intake (% of energy) and BMD were examined by using linear regression analysis and generalized estimating equations adjusted for confounders. The mean (+/-SD) protein intake at baseline was 15.5 +/- 3.2%. After multivariable adjustment, the mean BMD was similar across each tertile of protein intake. In cross-sectional analyses, low vegetable protein intake was associated with a lower BMD (P = 0.03 for hip, P = 0.10 for spine, and P = 0.04 for whole body). For every percentage increase in the percentage of energy from protein, no significant longitudinal changes in BMD were observed at any anatomic site over the follow-up period. Data from this longitudinal study suggest that a higher protein intake does not have an adverse effect on bone in premenopausal women. Cross-sectional analyses suggest that low vegetable protein intake is associated with lower BMD.
    American Journal of Clinical Nutrition 03/2010; 91(5):1311-6. · 6.50 Impact Factor
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    ABSTRACT: Most of the millions of oral contraceptive (OC) users are under 30 years of age and in the critical period for bone mass accrual. This cross-sectional study of 606 women aged 14-30 years examined both OC duration and estrogen dose and their association with bone mineral density (BMD) at the hip, spine, and whole body (dual-energy X-ray absorptiometry). Of 389 OC users and 217 nonusers enrolled, 50% were adolescents (14-18 years). Of OC users, 38% used "low-dose" OCs [<30 mcg ethinyl estradiol (EE)]. In adolescents, mean BMD differed by neither OC duration nor EE dose. However, 19- to 30-year-old women's mean BMD was lower with longer OC use for spine and whole body (p=.004 and p=.02, respectively) and lowest for >12 months of low-dose OCs for the hip, spine and whole body (p=.02, .003 and .002, respectively). Prolonged use of today's OCs, particularly <30 mcg EE, may adversely impact young adult women's bone density while using these agents.
    Contraception 01/2010; 81(1):35-40. · 3.09 Impact Factor

Publication Stats

7k Citations
2k Downloads
653.43 Total Impact Points

Institutions

  • 1986–2013
    • University of Washington Seattle
      • • Department of Medicine
      • • Department of Biostatistics
      Seattle, WA, United States
  • 2012
    • Kaiser Permanente
      Oakland, California, United States
  • 1999–2012
    • Group Health Cooperative
      • Group Health Research Institute
      Seattle, Washington, United States
  • 2000
    • Stanford University
      • Department of Pediatrics
      Stanford, CA, United States