How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Fracture liaison service-a multidisciplinary approach to osteoporosis management

A fracture liaison service is a systems-level multidisciplinary approach designed to reduce subsequent fracture risk in patients who recently sustained fragility fractures. It is estimated that one in three women and one in five men over the age of 50 years old have osteoporosis. Nonetheless, only 9 to 20% of patients who sustain an initial fragility fracture eventually receive any osteoporosis treatment. With the aim of preventing subsequent fractures, a fracture liaison service (FLS) works through identifying patients presenting with fragility fractures to the hospital and providing them with easier access to osteoporosis care through referrals for bone health and fracture risk assessment and recommendation or initiation of osteoporosis treatment. Currently, there are four major types of FLS models ranging from services that only identify at-risk patients and inform and educate the patient but take no further part in communicating their findings to other stakeholders in patients' care, to services that identify, investigate, and initiate treatment at the other end of the spectrum. In this article, we review the benefits, challenges, and outcomes of FLS in the American healthcare system with further exploration of the roles each member of the multidisciplinary team can play in improving patients' bone health.

Bone health education in individuals with spinal cord injury or disease-the Bare Bones Podcast Series: plan it, produce it, post it!

Introduction

The Consortium for Spinal Cord Medicine's inaugural Clinical Practice Guideline for Bone Health and Osteoporosis Management for Individuals with Spinal Cord Injury or Disease (CSCM-CPG) was published in 2022 for a clinician audience. The aim of this project was to develop a podcast series to ensure people with lived experience with Spinal Cord Injury or Disease (PLEX) understand the CSCM-CPG content and know how to act to reduce their fracture risk.

Methods

The "Bare Bones Podcast Series" consists of nine episodes; one related to each CSCM-CPG chapter. The podcast content and the questions asked in each podcast were co-developed by PLEX partners (PLEX-P) and the project team. Two PLEX-P acted as co-hosts for the series. The invited speaker(s) were CSCM-CPG expert panel members who participated in an informal dialogue with the hosts. Each podcast closes with a specific action a listener can do to advance their bone health. The related Educational Action Planning Tool (EAT) handouts contain text and infographic information specific to each podcast episode and include key concepts and a specific actionable take-home message. Local PLEX reviewers (PLEX-R) were invited to review podcast episodes and EATs and provide their feedback through focus group participation or one-on-one (1:1) interviews. The project team revised the podcast episodes and the EATs based on feedback from the PLEX-R prior to releasing them online.

Results

Nine podcast episodes and related EATs were designed and created collaboratively with 3 PLEX-P, 22 PLEX-R, 11 CSCM-CPG expert panel members, and the project team. The episodes were titled: "Introduction to the Bare Bones of Bone Health"; "Fracture 101"; "Blood Tests-a Window into You"; "I See Your Skeleton"; "Vitamin D for all, Calcium for Some"; "Get Moving and Loading"; "Pills or Poisons & Atomic Habits"; "Snap and Crack"; and "Directions for Research". The Bare Bones Podcast Series was shared through the project website.

Conclusions

The podcasts will aid PLEX and their family caregivers to advocate for ongoing bone health assessments and to promote an ongoing dialogue with care team members regarding how to prevent fractures and fracture-related morbidity and mortality.

Healthcare professionals' perspectives and experiences of osteoporosis medication treatment: a qualitative systematic review

This systematic review aimed to explore healthcare professionals' (HCPs) experiences and perspectives of osteoporosis medication treatment through thematic synthesis of qualitative studies. We found themes about how osteoporosis is perceived as a disease, treatment decision-making and what empowers HCPs to provide the best possible care.

PURPOSE

The systematic review aimed to describe the perspectives and experiences of HCPs regarding osteoporosis medication treatment.

METHODS

We performed searches in four electronic databases (Medline, Embase, PsycINFO and CINAHL) from database inception until May 2023 in any language. Data was analysed through inductive thematic synthesis.

RESULTS

We included 27 primary studies that incorporated the views of 495 different HCPs. The following themes were identified: low-priority disease, challenges in treatment decision-making, minimising drug burden, conscious of communication barriers, fragmented care and advice, confidence through experience and collaboration.

CONCLUSIONS

HCPs were enthusiastic about optimising osteoporosis care through interprofessional collaboration and expertise, as well as educating and monitoring patients on treatment. They advocated for safety, comfort and reducing overall drug burden, especially in older patients with comorbidities. However, they had differences in opinions regarding who has responsibility for diagnosing and treating osteoporosis and struggled to provide the best possible care due to competing priorities, limited time and lack of adequate knowledge or evidence. The findings highlight the important and complementary role of different HCPs in osteoporosis treatment through a multidisciplinary model of care.

Hounsfield units on abdominal computed tomography: a new tool for predicting osteoporosis

BACKGROUND

Osteoporosis can cause bone fractures and disability, but early diagnosis faces challenges. Our proposed diagnostic indicators offer a new approach for early detection, which benefits early identification.

PURPOSE

To determine the most appropriate threshold for predicting osteoporosis in patients with each section of vertebral body.

MATERIAL AND METHODS

A retrospective analysis of 210 patients, including 646 vertebrae, who had both abdominal computed tomography (CT) and dual-energy X-ray absorptiometry (DXA) within six months. The correlation between DXA T-score and CT Hounsfield units (HU) values was tested by Pearson. The area under the curve (AUC) was calculated using the threshold obtained from the regression equation.

RESULTS

The thresholds matching the T-score of -2.5 were 85, 95, 85, and 90 HU for the upper axial plane of the vertebral body (Lau), the middle axial plane of the vertebral body (Lam), the lower axial plane of the vertebral body (Lad), and the mid-sagittal plane of the vertebral body (Lsm), respectively. Defining osteoporosis using CT as Lau ≤ 85, Lam ≤ 95, Lad ≤ 85, or Lsm ≤ 90 HU had a specificity of 88.1% (116/134) and sensitivity of 90.8% (69/76) for distinguishing DXA osteoporosis of the lumbar spine in 210 patients. T-score ≤-2.5 defined as Lau ≤85 or Lam ≤95 or Lad ≤85 or Lsm ≤90 HU had a specificity of 85.9% (275/320) and sensitivity of 82.8% (270/326) for DXA T-score ≤-2.5 in 646 lumbar vertebrae.

CONCLUSION

CT HU values obtained based on different sections of the vertebral body in abdominal CT can be used as a supplementary measure to assess osteoporosis.

Future Fracture Risk in Upper Extremity Fracture and Non-Fracture Patients

BACKGROUND

Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture.

METHODS

In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture.

RESULTS

The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group.

CONCLUSIONS

This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

Bone mineral density of the ultra-distal radius: are we ignoring valuable information?

The current study explored the possible utilization in dual-X-ray-absorptiometry scanning (DXA) of the ultra-distal radius (UDR). This region of interest is currently unused and mostly unstudied in this context. The study findings suggest UDR as potential useful region of interest in DXA scanning and warrant further study of the site.

PURPOSE

Bone mineral density (BMD) measurement of a non-dominant arm is not routinely performed during dual-X-ray-absorptiometry (DXA) test, and the possible utility of ultra-distal (UDR) radius BMD is not well-studied. We evaluated in women, correlations of UDR BMD with fracture prevalence, fracture risk prediction by the fracture risk assessment tool (FRAX), and osteoporosis diagnosed by traditional sites.

METHODS

Women who underwent a routine DXA (including their non-dominant forearm and including UDR BMD) in a tertiary medical center were included. Risk factors relevant to FRAX calculation were assessed via a self-administered questionnaire. Spearman correlations of UDR BMD to 10-year risks of major osteoporotic and hip fractures (assessed by FRAX) were explored. The possible added value of UDR BMD in explaining prevalent osteoporotic fractures was assessed using a multivariable regression model incorporating age and traditional osteoporosis diagnosis.

RESULTS

The study included 1245 women with a median age of 66 years (interquartile range: 59-73), of whom 298 (24%) had UDR T-score ≤  - 2.5 and 154 (12%) reported prior fractures. UDR BMD was significantly negatively correlated with FRAX risk score for hip and major osteoporotic fractures (R =  - 0.5 and R =  - 0.41, respectively; P < 0.001). UDR T-score ≤  - 2.5 was associated with higher fracture prevalence (19% vs 10%; P < 0.001) and remained significant after adjusting for traditional BMD and age (OR 1.49, 1.01-2.19; P = 0.043).

CONCLUSION

UDR BMD correlates both with prior fractures and with predicted fracture risks and might pose added value over traditional DXA sites.

Understanding Physicians' Perceptions of Patient-Identified Barriers to Osteoporosis Medication Initiation: A Cognitive Mapping Approach

Objective

Interventions to initiate medication and increase adherence for postmenopausal women who have had a fragility fracture were not always successful. The purpose of this study was to derive an empirical framework for patient-identified barriers to osteoporosis medication initiation and adherence from physician experts.

Methods

A cognitive mapping approach involving nominal group technique (NGT) meetings and a card sorting and rating task were used to obtain formative data. We first conducted four NGT meetings with 18 women patients who were not on osteoporosis treatment to identify barriers to osteoporosis medication, then invited 27 osteoporosis physicians to sort and rate 25 patients identified barriers. Descriptive analysis, multidimensional scaling analysis, and hierarchical cluster analysis were applied for data analysis.

Results

A two-dimensional five-cluster cognitive map was derived to provide an organizational framework for understanding patients perceived barriers to medication initiation and adherence. The five clusters were concerns about side effects, experience of side effects, lifestyle changes, medication access and complexity, and patient uncertainty about treatment and trust in the provider. The two dimensions were interpreted as internal to patients (X-axis) and external to patients (Y-axis).

Conclusions/Implications

Views of patients solicited in a structured format provided directions to help in designing interventions to improve osteoporosis medication initiation and adherence.

Efficacy of the Combination of Teriparatide and Denosumab in the Treatment of Postmenopausal Osteoporosis: A Meta-Analysis

Aim: Evidence on the efficacy of combination treatment of teriparatide and denosumab for osteoporosis remains controversial. We aim to compare the efficacy between the combination treatment and monotherapy among patients with postmenopausal osteoporosis.

Methods and results: We systematically searched PubMed, EMBASE, the Cochrane Library, and Web of Science up to 26 January 2022, for relevant studies. This meta-analysis reviewed all randomized controlled trials (RCTs) that reported on the combination treatment of teriparatide and denosumab in patients with postmenopausal osteoporosis. The articles were examined individually by two reviewers, and the relevant data was extracted. We combined weighted mean difference (WMD) for bone mineral density (BMD) using random- or fixed- effect models and conducted subgroup analyses. Sensitivity analyses were performed, and possible publication bias was also assessed. Overall, combination treatment enhanced the mean percent change of bone mineral density in lumbar spine than monotherapy (WMD = 2.91, 95%CI: 1.983.83; p = 0.00). And, combination treatment has been beneficial for enhancing the mean percent change of BMD in hip (WMD = 3.19, 95%CI: 2.25∼4.13; p = 0.00). There was no significant difference between combination treatment and monotherapy in terms of the adverse events (RR = 0.81, 95%CI: 0.45∼1.45; p = 0.472).

Conclusion: The meta-analysis indicates that combination treatment led to greater BMD at the lumbar spine and hip in comparison to monotherapy, without an increased incidence of adverse events.

Systematic Review Registration: (https://inplasy.com/), identifier (Inplasy Protocol 2734).

Race and Age Impact Osteoporosis Screening Rates in Women Prior to Hip Fracture

Bone mineral density screening and clinical risk factors are important to stratify individuals for increased risk of fracture. In a population with no history of fractures or baseline bone density measurement, black women were less likely to be screened than white counterparts prior to hip fracture.

PURPOSE

To evaluate overall BMD (bone mineral density) screening rates within two years of hip fracture and to identify any disparities for osteoporosis screening or treatment in a female cohort who were eligible for screening under insurance and national recommendations.

METHODS

Data were obtained from 1,109 female patients listed in the Research Action for Health Network (REACHnet) database, which consists of multiple health partner systems in Louisiana and Texas. Patients < 65 years old or with a history of hip fracture or osteoporosis diagnosis, screening or treatment more than 2 years before hip fracture were removed.

RESULTS

Only 223 (20.1%) females were screened within the two years prior to hip fracture. Additionally, only 23 (10%) of the screened patients received treatment, despite 187 (86.6%) patients being diagnosed with osteoporosis or osteopenia. Screening rates reached a maximum of 27.9% in the 75-80 age group, while the 90 + age group had the lowest screening rates of 12%. We found a quadratic relationship between age and screening rates, indicating that the screening rate increases in age until age 72 and then decreases starkly. After adjusting for potential confounders, we found that black patients had significantly decreased screening rates compared to white patients (adjusted OR = .454, 95% CI = .227-.908, p value = .026) which held in general and for patient ages 65-97.

CONCLUSION

Despite national recommendations, overall BMD screening rates among women prior to hip fracture are low. If individuals are not initially screened when eligible, they are less likely to ever be screened prior to fracture. Clinicians should address racial disparities by recommending more screening to otherwise healthy black patients above the age of 65. Lastly, treatment rates need to increase among those diagnosed with osteoporosis since all patients went on to hip fracture.

Racial and Ethnic Disparities in Bone Health and Outcomes in the United States

Osteoporosis is a bone disease classified by deterioration of bone microarchitecture and decreased bone strength, thereby increasing subsequent risk of fracture. In the United States, approximately 54 million adults aged 50 years and older have osteoporosis or are at risk due to low bone mass. Osteoporosis has long been viewed as a chronic health condition affecting primarily non-Hispanic white (NHW) women; however, emerging evidence indicates racial and ethnic disparities in bone outcomes and osteoporosis management. The primary objective of this review is to describe disparities in bone mineral density (BMD), prevalence of osteoporosis and fracture, as well as in screening and treatment of osteoporosis among non-Hispanic black (NHB), Hispanic, and Asian adults compared with NHW adults living on the US mainland. The following areas were reviewed: BMD, osteoporosis prevalence, fracture prevalence and incidence, postfracture outcomes, DXA screening, and osteoporosis treatments. Although there are limited studies on bone and fracture outcomes within Asian and Hispanic populations, findings suggest that there are differences in bone outcomes across NHW, NHB, Asian, and Hispanic populations. Further, NHB, Asian, and Hispanic populations may experience suboptimal osteoporosis management and postfracture care, although additional population-based studies are needed. There is also evidence that variation in BMD and osteoporosis exists within major racial and ethnic groups, highlighting the need for research in individual groups by origin or background. Although there is a clear need to prioritize future quantitative and qualitative research in these populations, initial strategies for addressing bone health disparities are discussed. © 2021 American Society for Bone and Mineral Research (ASBMR).

Discontinuation of bisphosphonates in seniors: a systematic review on health outcomes

PURPOSE

Bisphosphonates are used to treat osteoporosis. Despite their benefits on bone mineral density (BMD) and fractures, they have shown adverse effects, sometimes severe, during chronic use. Taken for several years, they achieve long-term bone retention, making deprescribing feasible. This review aimed to synthesize evidence on the success and health outcomes of deprescribing of bisphosphonates in seniors, aged over 60 years.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including articles in English, French, or German published before July 2020. Eligible studies included seniors having discontinued bisphosphonates and reported on health outcomes; some allowed meta-analyses on fracture risk.

RESULTS

The review included 9 RCTs and 9 cohort studies of moderate quality. Bisphosphonates were discontinued after 2 to 7 years of use, and BMD or fractures were assessed during follow-up of 0.5 to 5 years. A significant reduction in BMD after discontinuation was observed in 9 of 10 studies. Results on fracture risk after discontinuation are mitigated: 6 RCT extensions showed no increase in the risk of any osteoporotic fractures after discontinuation. Meta-analyses including 4 RCTs showed an increased odds ratio of vertebral fractures of 2.04 (95% CI, 1.39-2.99) among discontinuers. Results from 2 large cohort studies showed no increased risks of any osteoporotic or vertebral fractures, while 2 studies found increased fracture risks.

CONCLUSION

Bisphosphonates have successfully been discontinued low overall fracture risk after at least 3 years of use, but a risk for decreased BMD and increased vertebral fractures remained.

Cost-effectiveness of secondary fracture prevention intervention for Medicare beneficiaries

Background

Secondary fracture prevention intervention such as fracture liaison services are effective for increasing osteoporosis treatment rates, but are not currently widely used in the United States. We evaluated the cost‐effectiveness of secondary fracture prevention intervention after osteoporotic fracture for Medicare beneficiaries.

Methods

An individual‐level state‐transition microsimulation model was developed to evaluate the cost‐effectiveness of secondary fracture prevention intervention compared with usual care for U.S. Medicare patients aged 65 and older who experience a new osteoporotic fracture. Patients who initiated pharmacotherapy and remained adherent were assumed to be treated for 5 years. Outcome measures included subsequent fractures, average lifetime costs, quality‐adjusted life‐years (QALYs), and incremental cost‐effectiveness ratios in 2020 U.S. dollars per QALY gained. The model time horizon was lifetime, and analysis perspective was payer.

Results

Base‐case analysis results showed that the secondary fracture prevention intervention strategy was both more effective and less expensive than usual care—thus, it was cost‐saving. Model findings indicated that the intervention would reduce the number of expected fractures by approximately 5% over a 5‐year period, preventing approximately 30,000 fractures for 1 million patients. Secondary fracture prevention intervention resulted in an average cost savings of $418 and an increase in QALYs of 0.0299 per patient over the lifetime; for 1 million patients who receive the intervention instead of usual care, expected cost savings for Medicare would be $418 million dollars. One‐way and probabilistic sensitivity analyses supported base‐case findings of cost savings.

Conclusion

Secondary fracture prevention intervention for Medicare beneficiaries after a new osteoporotic fracture is very likely to both improve health outcomes and reduce healthcare costs compared with usual care. Expansion of its use for this population is strongly recommended.

Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics

BACKGROUND

Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes.

METHODS

This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used.

FINDINGS

314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare.

INTERPRETATION

This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.

Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation

Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient's spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.

Osteoporosis in Parkinson's Disease: Relevance of Distal Radius Dual-Energy X-Ray Absorptiometry (DXA) and Sarcopenia

Osteoporotic fractures are common in Parkinson's disease (PD). Standard dual-energy X-ray absorptiometry (DXA) measuring bone mineral density (BMD) at the femoral neck and lumbar spine (central sites) has suboptimal sensitivity in predicting fracture risk in the general population. An association between sarcopenia and osteoporosis in PD has not been studied. We compared BMD and osteoporosis prevalence in PD patients vs controls; determined the osteoporosis detection rates using central alone vs central plus distal radius DXA; and analyzed factors (in particular, sarcopenia) associated with osteoporosis. One hundred and fifty-six subjects (102 patients with PD, 54 spousal/sibling controls) underwent femoral neck-lumbar spine-distal radius DXA. Seventy-three patients and 46 controls were assessed for sarcopenia using whole-body DXA and handgrip strength. Patients underwent clinical and serum biochemical evaluations. PD patients had significantly lower body mass index compared to controls. After adjustment for possible confounders, distal radius BMD and T-scores were significantly lower in PD patients compared to controls, but not at the femoral neck/lumbar spine. With distal radius DXA, an additional 11.0% of patients were diagnosed with osteoporosis (32.0% to 43.0%), vs 3.7% in controls (33.3% to 37.0%) additionally diagnosed; this increase was largely driven by the markedly higher detection rate in female PD patients. Female gender (adjusted odds ratio [OR_adjusted] = 11.3, 95% confidence interval [CI]: 2.6-48.6) and sarcopenia (OR_adjusted = 8.4, 95% CI: 1.1-64.9) were independent predictors for osteoporosis in PD. Distal radius DXA increased osteoporosis detection, especially in female PD patients, suggesting that diagnostic protocols for osteoporosis in PD could be optimized. A close association between osteoporosis and sarcopenia was documented for the first time in PD, which has important implications for clinical management and future research.

Improving Secondary Fracture Prevention After Vertebroplasty: Implementation of a Fracture Liaison Service

OBJECTIVE

The aim of our study was to evaluate a multidisciplinary fracture liaison service (FLS) to improve osteoporosis treatment and secondary fracture prevention for patients after vertebroplasty.

METHODS

A retrospective chart review of consecutive vertebroplasty patients from January 2016 to January 2020. FLS began in December 2016 allowing for before-and-after comparison. Statistical analysis included patient demographics and procedure characteristics. Proportion of patients evaluated by the FLS clinic and treatment modification were evaluated. Opt-in versus opt-out referral strategies were compared. Dual energy x-ray absorptiometry scans or vitamin D levels within 3 months before or after vertebroplasty were assessed. Time to event analysis was used to evaluate secondary fracture occurrence.

RESULTS

There were 137 vertebroplasty patients, 39 before FLS and 98 after FLS, included. Only 15% of all patients were already being treated in a bone health clinic. Of those referred and evaluated by the FLS, 73.0% had their osteoporosis treatment modified. Patients evaluated by the FLS were more likely to have a dual energy x-ray absorptiometry scan or a vitamin D level drawn (P < .001 for both). The opt-out referral was more effective with a 75.0% referral rate (P = .71). Secondary fracture of any kind occurred in 23.4% of all patients. Time to event analysis demonstrated a trend toward a reduced risk of secondary spinal fractures in the fracture prevention group with an adjusted hazard ratio of 0.39 (0.13-1.11, 95% confidence interval).

DISCUSSION

A multidisciplinary FLS can be implemented for patients after vertebroplasty to evaluate osteoporotic risk factors and optimize osteoporosis therapy, both of which are important factors in preventing secondary vertebral fractures.

Bone Mineral Density of the 1/3 Radius Refines Osteoporosis Diagnosis, Correlates With Prevalent Fractures, and Enhances Fracture Risk Estimates

OBJECTIVE

To investigate the added value of 1/3 radius (1/3R) for the diagnosis of osteoporosis by spine and hip sites and its correlation with prevalent fractures and predicted fracture risk.

METHODS

Fracture Risk Assessment Tool (FRAX) scores for hip and major osteoporotic fractures (MOF) with/without trabecular bone score were considered proxy for fracture risk. The contribution of 1/3R to risk prediction was depicted via linear regression models with FRAX score as the dependent variable-first only with central and then with radius T-score as an additional covariate. Significance of change in the explained variance was compared by F-test.

RESULTS

The study included 1453 patients, 86% women, aged 66 ± 10 years. A total of 32% (n = 471) were osteoporotic by spine/hip and 8% (n = 115) by radius only, constituting a 24.4% increase in the number of subjects defined as osteoporotic (n = 586, 40%). Prior fracture prevalence was similar among patients with osteoporosis by spine/hip (17.4%) and radius only (19.1%) (P = .77). FRAX prediction by a regression model using spine/hip T-score yielded explained variance of 51.8% and 49.9% for MOF and 39.8% and 36.4% for hip (with/without trabecular bone score adjustment, respectively). The contribution of 1/3R was statistically significant (P < .001) and slightly increased the explained variance to 52.3% and 50.4% for MOF and 40.9% and 37.4% for hip, respectively.

CONCLUSION

Reclassification of BMD results according to radius measurements results in higher diagnostic output. Prior fractures were equally prevalent among patients with radius-only and classic-site osteoporosis. FRAX tool performance slightly improved by incorporating radius BMD. Whether this approach may lead to a better fracture prediction warrants further prospective evaluation.

Upper Extremity Fragility Fractures

The population of elderly patients is rapidly increasing in the United States and worldwide, leading to an increased prevalence of osteoporosis and a concurrent rise in fragility fractures. Fragility fractures are defined as fractures involving a low-energy mechanism, such as a fall from a standing height or less, and have been associated with a significant increase in the risk of a future fragility fracture. Distal radius fractures in the elderly often present earlier than hip and vertebral fractures and frequently involve underlying abnormalities in bone mass and microarchitecture. This affords a unique opportunity for upper extremity surgeons to aid in the diagnosis and treatment of osteoporosis and the prevention of secondary fractures. This review aims to outline current recommendations for orthopedic surgeons in the evaluation and treatment of upper extremity fragility fractures.

Mobile health technologies for the management of rheumatic diseases: a systematic review of online stores in Brazil

Rheumatic diseases are serious conditions with a low uptake of conservative treatments. Mobile health (mHealth) applications (apps) offer potential to assist the self-management of rheumatic diseases. Our goal was to perform a systematic review of available mHealth apps for rheumatic diseases in Brazil. We focused on the most prevalent rheumatic diseases: osteoarthritis, rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, osteoporosis, and axial spondylarthritis. Google Play Store and AppStore in Brazil were queried by two independent reviewers on September 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Of the 3173 mHealth apps found, five were eligible for inclusion. Two for fibromyalgia and two for axial spondylarthritis offered exercise, educational content, and tools to track patient-reported symptoms; and one for osteoporosis offered educational content and tracking tools only. The included apps scored moderately on the MARS quality scale, with a mean score (SD) of 3.1 (0.7) on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement. There is growing interest in the development of mHealth technologies to support rheumatic diseases patients. Although the majority of the included apps came from non-profit organizations, they are still of poor quality and limited functionality. This study is a call for to the development of new user-centered mHealth apps that can empower rheumatic diseases patients in Brazil, especially in the area of osteoarthritis, rheumatoid arthritis, and lupus, since no apps were found.

Trajectories of Follow-up Compliance in a Fracture Liaison Service and Their Predictors: A Longitudinal Group-Based Trajectory Analysis

INTRODUCTION/OBJECTIVES

Identification of groups of patients following similar trajectories of time-varying patient characteristics are often of considerable clinical value. This study provides an example of how the identification of trajectory groups of patients can be useful.

METHODS

Using clinical and administrative data of a prospective cohort study aiming to improve the secondary prevention of osteoporosis-related fractures with a Fracture Liaison Service (FLS), trajectory groups for visit compliance over time (2-year follow-up) were predicted using group-based trajectory modeling. Predictors of trajectory groups were identified using multinomial logistic regressions.

RESULTS

Among 532 participants (86% women, mean age 63 years), three trajectories were identified and interpreted as high followers, intermediate followers, and low followers. The predicted probability for group-membership was: 48.4% high followers, 28.1% intermediate followers, 23.5% low followers. A lower femoral bone mineral density and polypharmacy were predictors of being in the high followers compared to the low followers group; predictors for being in the intermediate followers group were polypharmacy and referral to a bone specialist at baseline.

CONCLUSIONS

Results provided information on visit compliance patterns and predictors for the patients undergoing the intervention. This information has important implications when implementing such health services and determining their effectiveness.

Comparison of efficacy and safety of Chinese patent medicine in the treatment of postmenopausal osteoporosis: A protocol for systematic review and network meta-analysis

BACKGROUND

Postmenopausal osteoporosis (PMOP) is the focus and difficult problem in the world at present, and we found that Chinese patent medicine(CPM) shown a more miraculous effect. Many kinds of Chinese patent medicine have been proved to be effective in the treatment of this disease, but it is still unclear which kind of Chinese patent medicine has the best effect. Therefore, we propose a network meta-analysis (NMA) protocol to observe the efficacy of various CPM for this disease and provide guidance for clinical practice.

METHODS

We will use the NMA method to complete this study. First, all the randomized controlled trials of CPM or CPM combined with western medicine in the treatment of PMOP were collected by searching all online Chinese and English databases. The information time limit is from the establishment of the database to August 30, 2020. Then 2 staff members will sift through all the literature and analyze the data using Stata and Winbugs.

RESULTS

Through this analysis, we will observe and rank the clinical effects of different CPM for PMOP. The main evaluation indexes include: New fracture, Quality of life, Severe side effects, Death from all causes. Secondary outcome indicators include Bone Mineral density, clinical efficiency, and some laboratory indicators, such as estradiol, serum calcium, serum, etc. CONCLUSION:: This study will rank the therapeutic effects of various proprietary Chinese medicines in the treatment of PMOP, which will be helpful in improving the PMOP treatment regimen.INPLASY registration number: INPLASY202090047.

The Potential Influence of Bone-Derived Modulators on the Progression of Alzheimer's Disease

Bone, the major structural scaffold of the human body, has recently been demonstrated to interact with several other organ systems through the actions of bone-derived cells and bone-derived cell secretory proteins. Interestingly, the brain is one organ that appears to fall into this interconnected network. Furthermore, the fact that osteoporosis and Alzheimer's disease are two common age-related disorders raises the possibility that these two organ systems are interconnected in terms of disease pathogenesis. This review focuses on the latest evidence demonstrating the impact of bone-derived cells and bone-derived proteins on the central nervous system, and on how this may be relevant in the progression of Alzheimer's disease and for the identification of novel therapeutic approaches to treat this neurodegenerative disorder.

CT Phantom Evaluation of 67,392 American College of Radiology Accreditation Examinations: Implications for Opportunistic Screening of Osteoporosis Using CT

OBJECTIVE. The purpose of this study was to investigate whether systematic bias in attenuation measurements occurs among CT scanners made by four major manufacturers and the relevance of this bias regarding opportunistic screening for osteoporosis. MATERIALS AND METHODS. Data on attenuation measurement accuracy were acquired using the American College of Radiology (ACR) accreditation phantom and were evaluated in a blinded fashion for four CT manufacturers (8500 accreditation submissions for manufacturer A; 18,575 for manufacturer B; 8278 for manufacturer C; and 32,039 for manufacturer D). The attenuation value for water, acrylic (surrogate for trabecular bone), and Teflon (surrogate for cortical bone; Chemours) materials for an adult abdominal CT technique (120 kV, 240 mA, standard reconstruction algorithm) was used in the analysis. Differences in attenuation value across all manufacturers were assessed using the Kruskal-Wallis test followed by a post hoc test for pairwise comparisons. RESULTS. The mean attenuation value for water ranged from -0.3 to 2.7 HU, with highly significant differences among all manufacturers (p < 0.001). For the trabecular bone surrogate, differences in attenuation values across all manufacturers were also highly significant (p < 0.001), with mean values of 120.9 (SD, 3.5), 124.6 (3.3), 126.9 (4.4), and 123.9 (3.4) HU for manufacturers A, B, C, and D, respectively. For the cortical bone surrogate, differences in attenuation values across all manufacturers were also highly significant (p < 0.001), with mean values of 939.0 (14.2), 874.3 (13.3), 897.6 (11.3), and 912.7 (13.4) HU for manufacturers A, B, C, and D, respectively. CONCLUSION. CT scanners made by different manufacturers show systematic offsets in attenuation measurement when compared with each other. Knowledge of these off-sets is useful for optimizing the accuracy of opportunistic diagnosis of osteoporosis.

Biomechanical Computed Tomography analysis (BCT) for clinical assessment of osteoporosis

The surgeon general of the USA defines osteoporosis as "a skeletal disorder characterized by compromised bone strength, predisposing to an increased risk of fracture." Measuring bone strength, Biomechanical Computed Tomography analysis (BCT), namely, finite element analysis of a patient's clinical-resolution computed tomography (CT) scan, is now available in the USA as a Medicare screening benefit for osteoporosis diagnostic testing. Helping to address under-diagnosis of osteoporosis, BCT can be applied "opportunistically" to most existing CT scans that include the spine or hip regions and were previously obtained for an unrelated medical indication. For the BCT test, no modifications are required to standard clinical CT imaging protocols. The analysis provides measurements of bone strength as well as a dual-energy X-ray absorptiometry (DXA)-equivalent bone mineral density (BMD) T-score at the hip and a volumetric BMD of trabecular bone at the spine. Based on both the bone strength and BMD measurements, a physician can identify osteoporosis and assess fracture risk (high, increased, not increased), without needing confirmation by DXA. To help introduce BCT to clinicians and health care professionals, we describe in this review the currently available clinical implementation of the test (VirtuOst), its application for managing patients, and the underlying supporting evidence; we also discuss its main limitations and how its results can be interpreted clinically. Together, this body of evidence supports BCT as an accurate and convenient diagnostic test for osteoporosis in both sexes, particularly when used opportunistically for patients already with CT. Biomechanical Computed Tomography analysis (BCT) uses a patient's CT scan to measure both bone strength and bone mineral density at the hip or spine. Performing at least as well as DXA for both diagnosing osteoporosis and assessing fracture risk, BCT is particularly well-suited to "opportunistic" use for the patient without a recent DXA who is undergoing or has previously undergone CT testing (including hip or spine regions) for an unrelated medical condition.

Performance of a Fracture Liaison Service in an Orthopaedic Setting: A Report of Key Indicators and Improvement of Longitudinal Outcomes

BACKGROUND

Many Fracture Liaison Services (FLSs) have been successfully implemented, but very few incorporate systematic longitudinal follow-up. The objective of this study was to report on the performance of such an FLS using key performance indicators and longitudinal clinical outcomes.

METHODS

An FLS was implemented in 2 outpatient orthopaedic clinics. Men and women who were ≥40 years of age and had a recent fragility fracture were recruited. Participants were evaluated, treated when appropriate, and systematically followed over a 2-year period. Clinical data including chart review and questionnaires were collected. Medical services and hospitalization claims data were retrieved from administrative databases. The primary outcomes were the following key performance indicators: the numbers of investigated and treated patients, follow-up attendance, and the incidence of subsequent fractures. Secondary outcomes were the changes in bone turnover markers and quality of life, physical capacity, and pain scores between baseline and follow-up visits.

RESULTS

A total of 532 subjects with a mean age of 63.4 years were recruited; 85.7% were female. Bone mineral density results were collected for 472 subjects (88.7%) and a prescription for anti-osteoporosis medication was given to 86.6% of patients. Overall, 83.6% of patients attended at least 1 follow-up visit. The subsequent fracture incidence rate was 2.6 per 100 person-years (23 fractures). The mean level of type-I collagen C-telopeptide (CTX-1), a bone resorption marker, decreased >35%. Clinically important improvements of functional capacity scores (by 14.4% to 63.7%) and pain level (by 19.3% to 35.7%) were observed over time; however, the increase in quality-of-life scores was not clinically important (by 3% to 15.2%).

CONCLUSIONS

In this FLS, the rates of investigation, treatment, and participation were >80% over a 2-year period. The subsequent fragility fracture incidence rate was <3 per 100 person-years. These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective. A randomized controlled trial is needed to support these results.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Interventions to improve osteoporosis care: a systematic review and meta-analysis

Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription.

Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care?

OBJECTIVE

This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard.

METHODS

We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription.

RESULTS

A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098).

CONCLUSIONS

In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.

Fragility Fracture Prevention-Implementing a Fracture Liaison Service in a High Volume Orthopedic Hospital

Fragility fractures pose a serious threat to patient health, quality of life, and healthcare sustainability. In order to reduce their clinical, social, and economic burden, a Fracture Liaison Service (FLS) was introduced in a high volume orthopedic hospital in 2017. The purpose of this retrospective observational study is to describe the FLS protocol, introduce its preliminary outcomes, and provide an early evaluation in light of international guidelines and recommendations. All the performances suggested by the International Osteoporosis Foundation (IOF) are provided under the same institution by which a patient is admitted for surgery. Clinical indicators from patient history and administrative indicators from the hospital database have been used to estimate the spread of fragility fracture prevention and the degree of patient compliance to these programs. The research included 403 patients. Although, almost 1/3 were admitted for the second fragility fracture, only half received anti-osteoporotic treatment before it. The degree of prevention was even lower in the case of patients admitted for the first fragility fracture. The risk of being affected by a secondary fracture was seven times higher when patients did not attend any follow-up or diagnostic exam. In order to identify the main determinants of compliance with FLS and perform a cost-effectiveness analysis on a larger sample, it is fundamental to integrate data from different providers.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures.

RECENT FINDINGS

Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Vertebral Fracture Assessment Increases Use of Pharmacologic Therapy for Fracture Prevention in Clinical Practice

The impact of vertebral fracture assessment (VFA) on lateral spine images in clinical practice on subsequent patient use of fracture prevention medication is unknown. Our objective was to determine the association of prevalent vertebral fracture identified on bone density lateral spine images (positive VFA) with subsequent use of fracture prevention therapy in usual clinical practice, using the Manitoba Bone Density Program database prospective observational cohort. Since 2010, targeted VFA imaging has been done at the time of bone densitometry in Manitoba for 21% of women and men meeting criteria based on age, bone mineral density (BMD), height loss, and glucocorticoid use. Among 6652 treatment-naive individuals with at least 90 days follow-up who had VFA imaging, 923 (13.9%) had one or more definite vertebral fractures identified using a modified algorithm-based qualitative (ABQ) method. For those with a positive VFA, their bone density reports stated the patient was at high risk of subsequent fracture and qualified for fracture prevention therapy. Subsequent osteoporosis treatment initiated within the next 12 months was identified using population-based pharmacy data. Logistic regression models were used to estimate the association of positive VFA with subsequent prescription (Rx), compared to negative VFA. Fracture prevention medication was started by 2127 (32%) individuals, 52.3% with positive versus 28.4% with negative VFA (p value <0.001). This association was substantially stronger in those designated (before VFA results were known) to have low or moderate fracture risk compared to high fracture risk (interaction p value <0.001), and in those with osteopenia (OR 4.51; 95% CI, 3.48 to 5.85) compared to those with osteoporosis by BMD criteria (OR 1.72; 95% CI, 1.43 to 2.08, interaction p value <0.001). Targeted VFA imaging at the time of bone densitometry substantially improves identification of those at high fracture risk and fracture prevention medication use among those with prevalent vertebral fracture. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

Population-Based Osteoporosis Primary Prevention and Screening for Quality of Care in Osteoporosis, Current Osteoporosis Reports

PURPOSE OF REVIEW

Despite the high prevalence and impact of osteoporosis, screening and treatment rates remain low, with few women age 65 years and older utilizing osteoporosis screening for primary prevention.

RECENT FINDINGS

This review examines opportunities and challenges related to primary prevention and screening for osteoporosis at the population level. Strategies on how to identify individuals at high fracture risk and target them for treatment have lagged far behind other developments in the osteoporosis field. Most osteoporosis quality improvement strategies have focused on patients with recent or prior fracture (secondary prevention), with limited attention to individuals without prior fracture. For populations without prior fracture, the only quality improvement strategy for which meta-analysis demonstrated significant improvement in osteoporosis care was patient self-scheduling of DXA plus education Much more work is needed to develop and validate effective primary screening and prevention strategies and translate these into high-quality guidelines.

Acromial Stress Fractures: A Systematic Review

BACKGROUND

Acromial stress fracture (ASF) is a unique complication of reverse shoulder arthroplasty (RSA) that can have substantial influence on clinical results. The purpose of this review is to describe demographics, functional outcomes, and union rates for cases of RSA complicated by ASF.

METHODS

A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to identify studies that reported results of RSA complicated by ASF. Searches were performed using PubMed and Scopus up to January 1, 2018. Five articles met inclusion and exclusion criteria.

RESULTS

ASF occurred in 61 (6.9%) of 874 RSA cases identified. 82% of patients who sustained an ASF were female. ASF cases were, on average, 7 years older than cases that were not complicated by ASF. While improved compared to their preoperative state, patients who sustained an ASF demonstrated significantly less improvement in pain, function, and ROM compared to RSA patients without ASF.

CONCLUSION

Women and older patients appear to be at greater risk for an ASF after RSA. Though nonunion rates are high, fair outcomes can still be achieved in cases of ASF after RSA. Further study is needed to identify modifiable and non-modifiable risk factors associated with the development of ASF.

Persistence and compliance to osteoporosis therapy in a fracture liaison service: a prospective cohort study

Persistence and compliance to osteoporosis medications aiming to prevent fragility fractures are essential for fracture prevention, but are suboptimal in the population. A Fracture Liaison Service with a systematic follow-up led to ongoing therapy and optimal drug compliance for more than half of treated patients over 2 years.

PURPOSE

Fracture Liaison Services (FLS) have the potential to improve persistence and compliance to osteoporosis therapy. We aimed to assess patterns of drug use in a high-level intervention FLS.

METHODS

Women and men (> 40 years) with a fragility fracture were recruited in a FLS, where osteoporosis therapy was prescribed if appropriate. Based on claims data, patients who filled their prescription in the 3-month period following baseline were selected. The 1- and 2-year persistence rates were measured using survival analysis. In non-persistent subjects, 1-year treatment re-initiation was measured. The 1- and 2-year compliance levels were measured, using the proportion of days covered (PDC > 80% = compliant). Regression analyses were performed to identify predictors of non-persistence/compliance.

RESULTS

Out of 332 subjects with complete drug insurance coverage, 297 (89.5%) were prescribed osteoporosis therapy by the FLS, and 275 (92.6%) were dispensed. Two hundred sixty participants (86.9% female; mean age 65.6 years) were selected for having filled a prescription inside 3 months after baseline. The 1- and 2-year persistence rates were 66.4% and 55.6%, respectively. Treatment re-initiation was observed in 56% of non-persistent patients. PDC was > 80% in 64.2% for 1 year and 62.5% for 2 years. Older and younger age, smoking, higher spine bone mineral density, lower major FRAX risk, and missing follow-up visits were predictors of non-persistence and/or non-compliance.

CONCLUSIONS

After 2 years in a high-level intervention FLS, more than half the treated participants were persistent and compliant to treatment. Comparative effectiveness studies must be undertaken to determine whether this intervention is an improvement over usual care.

Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study

Background

Osteoporosis prevention, diagnosis and treatment remain suboptimal.

Objectives

We conducted a qualitative study to understand barriers towards care initiation and levers to improve awareness and management of osteoporosis among general practitioners (GPs).

Methods

Semi-structured face-to face interviews were conducted with 16 GPs in the Rhône area of France to explore their knowledge and representations regarding osteoporosis. A thematic analysis of transcripts was performed to identify GPs’ perceptions on osteoporosis diagnosis, prevention, treatment and patients’ expectations.

Results

Interviewed GPs considered osteoporosis far less important than other chronic diseases. They questioned whether osteoporosis was a disease or normal aspect of ageing. They associated osteoporosis with fragility fractures, female sex, menopause, and old age but rarely with male sex. They regarded bone mineral density as the reference diagnostic test, but certain GPs indicated that they had difficulties to interpret the results and to know when to prescribe. Biphosphonates were mentioned as the reference treatment but some GPs expressed distrust about osteoporosis medications. Most of them did not think to screen for osteoporosis risk factors in their patients in a preventive medical approach. They mentioned the lack of time to implement prevention and were expecting clear and pragmatic guidelines, as well as information campaigns in general population to increase awareness on osteoporosis.

Conclusion

GPs tended to underestimate the salience of osteoporosis. Clear recommendations, better awareness of GPs and the general population could improve osteoporosis prevention and treatment.

[Diagnostics and treatment of osteoporosis in patients over 65 years old : Current status and future perspectives]

Only one third of all women with osteoporosis over the age of 65 years are adequately treated; therefore, many experience fractures. For men the data are insufficient. Using a newly developed algorithm and based on the current guidelines, the diagnosis and specific treatment of osteoporosis can be easily set up. The differential treatment should be selected in an individualized approach based on the side effect profile of the specific medication. No statistically significant differences were found between most specific osteoporotic drugs in head-to-head comparisons. This article presents an overview of the currently available pharmaceutical and non-pharmaceutical forms of treatment as well as approaches with novel medications and interventions for a better control of osteoporosis.

Teriparatide versus bisphosphonates for treatment of postmenopausal osteoporosis: A meta-analysis

OBJECTIVE

This meta-analysis aims to compare the efficacy of teriparatide and bisphosphonates for reducing vertebral fracture risk and bone mineral density (BMD) in lumbar spine and femoral neck in postmenopausal women with osteoporosis.

METHODS

We searched the literature, via PubMed, Embase, Cochrane Library, Web of Science and Google database to screen citations from inception to April 2018 for inclusion in this study. Only randomized controlled trials that compared teriparatide and bisphosphonates for reducing vertebral fracture risk in postmenopausal women with osteoporosis were included. Stata 12.0 was used for meta-analysis.

RESULTS

Our meta-analysis results indicated that, compared with bisphosphonates, teriparatide was associated with a reduction of the vertebral fracture risk (risk ratio (RR) = 0.57, 95% confidence interval (CI): 0.35, 0.93, P = 0.024). Furthermore, teriparatide therapy increased the mean percent change in BMD in lumbar spine of 6 months, 12 months and 18 months than bisphosphonates with statistically significant (P < 0.05). And, teriparatide has only beneficial in increasing the mean percent change in BMD in femoral neck of 18 months (P < 0.05). There was no significant difference between teriparatide and bisphosphonates in terms of the adverse events (AEs, RR = 1.09, 95% CI 0.89, 1.33, P = 0.424).

CONCLUSIONS

Teriparatide is an effective agent in reducing the risk of vertebral fracture in postmenopausal women with osteoporosis. Furthermore, teriparatide can increase the BMD in lumbar spine and femoral neck in long-terms duration.

Rationale, study design, and descriptive data of the Lucky Bone™ Fracture Liaison Service

The study design of a multidisciplinary Fracture Liaison Service (2-year follow-up) aiming to optimize fragility fracture management in an outpatient setting is presented. Patient characteristics, investigation, and treatment initiation data at baseline were recorded. Results corroborate the care gap in osteoporosis management, reinforcing the need for secondary fracture prevention programs.

PURPOSE

This paper describes the study design, implementation, and baseline characteristics of a multidisciplinary Fracture Liaison Service (FLS) in Quebec (Canada).

METHODS

A FLS was implemented as a prospective cohort study. After identification, fracture risk was assessed and patients were started on treatment or referred, according to guidelines and risk assessment. Thereafter, patients were systematically followed over 2 years. Clinical data (fractures, bone density, blood testing (bone turnover markers), quality of life, physical disability) as well as administrative data (pharmacological, health services, hospitalization) was collected. Baseline descriptive data was analyzed and presented.

RESULTS

Of 542 recruited participants, 532 underwent baseline assessment (85.7% female, mean age 63.4 years). Overall, 29.7% of participants either withdrew from the study or were lost to follow-up. Almost 27% were referred to a specialist, while > 70% received anti-osteoporosis medication prescriptions through the FLS at baseline. Mean femoral T-score was - 1.6 ± 1.0 and vertebral T-score was - 1.7 ± 1.4. Nearly 19% of subjects reported being under anti-osteoporosis medication at the time of incident fracture. Thirty-three percent of participants reported a prior fracture history, of which 29.7% reported being given anti-osteoporosis therapy. Most fracture sites were to the wrist and ankle, while < 19% were hip/femur or vertebral fractures.

CONCLUSIONS

These results highlight the important care gap in fragility fracture management and reinforce the need for secondary fracture prevention programs. This prospective study will allow the evaluation of key performance indicators for outpatient clinic-based FLS, such as medication usage, by combining prospective clinical and administrative data.

Considerations in the Treatment of Osteoporotic Distal Radius Fractures in Elderly Patients

PURPOSE OF REVIEW

With the incidence of distal radius fractures increasing in the elderly population, we sought to summarize the current orthopedic and medical management of these fractures in the elderly osteoporotic population.

RECENT FINDINGS

The number of osteoporotic patients undergoing surgical fixation for distal radius fractures has increased in recent years. This is likely due to the improved outcomes seen with volar locking plates, as well as an increase in the number of fellowship-trained hand surgeons. Despite this potential improvement in acute fracture management, a majority of these patients are underdiagnosed and undertreated for their underlying osteoporosis or endocrinopathies. The implementation of fracture liaison services and the ability of the treating orthopedist to recognize this gap in patient care result in a higher number of patients initiating appropriate treatment. It is vital that when discussing acute fracture management, a thorough discussion is had with patients regarding functional outcome and the benefits of both surgical and non-operative management. As these fractures become more prevalent and a greater percentage undergo surgical intervention, the economic burden of distal radius fractures will continue to rise. It is imperative that the treating surgeon view these fractures as sentinel events that are predictive of future hip and vertebral fractures. While relatively new, the use of fracture liaison services to help aide in proper screening and treatment of osteoporotic patients is of great value. Non-pharmacologic therapy such as physical therapy, smoking and alcohol cessation programs, and dietary modifications are crucial in treating patients with osteoporosis. While bisphosphonates remain the first-line treatment in patients with osteoporosis, novel therapies show promise for future use.

Osteoporosis prevention: where are the barriers to improvement in a French general population? A qualitative study

We conducted a qualitative study with French men and women in order to provide insight into individuals' experiences, behaviors, and perceptions about osteoporosis (OP) and OP care. The data showed that both sexes, but especially men, were unfamiliar with OP, did not always feel concerned, and mistrusted pharmacological treatments.

INTRODUCTION

To engage actively in osteoporosis (OP) prevention, people need to have basic knowledge about the disease. The aim of this qualitative study was to explore knowledge and representations of OP care and prevention among both men and women.

METHODS

Focus groups were conducted in the Rhône-Alpes Region, France, with women aged 50-85 years and men aged 60-85 years, with or without a history of fragility fracture and/or an OP diagnosis (respectively referred to as "aware" or "unaware"). A total of 45 women (23 "aware" and 22 "unaware" in 5 and 4 focus groups, respectively) and 53 men (19 "aware" and 34 "unaware" in 3 and 4 focus groups, respectively) were included. A thematic analysis of transcripts was performed to explore knowledge and representations about OP, risk factors, prevention, and treatment.

RESULTS

The data showed that both sexes, but especially men, had limited knowledge of OP and considered it as a natural aging process not related to fragility fractures. They generally did not feel concerned by OP and no important difference was observed between "aware" and "unaware" patients. Women expressed their fear of the disease, associated with aging and the end of life, while men considered it to be a women's disease only. Both sexes were aware of OP risk factors, but were suspicious towards treatments because of the associated side effects.

CONCLUSION

Understanding people's representation of OP might help to provide patients with relevant information in order to optimize their preventive behavior and decrease the burden of the disease.