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Ansari H, Jaglal S, Cheung AM, Jain R, Weldon J, Kurdyak P. Osteoporosis management in adults with schizophrenia following index hip fracture event: a 10-year population-based retrospective cohort study, Ontario, Canada. Osteoporos Int 2024; 35:1289-1298. [PMID: 38760503 DOI: 10.1007/s00198-024-07123-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
Little is known about the incidence of osteoporosis testing and treatment in individuals with schizophrenia, who may be more likely to fracture. Using competing risk models, we found that schizophrenia was associated with lower incidence of testing or treatment. Implications are for understanding barriers and solutions for this disadvantaged group. PURPOSE Evidence suggests that individuals with schizophrenia may be more likely to experience hip fractures than the general population; however, little is known about osteoporosis management in this disadvantaged subpopulation. Our study objective was to compare bone mineral density (BMD) testing and pharmacologic treatment in hip fracture patients with versus without schizophrenia. METHODS This was a retrospective population-based cohort study leveraging health administrative databases, and individuals aged 66-105 years with hip fracture between fiscal years 2009 and 2018 in Ontario, Canada. Schizophrenia was ascertained using a validated algorithm. The outcome was a composite measure of (1) pharmacologic prescription for osteoporosis; or (2) a BMD test. Inferential analyses were conducted using Fine-Gray subdistribution hazard regression, with mortality as the competing event. RESULTS A total of 52,722 individuals aged 66 to 105 years who sustained an index hip fracture in Ontario during the study period were identified, of whom 1890 (3.6%) had schizophrenia. Hip fracture patients with vs without schizophrenia were more likely to be long-term care residents (44.3% vs. 18.1%; standardized difference, 0.59), frail (62.5% vs. 36.5%; standardized difference, 0.54) and without a primary care provider (9.2% vs. 4.8%; standardized difference, 0.18). In Fine-Gray models, schizophrenia was associated with a lower incidence of testing or treatment (0.795 (0.721, 0.877)). CONCLUSIONS In this population-based retrospective cohort study, a schizophrenia diagnosis among hip fracture patients was associated with a lower incidence of testing or treatment, after accounting for mortality, and several enabling and predisposing factors. Further research is required to investigate barriers to osteoporosis management in this disadvantaged population.
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Affiliation(s)
- H Ansari
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - S Jaglal
- ICES, Toronto, ON, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - A M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network and Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - R Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - J Weldon
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - P Kurdyak
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
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Ali A, Huszti E, Noordin S, Ali U, Sale JEM. Examining treatment targets and equity in bone-active medication use within secondary fracture prevention: a systematic review and meta-analysis. Osteoporos Int 2024:10.1007/s00198-024-07078-5. [PMID: 38740589 DOI: 10.1007/s00198-024-07078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE This systematic review seeks to evaluate the proportion of fragility fracture patients screened in secondary fracture prevention programs who were indicated for pharmacological treatment, received prescriptions for bone-active medications, and initiated the prescribed medication. Additionally, the study aims to analyze equity in pharmacological treatment by examining equity-related variables including age, sex, gender, race, education, income, and geographic location. METHODS We conducted a systematic review to ascertain the proportion of fragility fracture patients indicated for treatment who received prescriptions and/or initiated bone-active medication through secondary fracture prevention programs. We also examined treatment indications reported in studies and eligibility criteria to confirm patients who were eligible for treatment. To compute the pooled proportions for medication prescription and initiation, we carried out a single group proportional meta-analysis. We also extracted the proportions of patients who received a prescription and/or began treatment based on age, sex, race, education, socioeconomic status, location, and chronic conditions. RESULTS This review included 122 studies covering 114 programs. The pooled prescription rate was 77%, and the estimated medication initiation rate was 71%. Subgroup analysis revealed no significant difference in treatment initiation between the Fracture Liaison Service and other programs. Across all studies, age, sex, and socioeconomic status were the only equity variables reported in relation to treatment outcomes. CONCLUSION Our systematic review emphasizes the need for standardized reporting guidelines in post-fracture interventions. Moreover, considering equity stratifiers in the analysis of health outcomes will help address inequities and improve the overall quality and reach of secondary fracture prevention programs.
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Affiliation(s)
- Anum Ali
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada.
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Shahryar Noordin
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Usman Ali
- Department of Surgery, Aga Khan University, National Stadium Rd, P.O. Box 3500, Karachi City, Sindh, Pakistan
| | - Joanna E M Sale
- Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor - 155 College Street, Toronto, ON, M5T 3M6, Canada
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, 5th Floor - 149 College Street, Toronto, ON, M5B 1W8, Canada
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Cowan A, Jeyakumar N, McArthur E, Fleet JL, Kanagalingam T, Karp I, Khan T, Muanda FT, Nash DM, Silver SA, Thain J, Weir MA, Garg AX, Clemens KK. Hypocalcemia Risk of Denosumab Across the Spectrum of Kidney Disease: A Population-Based Cohort Study. J Bone Miner Res 2023; 38:650-658. [PMID: 36970786 DOI: 10.1002/jbmr.4804] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/28/2023] [Accepted: 03/21/2023] [Indexed: 04/11/2023]
Abstract
Denosumab can be used in patients with chronic kidney disease (CKD) but has been linked with cases of severe hypocalcemia. The incidence of and risk factors for hypocalcemia after denosumab use are not well established. Using linked health care databases at ICES, we conducted a population-based cohort study of adults >65 years old with a new prescription for denosumab or a bisphosphonate between 2012 and 2020. We assessed incidence of hypocalcemia within 180 days of drug dispensing and stratified results by estimated glomerular filtration rate (eGFR in mL/min/1.73 m2 ). We used Cox proportional hazards to assess risk factors for hypocalcemia. There were 59,151 and 56,847 new denosumab and oral bisphosphonate users, respectively. Of the denosumab users, 29% had serum calcium measured in the year before their prescription, and one-third had their serum calcium checked within 180 days after their prescription. Mild hypocalcemia (albumin corrected calcium <2.00 mmol/L) occurred in 0.6% (95% confidence interval [CI] 0.6, 0.7) of new denosumab users and severe hypocalcemia (<1.8 mmol/L) in 0.2% (95% CI 0.2, 0.3). In those with an eGFR <15 or receiving maintenance dialysis, the incidence of mild and severe hypocalcemia was 24.1% (95% CI 18.1, 30.7) and 14.9% (95% CI 10.1, 20.7), respectively. In this group, kidney function and baseline serum calcium were strong predictors of hypocalcemia. We did not have information on over-the-counter vitamin D or calcium supplementation. In new bisphosphonate users, the incidence of mild hypocalcemia was 0.3% (95% CI 0.3, 0.3) with an incidence of 4.7% (95% CI 1.5, 10.8) in those with an eGFR <15 or receiving maintenance dialysis. In this large population-based cohort, we found that the overall risk of hypocalcemia with new denosumab use was low but increased substantially in those with eGFR <15 mL/min/1.73 m2 . Future studies should investigate strategies to mitigate hypocalcemia. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Andrea Cowan
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
| | - Nivethika Jeyakumar
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Eric McArthur
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Jamie L Fleet
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Physical Medicine and Rehabilitation, Western University, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Igor Karp
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Tayyab Khan
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | | | - Danielle M Nash
- ICES, Toronto, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | | | - Jenny Thain
- Department of Medicine, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
| | - Matthew A Weir
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
| | - Amit X Garg
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Toronto, Canada
- Department of Medicine, Western University, London, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Canada
- St. Joseph's Health Care London, London, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Canada
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Konstantelos N, Rzepka AM, Burden AM, Cheung AM, Kim S, Grootendorst P, Cadarette SM. Fracture definitions in observational osteoporosis drug effects studies that leverage healthcare administrative (claims) data: a scoping review. Osteoporos Int 2022; 33:1837-1844. [PMID: 35578134 PMCID: PMC9463274 DOI: 10.1007/s00198-022-06395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/30/2022] [Indexed: 11/27/2022]
Abstract
UNLABELLED Healthcare administrative (claims) data are commonly utilized to estimate drug effects. We identified considerable heterogeneity in fracture outcome definitions in a scoping review of 57 studies that estimated osteoporosis drug effects on fracture risk. Better understanding of the impact of different fracture definitions on study results is needed. PURPOSE Healthcare administrative (claims) data are frequently used to estimate the real-world effects of drugs. Fracture incidence is a common outcome of osteoporosis drug studies. We aimed to describe how fractures are defined in studies that use claims data. METHODS We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and gray literature for studies published in English between 2000 and 2020 that estimated fracture effectiveness (hip, humerus, radius/ulna, vertebra) or safety (atypical fracture of the femur, AFF) of osteoporosis drugs using claims data in Canada and the USA. Literature searches, screening and data abstraction were completed independently by two reviewers. RESULTS We identified 57 eligible studies (52 effectiveness, 3 safety, 2 both). Hip fracture was the most common fracture site studied (93%), followed by humerus (66%), radius/ulna (59%), vertebra (61%), and AFF (9%). Half (n = 29) of the studies did not indicate specific data sources, codes, or cite a validation paper. Of the papers with sufficient detail, heterogeneity in fracture definitions was common. The most common definition within each fracture site was used by less than half of the studies that examined effectiveness (12 definitions in 29 hip fracture papers, 8 definitions in 17 humerus papers, 8 definitions in 13 radius/ulna papers, 9 definitions in 15 vertebra papers), and 3 definitions among 4 AFF papers. CONCLUSION There is ambiguity and heterogeneity in fracture outcome definitions in studies that leverage claims data. Better transparency in outcome reporting is needed. Future exploration of how fracture definitions impact study results is warranted.
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Affiliation(s)
- N Konstantelos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
| | - A M Rzepka
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - A M Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- ETH Zurich, Zurich, Switzerland
| | - A M Cheung
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - S Kim
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
| | - P Grootendorst
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- WHO Collaborating Centre for Governance, Accountability and Transparency in the Pharmaceutical Sector, Toronto, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- WHO Collaborating Centre for Governance, Accountability and Transparency in the Pharmaceutical Sector, Toronto, Canada
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, USA
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5
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Konstantelos N, Rzepka AM, Cadarette SM. Fracture outcome definitions in observational osteoporosis drug effects studies: a scoping review protocol. JBI Evid Synth 2021; 20:907-916. [PMID: 34636342 DOI: 10.11124/jbies-20-00509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to describe fracture outcome definitions in observational osteoporosis drug effects studies from Canada and the United States of America. INTRODUCTION Health care administrative data are commonly utilized in pharmacoepidemiologic studies. These data are used to define outcomes, such as fractures, and are critical to determining real-world safety and effectiveness of medications. However, there is no current standard for fracture outcome definitions in observational studies. As a result, fractures are inconsistently defined. To inform future research, a synthesis of how fractures are defined in observational studies using health care administrative claims data is needed. Providing clarity on how fractures are defined will provide guidance for future research. INCLUSION CRITERIA We will include observational studies from the United States and Canada published in English from 2000 to the present that consider the impact of osteoporosis pharmacotherapies on fracture risk and leverage health care administrative data. METHODS This review will follow the three-step JBI methodology for scoping reviews. We will search MEDLINE (Ovid), Embase (Ovid), and CINAHL (EBSCO). Following de-duplication, titles and abstracts will be screened independently by two reviewers. We will then conduct full-text screening for eligible studies. In addition, Canadian and American government pharmacovigilance websites will be searched to identify gray literature. Data extraction will be completed by two reviewers. Results will be presented in figures and tabular form.
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Affiliation(s)
- Natalia Konstantelos
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada ICES, Toronto, ON, Canada Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA WHO Collaborating Center for Governance, Accountability and Transparency in the Pharmaceutical Sector, University of Toronto, Toronto, ON, Canada
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Yoon AP, Lee YL, Kane RL, Kuo CF, Lin C, Chung KC. Development and Validation of a Deep Learning Model Using Convolutional Neural Networks to Identify Scaphoid Fractures in Radiographs. JAMA Netw Open 2021; 4:e216096. [PMID: 33956133 PMCID: PMC8103226 DOI: 10.1001/jamanetworkopen.2021.6096] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Scaphoid fractures are the most common carpal fracture, but as many as 20% are not visible (ie, occult) in the initial injury radiograph; untreated scaphoid fractures can lead to degenerative wrist arthritis and debilitating pain, detrimentally affecting productivity and quality of life. Occult scaphoid fractures are among the primary causes of scaphoid nonunions, secondary to delayed diagnosis. OBJECTIVE To develop and validate a deep convolutional neural network (DCNN) that can reliably detect both apparent and occult scaphoid fractures from radiographic images. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study used a radiographic data set compiled for all patients presenting to Chang Gung Memorial Hospital (Taipei, Taiwan) and Michigan Medicine (Ann Arbor) with possible scaphoid fractures between January 2001 and December 2019. This group was randomly split into training, validation, and test data sets. The images were passed through a detection model to crop around the scaphoid and were then used to train a DCNN model based on the EfficientNetB3 architecture to classify apparent and occult scaphoid fractures. Data analysis was conducted from January to October 2020. EXPOSURES A DCNN trained to discriminate radiographs with normal and fractured scaphoids. MAIN OUTCOMES AND MEASURES Area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. Fracture localization was assessed using gradient-weighted class activation mapping. RESULTS Of the 11 838 included radiographs (4917 [41.5%] with scaphoid fracture; 6921 [58.5%] without scaphoid fracture), 8356 (70.6%) were used for training, 1177 (9.9%) for validation, and 2305 (19.5%) for testing. In the testing test, the first DCNN achieved an overall sensitivity and specificity of 87.1% (95% CI, 84.8%-89.2%) and 92.1% (95% CI, 90.6%-93.5%), respectively, with an AUROC of 0.955 in distinguishing scaphoid fractures from scaphoids without fracture. Gradient-weighted class activation mapping closely corresponded to visible fracture sites. The second DCNN achieved an overall sensitivity of 79.0% (95% CI, 70.6%-71.6%) and specificity of 71.6% (95% CI, 69.0%-74.1%) with an AUROC of 0.810 when examining negative cases from the first model. Two-stage examination identified 20 of 22 cases (90.9%) of occult fracture. CONCLUSIONS AND RELEVANCE In this study, DCNN models were trained to identify scaphoid fractures. This suggests that such models may be able to assist with radiographic detection of occult scaphoid fractures that are not visible to human observers and to reliably detect fractures of other small bones.
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Affiliation(s)
- Alfred P. Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Yi-Lun Lee
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Robert L. Kane
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Chihung Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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Brüne M, Emmel C, Meilands G, Andrich S, Droste S, Claessen H, Jülich F, Icks A. Self-reported medication intake vs information from other data sources such as pharmacy records or medical records: Identification and description of existing publications, and comparison of agreement results for publications focusing on patients with cancer - a systematic review. Pharmacoepidemiol Drug Saf 2021; 30:531-560. [PMID: 33617072 DOI: 10.1002/pds.5210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/18/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE To identify and describe publications addressing the agreement between self-reported medication and other data sources among adults and, in a subgroup of studies dealing with cancer patients, seek to identify parameters which are associated with agreement. METHODS A systematic review including a systematic search within five biomedical databases up to February 28, 2019 was conducted as per the PRISMA Statement. Studies and agreement results were described. For a subgroup of studies dealing with cancer, we searched for associations between agreement and patients' characteristics, study design, comparison data source, and self-report modality. RESULTS The literature search retrieved 3392 publications. Included articles (n = 120) show heterogeneous agreement. Eighteen publications focused on cancer populations, with relatively good agreement identified in those which analyzed hormone therapy, estrogen, and chemotherapy (n = 11). Agreement was especially good for chemotherapy (proportion correct ≥93.6%, kappa ≥0.88). No distinct associations between agreement and age, education or marital status were identified in the results. There was little evaluation of associations between agreement and study design, self-report modality and comparison data source, thus not allowing for any conclusions to be drawn. CONCLUSION An overview of the evidence available from validation studies with a description of several characteristics is provided. Studies with experimental design which evaluate factors that might affect agreement between self-report and other data sources are lacking.
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Affiliation(s)
- Manuela Brüne
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Carina Emmel
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Gisela Meilands
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Silke Andrich
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Sigrid Droste
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Heiner Claessen
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Fabian Jülich
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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McKnight A, Vigod SN, Dennis CL, Wanigaratne S, Brown HK. Association Between Chronic Medical Conditions and Acute Perinatal Psychiatric Health-Care Encounters Among Migrants: A Population-Based Cohort Study. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:854-864. [PMID: 33167692 PMCID: PMC7658421 DOI: 10.1177/0706743720931231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To examine the relationship between prepregnancy chronic medical conditions (CMCs) and the risk of acute perinatal psychiatric health-care encounters (i.e., psychiatric emergency department visits, hospitalizations) among refugees, nonrefugee immigrants, and long-term residents in Ontario. METHODS We conducted a population-based study of 15- to 49-year-old refugees (N = 29,189), nonrefugee immigrants (N = 187,430), and long-term residents (N = 641,385) with and without CMC in Ontario, Canada, with a singleton live birth in 2005 to 2015 and no treatment for mental illness in the 2 years before pregnancy. Modified Poisson regression was used to estimate the relative risk of a psychiatric emergency department visit or hospitalization from conception until 1 year postpartum among women with versus without CMC, stratified by migrant status. An unstratified model with an interaction term between CMC and migrant status was used to test for multiplicativity of effects. RESULTS The association between CMC and risk of a psychiatric emergency department visit or hospitalization was stronger among refugees (adjusted relative risk [aRR] = 1.87; 95% confidence interval [CI], 1.36 to 2.58) compared to long-term residents (aRR = 1.39; 95% CI, 1.30 to 1.48; interaction P = 0.047). The strength of the association was no different in nonrefugee immigrants (aRR = 1.26; 95% CI, 1.05 to 1.51) compared to long-term residents (interaction P = 0.45). CONCLUSION Our study identifies refugee women with CMC as a high-risk group for acute psychiatric health care in the perinatal period. Preventive psychosocial interventions may be warranted to enhance supportive resources for all women with CMC and, in particular refugee women, to reduce the risk of acute psychiatric health care in the perinatal period.
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Affiliation(s)
- Anthony McKnight
- Dalla Lana School of Public Health, 7938University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Simone N Vigod
- ICES, Toronto, Ontario, Canada.,Department of Psychiatry, 7938University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Cindy-Lee Dennis
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Ontario, Canada
| | - Susitha Wanigaratne
- Manitoba Centre for Health Policy, 8664University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hilary K Brown
- Dalla Lana School of Public Health, 7938University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Psychiatry, 7938University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Interdisciplinary Centre for Health & Society, 33530University of Toronto Scarborough, Scarborough, Ontario, Canada
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9
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Bisphosphonate and denosumab initiation in older adults in Ontario, Canada: a population-based cohort study. Arch Osteoporos 2020; 15:133. [PMID: 32816151 DOI: 10.1007/s11657-020-00796-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED We provide an update on how commonly prescribed osteoporosis therapies are being initiated in older adults in Ontario. Patients newly prescribed denosumab are older, more often female, and have more comorbidities than those prescribed bisphosphonates. Their characteristics, monitoring, and persistence with prescribed therapy differ from clinical trial participants. Real-world studies on oral bisphosphonates and denosumab might be valuable. PURPOSE To provide a contemporary view on oral bisphosphonate and denosumab prescribing to older adults in routine care. METHODS Using linked healthcare databases, we conducted a population-based cohort study of adults ≥ 66 years newly prescribed oral bisphosphonates or denosumab between February 2013 and March 2017 in Ontario, Canada. We captured their clinical characteristics, monitoring, and continuous use of prescribed therapies. We illustrate how "real-world" new users of bisphosphonates and denosumab differ from randomized controlled trial (RCT) participants. RESULTS There were 107,847 individuals newly prescribed oral bisphosphonates (n = 59,996) or denosumab (n = 47,851) over the study period. Compared with new users of oral bisphosphonates, denosumab users were older (mean age 79.1 vs. 75.7 years), more often female (97.2 vs. 71.8%), from non-rural areas (93.9 vs. 89.9%), and resided in long-term care (10.9 vs. 3.3%). They had more comorbidities including dementia, falls, and fractures. Following their new prescription, denosumab users had more frequent testing of serum calcium. Duration of continuous use of denosumab was longer than bisphosphonates, and more bisphosphonate users had evidence of treatment discontinuation (56.7 bisphosphonate vs. 33.8% denosumab users discontinued therapy at 365 days). Compared with RCT participants, a higher proportion of "real-world" bisphosphonate and denosumab users had comorbidities including advanced kidney disease. CONCLUSION The clinical characteristics and monitoring of new users of bisphosphonates and denosumab generally align with practice guidelines, product monographs, and drug reimbursement criteria. Given differences between real-world users and RCT participants, there may be a role for safety and effectiveness studies of bisphosphonates and denosumab in routine care.
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Brown HK, Cairncross ZF, Lipscombe LL, Wilton AS, Dennis CL, Ray JG, Guttmann A, Vigod SN. Prepregnancy Diabetes and Perinatal Mental Illness: A Population-Based Latent Class Analysis. Am J Epidemiol 2020; 189:573-582. [PMID: 31712817 DOI: 10.1093/aje/kwz254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/20/2022] Open
Abstract
We examined the risk of any perinatal mental illness associated with prepregnancy diabetes and identified how diabetes duration, complexity, and intensity of care affect this risk. We performed a population-based study of women aged 15-49 years with (n = 14,186) and without (n = 843,818) prepregnancy diabetes who had a singleton livebirth (Ontario, Canada, 2005-2015) and no recent mental illness. Modified Poisson regression estimated perinatal mental illness risk between conception and 1 year postpartum in women with versus without diabetes and in diabetes groups, defined by a latent class analysis of diabetes duration, complexity, and intensity-of-care variables, versus women without diabetes. Women with diabetes were more likely than those without to develop perinatal mental illness (18.1% vs. 16.0%; adjusted relative risk = 1.11, 95% confidence interval: 1.07, 1.15). Latent classes of women with diabetes were: uncomplicated and not receiving regular care (59.7%); complicated, with longstanding diabetes, and receiving regular care (16.4%); and recently diagnosed, with comorbidities, and receiving regular care (23.9%). Perinatal mental illness risk was elevated in all classes versus women without diabetes (adjusted relative risks: 1.09-1.12), but results for class 2 were nonsignificant after adjustment. Women with diabetes could benefit from preconception and perinatal strategies to reduce their mental illness risk.
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Tecle N, Teitel J, Morris MR, Sani N, Mitten D, Hammert WC. Convolutional Neural Network for Second Metacarpal Radiographic Osteoporosis Screening. J Hand Surg Am 2020; 45:175-181. [PMID: 31959378 DOI: 10.1016/j.jhsa.2019.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 10/03/2019] [Accepted: 11/22/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Osteoporosis and osteopenia are extremely common and can lead to fragility fractures. The purpose of this study was to determine whether a computer learning system could classify whether a hand radiograph demonstrated osteoporosis based on the second metacarpal cortical percentage. METHODS We used the second metacarpal cortical percentage as the osteoporosis predictor. A total of 4,000 posteroanterior (PA) radiographs of the hand were standardized through laterality correction, vertical alignment correction, segmentation, proxy osteoporosis predictor, and full pipeline. Laterality was classified using a LeNet convolutional neural network (CNN). Vertical alignment classification used 2,000 PA x-rays to determine vertical alignment of the second metacarpal. We employed segmentation to determine which pixels belong to the second metacarpal from 1,000 PA x-rays using the FSN-8 CNN. The full pipeline was tested on 265 previously unseen PA x-rays. RESULTS Laterality classification accuracy was 99.62%, with a specificity of 100% and sensitivity of 99.3%. Rotation of the hand within 10° of vertical was accurate in 93.2% of films. Segmentation was 94.8% accurate. Proxy osteoporosis predictor was 88.4% accurate. Full pipeline accuracy was 93.9%. In the testing data set, the CNN had a sensitivity of 82.4% and specificity of 95.7%. In the balanced data set, 6 of 39 osteoporotic films were classified as nonosteoporotic; sensitivity was 82.4% and specificity, 94.3%. CONCLUSIONS We have created a series of CNN that can accurately identify osteoporosis from non-osteoporosis. Furthermore, our CNN is able to make adjustments to images based on laterality and vertical alignment. CLINICAL RELEVANCE Convolutional neural network and computer learning can be used as an adjunct to dual-energy x-ray absorptiometry scans or to screen and make appropriate referrals for further workup in patients with suspected osteoporosis.
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Affiliation(s)
- Nahom Tecle
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
| | - Jack Teitel
- Health Lab, University of Rochester, Rochester, NY
| | - Michael R Morris
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY
| | - Numair Sani
- Health Lab, University of Rochester, Rochester, NY
| | - David Mitten
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY; Health Lab, University of Rochester, Rochester, NY
| | - Warren C Hammert
- Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY.
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Watt JA, Gomes T, Bronskill SE, Huang A, Austin PC, Ho JM, Straus SE. Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study. CMAJ 2019; 190:E1376-E1383. [PMID: 30478215 DOI: 10.1503/cmaj.180551] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Trazodone is increasingly prescribed for behavioural and psychological symptoms of dementia, but little is known about its risk of harm. Our objective was to describe the comparative risk of falls and fractures among older adults with dementia dispensed trazodone or atypical antipsychotics. METHODS The study cohort included adults with dementia (excluding patients with chronic psychotic illnesses) living in long-term care and aged 66 years and older. Data were obtained from routinely collected, linked health administrative databases in Ontario, Canada. We compared new users of trazodone with new users of atypical antipsychotics (quetiapine, olanzapine or risperidone) between Dec. 1, 2009, and Dec. 31, 2015. The primary outcome was a composite of fall or major osteoporotic fracture within 90 days of first prescription. Secondary outcomes were falls, major osteoporotic fractures, hip fractures and all-cause mortality. RESULTS We included 6588 older adults dispensed trazodone and 2875 dispensed an atypical antipsychotic, of whom 95.2% received a low dose of these medications. Compared with use of atypical antipsychotics, use of trazodone was associated with similar rates of falls or major osteoporotic fractures (weighted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.73 to 1.07), major osteoporotic fracture (weighted HR 1.03, 95% CI 0.73 to 1.47), falls (weighted HR 0.91, 95% CI 0.75 to 1.11) and hip fractures (weighted HR 0.92, 95% CI 0.59 to 1.43). Use of trazodone was associated with a lower rate of mortality (weighted HR 0.75, 95% CI 0.66 to 0.85). INTERPRETATION Trazodone is not a uniformly safer alternative to atypical antipsychotics, given the similar risk of falls and fractures among older adults with dementia.
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Affiliation(s)
- Jennifer A Watt
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Tara Gomes
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Susan E Bronskill
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Anjie Huang
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Peter C Austin
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Joanne M Ho
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont
| | - Sharon E Straus
- Division of Geriatric Medicine (Watt, Straus), University of Toronto; Li Ka Shing Knowledge Institute (Watt, Gomes, Straus), St. Michael's Hospital; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; ICES Central (Bronskill, Huang, Austin); Institute of Health Policy, Management, and Evaluation (Bronskill, Austin), University of Toronto, Toronto Ont.; ICES McMaster (Ho); Department of Medicine (Ho), McMaster University, Hamilton, Ont.
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Ban JK, Hao BB, McCarthy L, Guilcher SJT, Cadarette SM. Denosumab utilization among older adults in Ontario: patient characteristics, persistence with therapy, and return to therapy after an extended gap. Osteoporos Int 2019; 30:1865-1872. [PMID: 31317248 DOI: 10.1007/s00198-019-05051-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
UNLABELLED We studied 46,797 older adults who initiated denosumab in Ontario, Canada. Patient characteristics remained relatively stable over time and aligned with public reimbursement restrictions. Almost half of patients persisted with therapy for at least 3 years. Fifty-nine percent of patients who discontinued denosumab returned to treatment within 3.6 years. INTRODUCTION The purpose of this study was to describe the characteristics of patients who initiated denosumab and estimate persistence with therapy. METHODS We identified older adults (aged ≥ 66 years) in Ontario who initiated denosumab between 2012/02 and 2015/03 and followed them to 2016/03. Patient characteristics were summarized using medical and pharmacy claims in the year before starting denosumab and osteoporosis drug use considered since 1996/10. Persistence with denosumab and return after discontinuation (> 90-day gap) were estimated using Kaplan-Meier curves. Analyses were stratified by community and long-term care (LTC) residence. RESULTS We identified 46,797 patients (monthly mean = 1263, SD = 187); 97% female, 13% LTC. Community-dwelling patients had a higher prevalence of bone mineral density testing (62% vs. 5%), yet were younger (mean age 78.5 vs. 86.6 years) and had lower prevalence of hip fractures (3% vs. 10%) compared to LTC patients. Eighty-two percent of patients had used osteoporosis medications in the past; 99% of whom took an oral bisphosphonate. Persistence was similar between community-dwelling and LTC patients: 59% persisted ≥ 2 years, 48% ≥ 3 years, and 38% ≥ 4 years, yet a larger proportion of LTC patients returned to denosumab after discontinuation (76% vs. 57%). CONCLUSIONS Denosumab utilization is increasing at a steady rate in Ontario. However, persistence remains a concern given the highly reversible pharmacokinetic profile of denosumab that results in a rapid increased fracture risk following discontinuation. Over 80% of patients had a history of oral bisphosphonate therapy, which may persist in bone despite discontinuing denosumab. Consequently, better understanding of denosumab safety and effectiveness among real-world users is important.
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Affiliation(s)
- J K Ban
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - B B Hao
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - L McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - S J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Sujic R, Beaton DE, Mamdani M, Cadarette SM, Luo J, Jaglal S, Sale JEM, Jain R, Bogoch E. Five-year refracture rates of a province-wide fracture liaison service. Osteoporos Int 2019; 30:1671-1677. [PMID: 31152183 DOI: 10.1007/s00198-019-05017-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 05/14/2019] [Indexed: 11/26/2022]
Abstract
UNLABELLED We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk. INTRODUCTION To examine refractures among patients screened in a province-wide fracture liaison service (FLS). METHODS We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates. RESULTS The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70 years: HR = 1.3, CI 95%, 1.0-1.7; 71-80 years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5). CONCLUSIONS One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.
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Affiliation(s)
- R Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - D E Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Work & Health, Toronto, ON, Canada
| | - M Mamdani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - S M Cadarette
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - J Luo
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - S Jaglal
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - R Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - E Bogoch
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Mobility Program, St. Michael's Hospital, Toronto, ON, Canada
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Kapoor E, Austin PC, Alibhai SM, Cheung AM, Cram P, Casaubon LK, Fang J, Porter J, Smith EE, Prager M, Kapral MK. Screening and Treatment for Osteoporosis After Stroke. Stroke 2019; 50:1564-1566. [DOI: 10.1161/strokeaha.118.024685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eshita Kapoor
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | | | - Shabbir M.H. Alibhai
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | - Angela M. Cheung
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | - Peter Cram
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | - Leanne K. Casaubon
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, Canada (P.C.A., J.F., J.P., M.K.K.)
| | - Joan Porter
- ICES, Toronto, Canada (P.C.A., J.F., J.P., M.K.K.)
| | - Eric E. Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.)
| | - Marla Prager
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
| | - Moira K. Kapral
- From the Department of Medicine, University of Toronto, Canada (E.K., S.M.H.A., A.M.C., P.C., L.K.C., M.P., M.K.K.)
- ICES, Toronto, Canada (P.C.A., J.F., J.P., M.K.K.)
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Giannakeas V, Cadarette SM, Ban JK, Lipscombe L, Narod SA, Kotsopoulos J. Denosumab and breast cancer risk in postmenopausal women: a population-based cohort study. Br J Cancer 2018; 119:1421-1427. [PMID: 30420611 PMCID: PMC6265331 DOI: 10.1038/s41416-018-0225-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Denosumab inhibits the receptor activator of nuclear factor κB (RANK) pathway and is used to treat osteoporosis. Emerging evidence suggests RANK-blockade may play a role in mammary tumourigenesis. Thus, we undertook a population-based study of denosumab use and breast cancer risk in a large cohort of postmenopausal women. METHODS We included women 67+ years with prior bisphosphonate use who filled a first prescription for denosumab. They were matched on age, date, cumulative prior use of and time since last use of a bisphosphonate to women with no history of denosumab. Cox proportional hazards was used to estimate the hazard ratio (HR) of breast cancer with denosumab use. RESULTS A total of 100,368 women were included in the analysis with 1271 incident breast cancer events. Denosumab use was associated with a 13% decreased breast cancer risk (HR = 0.87; 95% CI 0.76-1.00). There was no relationship between increasing number of denosumab doses and breast cancer risk (P-trend = 0.15). CONCLUSION These findings suggest a potential protective effect of ever denosumab use on breast cancer risk in a cohort of older women previously treated with bisphosphonates.
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Affiliation(s)
- Vasily Giannakeas
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Suzanne M Cadarette
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Joann K Ban
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Lorraine Lipscombe
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Beaton DE, Mamdani M, Zheng H, Jaglal S, Cadarette SM, Bogoch ER, Sale JEM, Sujic R, Jain R. Improvements in osteoporosis testing and care are found following the wide scale implementation of the Ontario Fracture Clinic Screening Program: An interrupted time series analysis. Medicine (Baltimore) 2017; 96:e9012. [PMID: 29310418 PMCID: PMC5728819 DOI: 10.1097/md.0000000000009012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We evaluated a system-wide impact of a health intervention to improve treatment of osteoporosis after a fragility fracture. The intervention consisted of assigning a screening coordinator to selected fracture clinics to identify, educate, and follow up with fragility fracture patients and inform their physicians of the need to evaluate bone health. Thirty-seven hospitals in the province of Ontario (Canada) were assigned a screening coordinator. Twenty-three similar hospitals were control sites. All hospitals had orthopedic services and handled moderate-to-higher volumes of fracture patients. Administrative health data were used to evaluate the impact of the intervention.Fragility fracture patients (≥50 years; hip, humerus, forearm, spine, or pelvis fracture) were identified from administrative health records. Cases were fractures treated at 1 of the 37 hospitals assigned a coordinator. Controls were the same types of fractures at the control sites. Data were assembled for 20 quarters before and 10 quarters after the implementation (from January 2002 to March 2010). To test for a shift in trends, we employed an interrupted time series analysis-a study design used to evaluate the longitudinal effects of interventions, through regression modelling. The primary outcome measure was bone mineral density (BMD) testing. Osteoporosis medication initiation and persistence rates were secondary outcomes in a subset of patients ≥66 years of age.A total of 147,071 patients were used in the analysis. BMD testing rates increased from 17.0% pre-intervention to 20.9% post-intervention at intervention sites (P < .01) compared with no change at control sites (14.9% and 14.9%, P = .33). Medication initiation improved significantly at intervention sites (21.6-23.97%; P = .02) but not at control sites (17.5-18.5%; P = .27). Persistence with bisphosphonates decreased at all sites, from 59.9% to 56.4% at intervention sites (P = .02) and more so from 62.3% to 54.2% at control sites (P < .01) using 50% proportion of days covered (PDC 50).Significant improvements in BMD testing and treatment initiation were observed after the initiation of a coordinator-based screening program to improve osteoporosis management following fragility fracture.
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Affiliation(s)
- Dorcas E. Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Occupational Sciences and Occupational Therapy, University of Toronto
- Institute for Work & Health
| | - Muhammad Mamdani
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute for Clinical Evaluative Sciences
- Leslie Dan Faculty of Pharmacy, University of Toronto
| | - Hong Zheng
- Institute for Clinical Evaluative Sciences
| | - Susan Jaglal
- Institute for Clinical Evaluative Sciences
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy, University of Toronto
| | - Suzanne M. Cadarette
- Institute for Clinical Evaluative Sciences
- Leslie Dan Faculty of Pharmacy, University of Toronto
| | - Earl R. Bogoch
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto
| | - Joanna E. M. Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Rebeka Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
| | - Ravi Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
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Beaton DE, Vidmar M, Pitzul KB, Sujic R, Rotondi NK, Bogoch ER, Sale JEM, Jain R, Weldon J. Addition of a fracture risk assessment to a coordinator's role improved treatment rates within 6 months of screening in a fragility fracture screening program. Osteoporos Int 2017; 28:863-869. [PMID: 27770155 DOI: 10.1007/s00198-016-3794-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/27/2016] [Indexed: 12/26/2022]
Abstract
UNLABELLED We evaluated the impact of a more intensive version of an existing post-fracture coordinator-based fracture prevention program and found that the addition of a full-risk assessment improved treatment rates. These findings provide additional support for more intensive programs aimed at reducing the risk of re-fractures. INTRODUCTION Evidence-based guidelines support coordinator-based programs to improve post-fracture osteoporosis guideline uptake, with more intensive programs including bone mineral density (BMD) testing and/or treatment being associated with better patient outcomes. The purpose of this study was to evaluate the impact of a more intensive version (BMD "fast track") of an existing provincial coordinator-based program. METHODS We compared two versions of the program that screened treatment naïve fragility fracture patients (>50 years). Cases came from the BMD fast track program that included full fracture risk assessment and communication of relevant guidelines to the primary care provider (PCP). Matched controls were selected from the usual care program matching according to age, sex, fracture type, and date. Two matching techniques were used: traditional (hard) matching (TM) and propensity score matching (PS). The outcomes were treatment initiation with bone sparing medication, BMD testing rate, and the rate of returning to discuss the test results with a PCP. RESULTS The program improvements led to a significant improvement in treatment initiation within 6 months from 16 % (controls based on PS) or 21 % (controls based on TM) to 32 % (cases). Ninety percent of patients in the BMD fast track program returned to their PCP to discuss bone health in the cases versus 60 % of the controls (for TM and PS). BMD testing occurred in 96 % of cases compared to the 66 (TM) or 65 % (PS) of the matched controls. CONCLUSIONS Addition of a full-risk assessment to a coordinator-based program significantly improved treatment rates within 6 months of screening.
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Affiliation(s)
- D E Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - M Vidmar
- Analytics & Informatics: Access to Care, Cancer Care Ontario, Toronto, ON, Canada
| | - K B Pitzul
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - R Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - N K Rotondi
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - E R Bogoch
- Mobility Program, St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - R Jain
- Osteoporosis Canada, Toronto, ON, Canada
| | - J Weldon
- Osteoporosis Canada, Toronto, ON, Canada
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Abstract
BACKGROUND It remains uncertain whether kidney transplant recipients are a high-risk group for fracture. METHODS We conducted a cohort study using Ontario, Canada health care databases to estimate the 3-, 5- and 10-year cumulative incidence of nonvertebral fracture (proximal humerus, forearm, hip) in adult kidney transplant recipients between 1994 and 2009, stratifying by sex and age (<50 versus ≥50 years) at transplant. We also assessed the 3-year cumulative incidence of all fracture locations (excluding skull, toes, and fingers) and falls, 10-year cumulative incidence of hip fracture alone, and nonvertebral fracture incidence in recipients compared to nontransplant reference groups matched on age, sex, and cohort entry year. We studied 4821 recipients (median age, 50 years). RESULTS Among the age and sex strata, female recipients aged 50 years or older had the highest 3-year cumulative incidence of nonvertebral fracture (3.1%; 95% confidence interval [95% CI], 2.1-4.4%). Recipients had a higher 3-year cumulative incidence of nonvertebral fracture (1.6%; 95% CI, 1.3-2.0%) compared to the general population with no previous nonvertebral fracture (0.5%; 95% CI, 0.4-0.6%; P < 0.0001) and nondialysis chronic kidney disease (1.1%; 95% CI, 0.9-1.2%; P = 0.03), but a lower fracture incidence than the general population with a previous nonvertebral fracture (2.3%; 95% CI, 1.9-2.8%; P = 0.007). The 10-year cumulative incidence of hip fracture in all recipients was 1.7% (≥3% defined as high risk in clinical guidelines). CONCLUSIONS Kidney transplant recipients may have a lower fracture risk than previously suggested in the literature. Results inform our understanding of fracture incidence after kidney transplantation and how it compares to nontransplant populations.
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Naylor KL, Zou G, Leslie WD, McArthur E, Lam NN, Knoll GA, Kim SJ, Fraser LA, Adachi JD, Hodsman AB, Garg AX. Frequency of bone mineral density testing in adult kidney transplant recipients from Ontario, Canada: a population-based cohort study. Can J Kidney Health Dis 2016; 3:2. [PMID: 26779343 PMCID: PMC4715326 DOI: 10.1186/s40697-016-0092-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/17/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We lack consensus on the clinical value, frequency, and timing of bone mineral density (BMD) testing in kidney transplant recipients. This study sought to determine practice patterns in BMD testing across kidney transplant centres in Ontario, Canada, and to compare the frequency of testing in kidney transplant recipients to non-transplant reference groups. METHODS Using healthcare databases from Ontario, Canada we conducted a population-based cohort study of adult kidney transplant recipients who received a transplant from 1994-2009. We used logistic regression to determine if there was a statistically significant difference across transplant centres in the decision to perform at least one BMD test after transplantation, adjusting for covariates that may influence a physician's decision to order a BMD test. We used the McNemar's test to compare the number of recipients who had at least one BMD test to non-transplant reference groups (matching on age, sex, and date of cohort entry). RESULTS In the first 3 years after transplant, 4821 kidney transplant recipients underwent 4802 BMD tests (median 1 test per recipient, range 0 to 6 tests), costing $600,000 (2014 CAD equivalent dollars). Across the six centres, the proportion of recipients receiving at least one BMD test varied widely (ranging from 15.6 to 92.1 %; P < 0.001). Over half (58 %) of the recipients received at least one BMD test post-transplant, a value higher than two non-transplant reference groups (general population with a previous non-vertebral fracture [hip, forearm, proximal humerus], 13.8 %; general population with no previous non-vertebral fracture, 8.5 %; P value <0.001 for each of the comparisons). CONCLUSIONS There is substantial practice variability in BMD testing after transplant. New high-quality information is needed to inform the utility, optimal timing, and frequency of BMD testing in kidney transplant recipients.
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Affiliation(s)
- Kyla L Naylor
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario Canada ; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada ; Institute for Clinical Evaluative Sciences, Room ELL-111, Westminster, London Health Sciences Centre, 800 Commissioners Road East,London, Ontario, N6A 4G5 Canada
| | - Guangyong Zou
- Department of Epidemiology & Biostatistics, Western University, London, Ontario Canada
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario Canada
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, AB Canada
| | - Gregory A Knoll
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario Canada ; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada ; Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario Canada
| | - Lisa-Ann Fraser
- Division of Endocrinology, Western University, London, Ontario Canada
| | - Jonathan D Adachi
- Division of Rheumatology, McMaster University, Hamilton, Ontario Canada
| | | | - Amit X Garg
- Institute for Clinical Evaluative Sciences (ICES), London, Ontario Canada ; Department of Epidemiology & Biostatistics, Western University, London, Ontario Canada ; Division of Nephrology, Western University, London, Ontario Canada
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Albaum JM, Lévesque LE, Gershon AS, Liu G, Cadarette SM. Glucocorticoid-induced osteoporosis management among seniors, by year, sex, and indication, 1996-2012. Osteoporos Int 2015; 26:2845-52. [PMID: 26138581 DOI: 10.1007/s00198-015-3200-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/05/2015] [Indexed: 01/30/2023]
Abstract
UNLABELLED We identified that glucocorticoid-induced osteoporosis management (bone mineral density testing or osteoporosis treatment) among seniors improved among men (2 to 23 %) and women (10 to 48 %) between 1996 and 2007, and then remained relatively stable through to 2012. Differences were also noted by indication (from a low of 21 % for respiratory conditions to a high of 41 % for rheumatic conditions). PURPOSE The aim of our study was to describe the proportion of chronic oral glucocorticoid (GC) users that receive osteoporosis management (bone mineral density test or osteoporosis treatment) by sex and over time. METHODS We identified community-dwelling older adults initiating chronic oral GC therapy in Ontario using pharmacy data from 1996 to 2012. Chronic GC use was defined as greater than or equal to two oral GC prescriptions dispensed and ≥450 mg prednisone equivalent over a 6-month period. Osteoporosis management within 6 months of starting chronic GC therapy was examined by sex, year, indication for therapy, and osteoporosis management history. Results were summarized using descriptive statistics. RESULTS We identified 72,099 men and 95,975 women starting chronic oral GC therapy (mean age = 74.9 years, SD = 6.5). Approximately two thirds of patients (65 %) received ≥900 mg within the 6-month chronic use window. GC-induced osteoporosis management increased from 2 to 23 % (men) and 10 to 48 % (women) between 1996 and 2007, and then remained relatively stable through to 2012. A higher proportion of patients with prior osteoporosis management were managed within 6 months (56 % men, 67 % women) of chronic GC use, compared to patients without prior management (12 % men, 23 % women). Patients with rheumatic disease were managed most commonly (41 %), and patients with respiratory conditions were managed least commonly (21 %). CONCLUSIONS GC-induced osteoporosis management improved significantly over time for both sexes yet remains low. Significant care gaps by sex and between clinical areas represent a missed opportunity for fracture prevention among patients requiring chronic GC therapy.
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Affiliation(s)
- J M Albaum
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - L E Lévesque
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - A S Gershon
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - G Liu
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
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Cadarette SM, Wong L. An Introduction to Health Care Administrative Data. Can J Hosp Pharm 2015; 68:232-7. [PMID: 26157185 DOI: 10.4212/cjhp.v68i3.1457] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Suzanne M Cadarette
- PhD, is Associate Professor with the Leslie Dan Faculty of Pharmacy, University of Toronto, and Senior Adjunct Scientist with the Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Lindsay Wong
- BScPhm, PharmD, was, at the time of writing, a student in the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario. She is currently a pharmacy intern at St Michael's Hospital, Toronto, Ontario
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Jandoc R, Jembere N, Khan S, Russell SJ, Allard Y, Cadarette SM. Osteoporosis management and fractures in the Métis of Ontario, Canada. Arch Osteoporos 2015; 10:12. [PMID: 25910866 PMCID: PMC4412654 DOI: 10.1007/s11657-015-0212-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 02/17/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED Half of Métis citizens, compared to less than 10 % of the general population of Ontario, reside in northern regions, with little access to bone mineral density (BMD) testing. Métis citizens had lower sex-specific and age-standardized rates of BMD testing, yet similar rates of fracture (both sexes) and pharmacotherapy (women only). PURPOSE To examine osteoporosis management and common osteoporosis-related fractures among Métis citizens compared to the general population of older adults residing in Ontario. METHODS We linked healthcare (medical and pharmacy) utilization and administrative (demographic) databases with the Métis Nation of Ontario citizenship registry to estimate osteoporosis management (bone mineral density [BMD] testing, pharmacotherapy) and fractures (hip, humerus, radius/ulna) among adults aged ≥50 years, from April 1, 2006 to March 31, 2011. Pharmacotherapy data were limited to residents aged ≥65 years. Sex-specific and age-standardized rates were compared between the Métis and the general population. Multivariable logistic regression was used to compare rates of BMD testing after controlling for differences in age and region of residence between the Métis and the general population. RESULTS We studied 4219 Métis citizens (55 % men), and 140 (3 %) experienced a fracture. Half of Métis citizens, compared to less than 10 % of the general population of Ontario, resided in northern regions. We identified significantly lower sex-specific and age-standardized rates of BMD testing among Métis compared to the general population, yet found little difference in fracture rates (both sexes) or pharmacotherapy (women only). Differences in BMD testing disappeared after adjusting for region of residence among women yet remained significant among men. CONCLUSIONS Despite finding significantly lower rates of osteoporosis management among men, Métis men and women were found to have similar age-standardized fracture rates to the general population.
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Affiliation(s)
- Racquel Jandoc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | | | - Saba Khan
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | | | | | - Suzanne M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada ,Institute for Clinical Evaluative Sciences, Toronto, ON Canada ,Leslie L. Dan Pharmacy Building, University of Toronto, 144 College Street, Toronto, ON M5S 3M2 Canada
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Ioannidis G, Pallan S, Papaioannou A, Mulgund M, Rios L, Ma J, Thabane L, Davison KS, Josse RG, Kovacs CS, Kreiger N, Olszynski WP, Prior JC, Towheed T, Adachi JD. Glucocorticoids predict 10-year fragility fracture risk in a population-based ambulatory cohort of men and women: Canadian Multicentre Osteoporosis Study (CaMos). Arch Osteoporos 2014; 9:169. [PMID: 24577853 PMCID: PMC5112017 DOI: 10.1007/s11657-013-0169-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 12/16/2013] [Indexed: 02/03/2023]
Abstract
UNLABELLED We determined the prospective 10-year association among incident fragility fractures and four glucocorticoid (GC) treatment groups (Never GC, Prior GC, Baseline GC, and Ever GC). Results showed that GC treatment is associated with increased 10-year incident fracture risk in ambulatory men and women across Canada. PURPOSE Using the Canadian Multicentre Osteoporosis Study dataset, we determined the prospective 10-year association between incident fragility fractures and GC treatment. METHODS We conducted a 10-year prospective observational cohort study at nine sites across Canada. A total of 9,263 ambulatory men and women 25 years of age and older were included in the analysis. Multivariable Cox proportional hazards analyses were conducted to determine the relationship among GC treatment groups in four levels that included Never GC, Prior GC, Baseline GC, and Ever GC (combined baseline and prior groups) and time to fracture. RESULTS In each of the Never GC, Prior GC, Baseline GC, and Ever GC treatment groups, the number of participants were 8,832 (95.4 %), 303 (3.3 %), 128 (1.4 %), and 431 (4.7 %), respectively. Of the 9,263 individuals enrolled, incident fragility non-spine, hip, spine, and any fractures were experienced by a total of 896 (9.67 %), 157 (1.69 %), 130 (1.40 %), and 1,102 (11.90 %) over 10-years, respectively. For men and women combined, prior GC treatment was associated with a higher hazard ratio (HR) for time to incident non-vertebral (HR = 1.5, 95 % confidence interval [CI] = 1.1, 2.0), hip (HR = 2.1, 95 % CI = 1.1, 4.0), and any fracture (HR = 1.4, 95 % CI = 1.0, 1.8) compared with never GC treatment. CONCLUSIONS GC treatment is associated with increased 10-year incident fracture risk; this highlights the importance of considering therapy to prevent GC-induced fractures for patients who are using GC for various medical conditions.
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Affiliation(s)
| | - Shelley Pallan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Manisha Mulgund
- Department of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Lorena Rios
- Medicina Interna, Hospital Clinico FUSAT, Rancagua, VI Region, Chile
| | - Jinhui Ma
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | - Robert G. Josse
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christopher S. Kovacs
- Faculty of Medicine- Endocrinology, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | - Nancy Kreiger
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Jerilynn C. Prior
- Department of Medicine/Endocrinology, University of British Columbia, British Columbia, Canada
| | - Tanveer Towheed
- Department of Medicine, Queen’s University, Kingston, ON, Canada
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Sale JE, Beaton D, Posen J, Bogoch E. Medication initiation rates are not directly comparable across secondary fracture prevention programs: reporting standards based on a systematic review. J Clin Epidemiol 2013; 66:379-385.e4. [DOI: 10.1016/j.jclinepi.2012.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 09/28/2012] [Accepted: 10/24/2012] [Indexed: 01/08/2023]
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Burden AM, Huang A, Tadrous M, Cadarette SM. Variation in the days supply field for osteoporosis medications in Ontario. Arch Osteoporos 2013; 8:128. [PMID: 23475734 DOI: 10.1007/s11657-013-0128-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 02/12/2013] [Indexed: 02/03/2023]
Abstract
UNLABELLED We examined pharmacy claims for osteoporosis medications dispensed in the community (78 %) and long-term care (LTC) to determine if days supply values matched expected dosing intervals. Results identify potential reporting errors that can have implications for drug exposure misclassification, particularly in LTC where only 59 % of reported values matched expected values. INTRODUCTION The days supply field is commonly used to examine patterns of drug utilization and classify drug exposure, yet its accuracy has received little attention. We sought to describe the days supply reported for osteoporosis drugs and examine if values matched expected therapeutic dosing intervals. METHODS We examined days supply values for osteoporosis medications submitted to the Ontario Drug Benefits program for seniors, 1997-2011. Days supply values were evaluated by dosing regimen and setting (community or long-term care [LTC]) and compared to pre-defined expected values. We defined expected days supply by the therapeutic dosing interval: daily in 7- or 30-day intervals, or as 100 days; weekly in 7- or 30-day intervals; monthly and daily nasal spray in 28- or 30-day intervals; and cyclical etidronate as a 90-day supply. RESULTS We identified 17,615,404 osteoporosis prescriptions, with 78 % dispensed in the community. Most daily oral prescriptions were dispensed by an expected therapeutic dosing interval (97 %). Annual IV zoledronic acid was most commonly dispensed as a 1-day supply (62 %). Distinct differences in agreement were observed for other regimens, with the expected days supply more commonly reported in community versus LTC: cyclical etidronate (86 % vs. 40 %), weekly (91 % vs. 60 %), monthly (94 % vs. 35 %), and nasal spray (84 % vs. 40 %). CONCLUSIONS Results suggest that inaccuracies in the days supply field exist, particularly among prescriptions dispensed in LTC. Inaccurate reporting may have significant implications for osteoporosis drug exposure misclassification.
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Affiliation(s)
- Andrea M Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Cadarette SM, Carney G, Baek D, Gunraj N, Paterson JM, Dormuth CR. Osteoporosis medication prescribing in British Columbia and Ontario: impact of public drug coverage. Osteoporos Int 2012; 23:1475-80. [PMID: 21901476 PMCID: PMC3304053 DOI: 10.1007/s00198-011-1771-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 08/11/2011] [Indexed: 11/25/2022]
Abstract
UNLABELLED We compared the patterns of osteoporosis medication prescribing between two provinces in Canada with different public drug coverage policies. Oral bisphosphonates were the primary drugs used, yet access to the second-generation oral bisphosphonates (alendronate, risedronate) was limited in one region. Implications of differential access to oral bisphosphonates warrants further study. INTRODUCTION Approved therapies for treating osteoporosis in Canada include bisphosphonates, calcitonin, denosumab, raloxifene, and teriparatide. However, significant variation in access to these medications through public drug coverage exists across Canada. We sought to compare patterns of osteoporosis medication prescribing between British Columbia (BC) and Ontario. METHODS Using dispensing data from BC (PharmaNet) and Ontario (Ontario Drug Benefits), we identified all new users of osteoporosis medications aged 66 or more years from 1995/1996 to 2008/2009. We summarized the number of new users by fiscal year, sex, and index drug for each province. BC data were also stratified by whether drugs were dispensed within or outside public PharmaCare. RESULTS We identified 578,254 (n = 122,653 BC) eligible new users. Overall patterns were similar between provinces: (1) most patients received an oral bisphosphonate (93% in BC and 99% in Ontario); (2) etidronate prescribing declined after 2001/2002, reaching a low of 41% in BC and 10% in Ontario in 2008/2009; and (3) the proportion of males treated increased over time, from 7% in 1996/1997 to 25% in 2008/2009. However, we note major differences within versus outside the BC PharmaCare system. In particular, <2% of drugs dispensed within PharmaCare compared to 79% of drugs dispensed outside PharmaCare were for a second-generation bisphosphonate (alendronate or risedronate). CONCLUSIONS Oral bisphosphonates are the primary drugs used to treat osteoporosis in Canada. Prescribing practices changed over time as newer medications came to market, yet access to second-generation bisphosphonates through BC PharmaCare was limited. Implications of differential access to oral bisphosphonates warrants further study.
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Affiliation(s)
- S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, M5S 3M2, ON, Canada.
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Burden AM, Paterson JM, Solomon DH, Mamdani M, Juurlink DN, Cadarette SM. Bisphosphonate prescribing, persistence and cumulative exposure in Ontario, Canada. Osteoporos Int 2012; 23:1075-82. [PMID: 21604008 PMCID: PMC3277689 DOI: 10.1007/s00198-011-1645-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 03/15/2011] [Indexed: 11/02/2022]
Abstract
UNLABELLED We studied new users of oral bisphosphonates and found that less than half persisted with therapy for 2 years, and interruptions in use were common. During a median observation period of 4.7 years, 10% of patients filled only a single prescription, 37% switched therapies and median cumulative exposure was 2.2 years. INTRODUCTION We sought to describe bisphosphonate prescribing, persistence and cumulative exposure among seniors in Ontario, Canada. METHODS We used Ontario Drug Benefit pharmacy claims to identify residents aged ≥ 66 years who initiated oral bisphosphonate therapy between April 1996 and March 2009. The first date of bisphosphonate dispensing was considered the index date. Persistence with therapy was defined as continuous treatment with no interruption exceeding 60 days. We examined persistence with therapy and the number of extended gaps (>60 days) between prescriptions over time periods ranging from 1 to 9 years. We also identified the proportion of patients filling only a single prescription and switching to a different bisphosphonate, and calculated the median days of exposure irrespective of gaps in therapy. RESULTS A total of 451,113 eligible new bisphosphonate users were identified: mean age = 75.6 years (SD = 6.9), 84% female, and median follow-up length = 4.7 years. Persistence with therapy declined from 63% at 1 year to 46% at 2 years and 12% at 9 years. Among those with at least 5 years of follow-up (n = 213,029), 61% had one or more extended gaps in bisphosphonate therapy. Overall, 10% of patients filled only a single prescription, 37% switched to a different bisphosphonate and the median exposure was 2.2 years. CONCLUSION Less than half of patients persisted with bisphosphonate therapy for 2 years and interruptions in therapy were common, with most patients experiencing two or more >60-day gaps in therapy. Interventions are needed to improve persistence with bisphosphonate therapy and reduce the frequency of gaps in treatment.
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Affiliation(s)
- A. M. Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
| | - J. M. Paterson
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Department of Family Medicine, McMaster University, Hamilton, ON Canada
- Centre for Evaluation of Medicines, St. Joseph’s Healthcare, Hamilton, ON Canada
| | - D. H. Solomon
- Division of Rheumatology, Immunology and Allergy and Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - M. Mamdani
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON Canada
| | | | - S. M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON Canada M5S 3M2
- Institute for Clinical Evaluative Sciences, Toronto, ON Canada
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Jaglal SB, Donescu OS, Bansod V, Laprade J, Thorpe K, Hawker G, Majumdar SR, Meadows L, Cadarette SM, Papaioannou A, Kloseck M, Beaton D, Bogoch E, Zwarenstein M. Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial. Osteoporos Int 2012; 23:87-95. [PMID: 21779817 PMCID: PMC3249212 DOI: 10.1007/s00198-011-1726-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 06/01/2011] [Indexed: 11/30/2022]
Abstract
UNLABELLED We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management. INTRODUCTION To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control). METHODS A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications. RESULTS Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0). CONCLUSIONS A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.
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Affiliation(s)
- S B Jaglal
- Toronto Rehabilitation Institute, Toronto, ON, Canada.
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Bibliography. Parathyroids, bone and mineral metabolism. Current world literature. Curr Opin Endocrinol Diabetes Obes 2011; 18:418-22. [PMID: 22024994 DOI: 10.1097/med.0b013e32834decbe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bessette L, Davison KS, Jean S, Roy S, Ste-Marie LG, Brown JP. The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial. Osteoporos Int 2011; 22:2963-72. [PMID: 21311871 DOI: 10.1007/s00198-011-1533-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED This study assessed whether osteoporosis diagnosis and treatment after an osteoporotic fracture can be increased by providing osteoporosis reading material to patients and family doctors or by watching a videocassette about osteoporosis. Educating patients about osteoporosis had little impact on whether a woman received an osteoporosis diagnosis or treatment. INTRODUCTION The purpose of this study was to investigate the impact of two education-based interventions on osteoporosis diagnosis and treatment in women ≥ 50 years of age after fragility fracture. METHODS Six to eight months after fracture, women were randomized into three groups: (1) control, (2) written materials, or (3) videocassette and written materials. Written materials for both the patient and physician detailed osteoporosis, fragility fracture, and available treatments; written materials for physicians were provided through patients. The educational videocassette presented similar information as the written material, but in greater depth. Rates of osteoporosis diagnosis and treatment following intervention were compared among groups using survival analysis methods. Statistical significance was set at p < 0.0167. RESULTS At randomization, 1,174 women were without osteoporosis diagnosis and treatment, and after follow-up, 12% of the control group, 15% of the written materials group (p = 0.073), and 16% (p = 0.036) of the videocassette and written materials group were diagnosed with osteoporosis (statistical comparisons to control). Treatment rates were 8% for the control group, 12% for the written materials group (p = 0.052), and 11% for the videocassette and written materials group (p = 0.157). At randomization, 1,314 women were without treatment and after follow-up therapy was initiated in 10% of the control group, 13% of the written materials group (p = 0.107), and 13% of the videocassette and written materials group (p = 0.238). CONCLUSIONS The educational interventions assessed in this trial were not satisfactory to increase osteoporosis diagnosis or treatment in recently fractured women to a clinically meaningful degree.
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Affiliation(s)
- L Bessette
- Department of Medicine, CHUL Research Centre, Laval University, Quebec City, PQ, Canada.
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Elias MN, Burden AM, Cadarette SM. The impact of pharmacist interventions on osteoporosis management: a systematic review. Osteoporos Int 2011; 22:2587-96. [PMID: 21720894 PMCID: PMC3169776 DOI: 10.1007/s00198-011-1661-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 02/25/2011] [Indexed: 01/22/2023]
Abstract
UNLABELLED We completed a systematic review of the literature to examine the impact of pharmacist interventions in improving osteoporosis management. Results from randomized controlled trials suggest that pharmacist interventions may improve bone mineral density testing and calcium intake among patients at high risk for osteoporosis. INTRODUCTION Pharmacists play a key role in many healthcare systems by helping patients manage chronic diseases. We completed a systematic review of the literature to identify randomized controlled trials (RCTs) that have examined the impact of pharmacy interventions in narrowing two gaps in osteoporosis management: identifying at-risk individuals and improving adherence to therapy. METHODS We searched the electronic databases of EMBASE, HealthStar, International Pharmaceutical Abstracts, MEDLINE, and PubMed from database development to April 2010, examined grey literature, and completed manual searches of reference lists to identify English-language research that examined osteoporosis management interventions within pharmacy practice. Results from RCTs were abstracted and assessed for bias. RESULTS We identified 25 studies that examined pharmacist interventions in osteoporosis management: 16 cohort, 5 cross-sectional, 1 historical/ecological control, and 3 RCTs. RCT interventions included osteoporosis educational and counseling programs, screening by pharmacists based on risk factor assessment or bone mineral density testing, and physician contact or recommendations for patients to follow-up with a general practitioner. Results from the three RCTs suggest that pharmacist interventions may improve bone mineral density testing (targeted screening) and calcium intake among patients at high risk for osteoporosis. However, two of the three RCTs had high risk of bias, and no study examined the impact of pharmacist intervention on osteoporosis treatment adherence. CONCLUSIONS Data support the potential role for pharmacists to help reduce gaps in osteoporosis management through improved identification of high-risk patients. More research is needed to examine pharmacist interventions on osteoporosis treatment adherence.
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Affiliation(s)
- M. N. Elias
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON M5S 3M2 Canada
| | - A. M. Burden
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON M5S 3M2 Canada
| | - S. M. Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON M5S 3M2 Canada
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