The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial

Secondary fracture prevention in primary care: a narrative review

The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background

The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

Methods

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.

Results

At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Conclusions

The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Educational booklet reinforces knowledge of osteoporosis and influences intentions to improve bone health in previously diagnosed and treated patients

We examined individuals' experiences using an educational booklet developed by the Ontario Osteoporosis Strategy. The booklet appeared to motivate individuals to make changes to their existing management of their bone health and served as a reference tool reaffirming current practices and beliefs for others.

INTRODUCTION

The purpose of this study was to examine individuals' experiences of the educational booklet and explore the influence of the booklet on individuals' beliefs and actions regarding their bone health.

METHODS

Eligible individuals were those who had been prescribed medication to treat low bone mass. One-on-one telephone interviews were conducted over an 18-month period. Participants were interviewed for approximately 1 hour and asked to provide their feedback on the booklet, and to discuss what they were doing with respect to the recommendations made in the booklet.

RESULTS

We interviewed 50 participants who ranged in age from 58 to 89. The overall impression of the booklet was positive. Participants described the language in the booklet as clear and easy to understand. Participants stated that they would have appreciated receiving this tool at the onset of their diagnosis. Forty-two participants had already taken action, or expressed an intention to make changes, to their existing routines to improve their bone health. In contrast, eight participants used the booklet to reaffirm current practices and beliefs. For these individuals, the recommendations made in the booklet were consistent with what they had already been doing.

CONCLUSION

The booklet can engage patients in discussions about bone health. The booklet appeared to motivate individuals to make changes to their existing routines in an effort to achieve better health outcomes for their bone health. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial.

Establishment of the concurrent experimental model of osteoporosis combined with Alzheimer's disease in rat and the dual-effects of echinacoside and acteoside from Cistanche tubulosa

ETHNOPHARMACOLOGICAL RELEVANCE

Cistanche tubulosa is a precious traditional Chinese medicine that has been widely used in the treatment of osteoporosis and Alzheimer's disease. Echinacoside and acteoside are the main active constituents in Cistanche tubulosa that have the pharmacological activities with research value. It has been reported that echinacoside and acteoside could improve the learning and memory ability, promote the proliferation and differentiation of osteoblast.

AIM OF STUDY

Echinacoside and acteoside from Cistanche tubulosa have shown significant activities of anti-osteoporosis and anti-Alzheimer's disease, while these effects have not been studied concurrently in a rat model. The aim of this study was to establish and verify the model of osteoporosis combined with Alzheimer's disease in rat, and to investigate the double effects of echinacoside and acteoside on this concurrent model.

MATERIALS AND METHODS

Three model groups of ovariectomy (OVX), sham surgery with D-galactose and AlCl₃ (D), ovariectomy with D-galactose and AlCl₃ (OVX + D) were set at the same time. The rats in drug treatment groups were ovariectomized. While conducting the intraperitoneal injection of D-galactose and intragastric administration of AlCl₃ in the rats of drug treatment groups, the rats were orally administered echinacoside (90 mg/kg/d), acteoside (90 mg/kg/d) and the positive control drugs of estradiol valerate (0.6 mg/kg/d), donepezil HCl (0.8 mg/kg/d), respectively. After the drug treatment of 8 weeks, Morris Water Maze (MWM) test for 6 days was firstly performed. The rats were then sacrificed to harvest the blood, uteri, femora, tibiae and brain tissues. The serum was used for biochemical tests. The uteri were used for histomorphometry. The right femora were used for Micro-CT and histomorphometry, respectively. The right tibiae were used for biomechanical test. The hippocampus collected on ice box was used for biochemical tests. The brain collected by perfusion was used for histomorphometry.

RESULTS

Compared with Sham group, OVX + D group could significantly reduce the learning and memory ability by causing oxidative damage, impairing neurons in hippocampus and affecting the hydrolysis and synthesis of acetylcholine. Meanwhile, the activities of BALP and TRAP in OVX + D group increased significantly (P < 0.001) as compared to Sham group. In addition, compared with Sham group, the mean bone mineral density obviously decreased (P < 0.05), the trabecular bone mass and microarchitecture were also destroyed significantly in OVX + D group. Furthermore, the maximum load and maximum stress significantly reduced (P < 0.01) and the energy absorption also decreased greatly as compared to Sham group. After administrated with echinacoside and acteoside, the typical pathological features of osteoporosis and Alzheimer's disease were ameliorated.

CONCLUSIONS

The model of osteoporosis combined with Alzheimer's disease in rat was feasible and successfully established. Echinacoside and acteoside also showed some significant effects on this concurrent model, and they could be potential candidates from Cistanche tubulosa with double effects for further study.

Video Narratives Intervention Among Stroke Survivors: Feasibility and Acceptability Study of a Randomized Controlled Trial

BACKGROUND

A large number of stroke survivors worldwide suffer from moderate to severe disability. In Malaysia, long-term uncontrolled stroke risk factors lead to unforeseen rates of recurrent stroke and a growing incidence of stroke occurrence across ages, predominantly among the elderly population. This situation has motivated research efforts focused on tapping into patient education, especially related to patient self-efficacy of understanding and taking medication appropriately. Video narratives integrated with health belief model constructs have demonstrated potential impacts as an aide to patient education efforts.

OBJECTIVE

The aim of this study was to investigate the feasibility and acceptability of study procedures based on a randomized controlled trial protocol of a video narratives intervention among poststroke patients. We also aimed to obtain preliminary findings of video narratives related to medication understanding and use self-efficacy (MUSE) and blood pressure control.

METHODS

A parallel group randomized controlled trial including a control group (without video viewing) and an intervention group (with video viewing) was conducted by researchers at a neurology outpatient clinic on poststroke patients (N=54). Baseline data included patients' sociodemographic characteristics, medical information, and all outcome measures. Measurements of MUSE and blood pressure following the trial were taken during a 3-month follow-up period. Feasibility of the trial was assessed based on recruitment and study completion rates along with patients' feedback on the burden of the study procedures and outcome measures. Acceptability of the trial was analyzed qualitatively. Statistical analysis was applied to ascertain the preliminary results of video narratives.

RESULTS

The recruitment rate was 60 out of 117 patients (51.3%). Nevertheless, the dropout rate of 10% was within the acceptable range. Patients were aged between 21 and 74 years. Nearly 50 of the patients (>85%) had adequate health literacy and exposure to stroke education. Most of the patients (>80%) were diagnosed with ischemic stroke, whereby the majority had primary hypertension. The technicalities of randomization and patient approach were carried out with minimal challenge and adequate patient satisfaction. The video contents received good responses with respect to comprehension and simplicity. Moreover, an in-depth phone interview with 8 patients indicated that the video narratives were considered to be useful and inspiring. These findings paralleled the preliminary findings of significant improvement within groups in MUSE (P=.001) and systolic blood pressure control (P=.04).

CONCLUSIONS

The queries and feedback from each phase in this study have been acknowledged and will be taken forward in the full trial.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN 12618000174280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373554.

Comparison of multimedia and printed patient education tools for patients with osteoporosis: a 6-month randomized controlled trial

We conducted a randomized controlled trial to compare the efficacy of adding a video tool to a printed booklet on osteoporosis. Both strategies were effective in increasing knowledge and decreasing decisional conflict. There was no difference in the measured outcomes between the intervention and control groups. Patient preferences and learning styles are key factors in deciding a presentation format when educating patients with osteoporosis.

INTRODUCTION

Innovative approaches to patient education about self-management in osteoporosis may improve outcomes.

METHODS

We conducted a randomized controlled trial to compare the efficacy of adding a multimedia patient education tool involving video modeling to a printed educational booklet on osteoporosis. Participants were post-menopausal women with osteoporosis. We assessed osteoporosis knowledge, decisional conflict, self-efficacy, and effectiveness in disease management at baseline, immediately post-intervention, and at 3 and 6 months. Linear regression models were used to explore changes in outcomes at 6 months with respect to baseline characteristics.

RESULTS

Two hundred and twenty-five women were randomized, 111 to receive the multimedia tool in addition to the booklet and 114 to receive the booklet alone. Knowledge and decisional conflict scores significantly improved in both groups at all post-intervention assessment points, but with no significant differences in score changes between the groups. Self-efficacy and disease management effectiveness showed no significant changes from baseline. In the entire cohort, younger age was associated with better effectiveness in disease management and Hispanic women had greater gains in knowledge at 6 months compared to White women. Women with limited health literacy who had received the multimedia tool in addition to the printed materials had higher decisional conflict than those who received printed materials alone.

CONCLUSION

Both multimedia and printed tools increased knowledge and decreased decisional conflict to the same extent, neither of the educational materials proved to be better than the other. For women with limited health literacy, receiving the booklet alone was more effective in reducing decisional conflict after 6 months, than adding the multimedia tool.

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

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

Establishment of Fracture Liaison Service in Korea: Where Is It Stand and Where Is It Going?

The elderly population growth rate is extremely high in Korean society, and life expectancy is close to 85 years old for women and 80 for men as of people born in 2015. The future hip fracture prediction model of Korea shows that the elderly hip fracture rate will increase by 1.4 times by 2025, which will impose a serious socioeconomic burden on Korean society and become a key issue of public health management. The fracture liaison service (FLS) is defined adequate treatment and services for patients over 50 years old with fragility fractures, enabling systematic identification and decreasing the risk of subsequent osteoporotic fractures. In Korean society, the introduction of FLS, which is verified not only in the socioeconomic aspects but also in the treatment of patients, is thought to be essential. However, the challenges that need to be addressed in order to implement FLS include the lack of awareness regarding the necessity of this system, the lack of healthcare systems, and inadequate policies. In the future, further studies on the FLS and its clinical and socioeconomic effects for the Korean medical system will be necessary.

Breaking the cycle of recurrent fracture: implementing the first fracture liaison service (FLS) in British Columbia, Canada

Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring.

PURPOSE

Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada.

METHODS

A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months.

RESULTS

A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group.

CONCLUSION

In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.

Utilising Digital Health Technology to Support Patient-Healthcare Provider Communication in Fragility Fracture Recovery: Systematic Review and Meta-Analysis

The objective of this review is to evaluate the effectiveness of digital health supported targeted patient communication versus usual provision of health information, on the recovery of fragility fractures. The review considered studies including older people, aged 50 and above, with a fragility fracture. The primary outcome was prevention of secondary fractures by diagnosis and treatment of osteoporosis, and its adherence. This review considered both experimental and quasi-experimental study designs. A comprehensive search strategy was built to identify key terms including Medical subject headings (MeSH) and applied to the multiple electronic databases. An intention to treat analysis was applied to those studies included in the meta-analysis and odds ratio was calculated with random effects. Altogether, 15 studies were considered in the final stage for this systematic review. Out of these, 10 studies were Randomised controlled trials (RCT) and five were quasi experimental studies, published between the years 2003 and 2016 with a total of 5037 participants. Five Randomised control trails were included in the meta-analysis suggesting that digital health supported interventions were overall, twice as effective when compared with the usual standard care (OR 2.13, 95% CI 1.30–3.48), despite the population sample not being homogeneous. Findings from the remaining studies were narratively interpreted.

Effectiveness of Knowledge Translation Strategies in Audiovisual Language Compared With Other Languages to Improve Health Outcomes in Individuals and the General Population: Systematic Review

BACKGROUND

Knowledge translation (KT) not only encompasses a series of final actions in areas of dissemination, but also the identification of strategies for the implementation of this process.

OBJECTIVE

To evaluate the effectiveness of KT strategies in audiovisual language compared with other languages to improve health outcomes in the general population.

METHODS

We performed a search in MEDLINE, CENTRAL, PsycARTICLES, the WHO International Clinical Trials Registry Platform, EMBASE and LILACS.

RESULTS

We included 63 studies encompassing a broad range of study populations, languages that were compared to audiovisual language and measurement scales for outcomes. These studies presented a high risk of bias and the quality of evidence was not sufficient to draw conclusions about the effectiveness of the evaluated languages for knowledge translation.

CONCLUSIONS

We identified different languages that could be used in knowledge translation. The knowledge and the effects produced as a result of the strategy diminish as time progresses, regardless of the type of language used. This is an important point to consider when implementing this type of strategy.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

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

Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

Identifying characteristics of an effective fracture liaison service: systematic literature review

Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.

Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review

The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis

Osteoporosis is affecting over 200 million people worldwide. Despite available guidelines, care for these patients remains sub-optimal. We developed an osteoporosis tool to address the multiple dimensions of chronic disease management. Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment, so we are revising this tool to include multiple chronic conditions including an update of evidence about osteoporosis. Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis. We searched bibliometric databases for randomized controlled trials (RCTs) in any language evaluating osteoporosis disease management interventions in adults at risk for osteoporosis. Reviewer pairs independently screened citations and full-text articles, extracted data, and assessed risk of bias. Analysis included random effects meta-analysis. Primary outcomes were osteoporosis investigations and treatment, and fragility fractures. Fifty-five RCTs and one companion report were included in the analysis representing 165,703 patients. Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications, and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations. No significant impact was found for any type of intervention to reduce fracture. Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment. Patient education appears to be an important component in osteoporosis disease management.

A Bone Health Intervention for Chinese Immigrants in Santa Clara County

BACKGROUND

Among Chinese immigrants, osteoporosis is undertreated, misdiagnosed, and a leading cause of fragility fractures. In orthopaedic surgery departments, prevention education and health behavior change programs are necessary to improve their bone health.

PURPOSE

The purpose of this study was to examine the effectiveness of an osteoporosis prevention education program on participants' self-efficacy with regard to exercise and nutrition when provided by an orthopaedic surgery team during an annual Chinese Health Fair in Santa Clara County, CA.

METHODS

This pilot study used a single-group pretest and posttest design. Chinese immigrants at risk of osteoporosis were recruited during a 1-day health fair. The Bone Health Intervention (BHI) included orthopaedic surgeon consultation, visual aids including osteoporosis images and bone models, a video that included a discussion on calcium and vitamin D in the Chinese diet and culturally-acceptable exercise, and osteoporosis educational handouts. The Osteoporosis Self-Efficacy Scale (OSES) was utilized to measure participants' confidence in the ability to participate in self-care behaviors related to physical activity and calcium intake before and after the intervention. Paired t tests were used to compare participants' OSES scores pre- and postintervention.

RESULTS

There was a significant increase in mean OSES scores postintervention, indicating that the intervention could be an effective method of increasing participants' self-efficacy regarding calcium intake and time spent in exercising.

CONCLUSION

These results indicate that a culturally meaningful education program can potentially reduce fragility fracture risk. Orthopaedic health providers are ideal candidates to deliver preventive care education to improve outcomes for Chinese immigrants.

Professional interventions for general practitioners on the management of musculoskeletal conditions

BACKGROUND

Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.

OBJECTIVES

To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. 

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.

MAIN RESULTS

Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.

AUTHORS' CONCLUSIONS

There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

The interaction of MMP-2/B7-H3 in human osteoporosis

The immune costimulatory molecule B7-H3 has been shown to be involved in the regulation of murine bone formation. However, the role of B7-H3 in bone metabolic diseases remains unknown. In our study, matrix metalloproteinase 2 (MMP-2) and soluble B7-H3 (sB7-H3) were found to be correlatively up-regulated in the sera of osteoporosis patients. Furthermore, our results showed that MG63 cells treated with MMP-2 inhibitors produced lower amounts of sB7-H3 while cells with recombinant MMP-2 had an increased membrane B7-H3 (mB7-H3) shedding. Therefore, elevated MMP-2 levels resulted in an elevation of serum sB7-H3 and reduction of osteoblastic mB7-H3. B7-H3 knockdown in MG63 cells significantly decreased osteoblastic markers and substantially decreased the number of mineralized nodules after 21days. Thus, B7-H3-deficient MG63 cells exhibited impaired bone formation. These results suggest that mB7-H3 is required for the later phases of osteoblast differentiation and that MMP-2/B7-H3 plays a negative regulatory role in osteoporosis.

A survey of outcomes and management of patients post fragility fractures in China

We found that the fragility hip and vertebral fractures caused excess mortality rates in this Chinese female population, which was unexpectedly lower than those in western countries and other Asian countries. This was the first nationwide survey relating to post-fracture outcomes conducted among Chinese population in Mainland China.

INTRODUCTION

This study aimed to investigate the mortality, self-care ability, diagnosis, and medication treatment of osteoporosis following fragility hip and vertebral fractures through a nationwide survey among female patients aged over 50 in Mainland China.

METHODS

This was a multicenter, retrospective cohort study based on medical chart review and patient questionnaire. Female patients aged 50 or older admitted for low-trauma hip or vertebral fractures and discharged from Jan 1, 2008 to Dec 31, 2012 were followed.

RESULTS

Total of 1151 subjects of hip fracture and 842 subjects of vertebral fracture were included. The mean age was 73.4 ± 10.0, and the median of duration from index fracture to interview was 2.6 years. The overall 1-year, 2-year, 3-year, 4-year, and 5-year cumulative mortality rates were 3.5, 7.0, 11.2, 13.1, and 16.9 %, respectively. The first year mortality rates in hip (3.8 %, 95% CI 3.3-4.4 %) and vertebral fracture (3.1 %, 95% CI 2.5-3.7 %) were significantly higher than that in the general population (1.6 %). Impaired self-care ability was observed in 33.2, 40.6, and 23.8 % of overall, hip fracture, and vertebral fracture group, respectively. The overall diagnosis rate of osteoporosis was 56.8 %, and bone mineral density (BMD) measurement had never been conducted in 42.0 % among these women. After the index fracture, 69.6 % of them received supplements and/or anti-osteoporotic medications, among which 39.6 % only received calcium with/without vitamin D supplementation.

CONCLUSIONS

The osteoporotic hip and vertebral fractures caused excess mortality rates in this population of Mainland China. The current diagnosis and medical treatment following the fragility fractures is still insufficient in Mainland China.

The impact of educational interventions on modifiable risk factors for osteoporosis after a fragility fracture

The purpose of this study was to investigate the impact of two educational interventions on the intake of calcium and vitamin D supplements and modifiable risk factors for osteoporosis in women ≥50 years with a fragility fracture (FF). Within 6-8 months of fracture, women were randomized to one of three intervention groups: usual care (UC), written materials (WM), or videocassette and written materials (VC). The written materials for patients and their physician provided information on osteoporosis, FF, and available treatments; written materials for physician were provided through patients. The videocassette presented similar information as the written material, but in greater depth. Twelve months after randomization, the effectiveness of the interventions was assessed. The study cohort consisted of 1,175 women undiagnosed and untreated for osteoporosis. After 12 months, the mean intake of Ca supplements increased by 33, 93, and 91 mg/day for the UC, WM, and VC groups, respectively (p value, WM vs UC = 0.163; VC vs UC = 0.026); the corresponding mean increases for vitamin D were 58, 105, and 118 IU/day (p value, WM vs UC = 0.214; VC vs UC = 0.012). The proportion of women who increased their Ca and vitamin D intake by supplements was similar in all three groups. The intervention had a greater impact in those not taking supplements at randomization and had no impact on modifiable risk factors. In women without diagnosis and treatment for osteoporosis, the interventions seem effective at increasing the amounts of Ca and vitamin D supplements, but not effective at inciting more women to increase their consumption. Therefore, the clinical significance of the impact of the intervention is difficult to evaluate.

Clinical efficacy of a fragility care program in distal radius fracture patients

PURPOSE

To assess the quality of an initiative to improve the diagnosis and management of osteoporosis in patients over 50 years of age with distal radius fractures (DRF).

METHODS

A retrospective review was conducted to determine the baseline percentage of individuals undergoing osteoporosis screening after DRF. Thereafter, a study was implemented in which DRF patients who were not being treated for osteoporosis or had not recently undergone screening were offered a dual-energy x-ray absorptiometry scan and referral to endocrinology at the initial hand surgery clinic visit. Patients who declined participation were contacted by a patient educator to discuss the benefits of screening and address their concerns. Those who then wanted to receive an osteoporosis evaluation were scheduled for bone scanning and endocrinology consultation.

RESULTS

During the baseline period, 7 patients (15%) were screened, and 41 (85%) were not screened. During the active phase of the initiative, 82 patients over 50 years of age were treated for a DRF at our institution. A total of 44 patients were identified for potential osteoporosis screening, and 35 patients met inclusion criteria. Of these, 19 (54%) agreed to screening after the initial orthopedic evaluation, and 16 declined. After speaking to a patient educator, 9 of these 16 patients agreed to screening. Of the remaining 7 patients, 4 again declined screening and 3 were unavailable by telephone. Overall, 80% of patients who were identified in the initiative agreed to osteoporosis screening after the combination of recommendation during hand surgery clinic visit and patient education by telephone, and 64% were diagnosed with osteoporosis/osteopenia as a result of completing screening.

CONCLUSIONS

An integrated model of care among orthopedic surgeons, patient educators, and endocrinologists substantially increased screening for osteoporosis after DRF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Priming primary care physicians to treat osteoporosis after a fragility fracture: an integrated multidisciplinary approach

OBJECTIVE

To evaluate 2 incremental levels of intervention designed to increase initiation of osteoporosis treatment by primary care physicians (PCP) following fragility fractures (FF).

METHODS

Women and men over age 50 years were screened for incident FF in fracture clinics, and eligible outpatients were randomly assigned to standard care (SC) or to either minimal (MIN) or intensive (INT) interventions. The MIN and INT interventions were intended to educate and motivate both patients and PCP, but differed in their frequency of contact and information content. Delivery of osteoporosis medication was confirmed with pharmacists. Treatment rates were analyzed using an intention-to-treat approach.

RESULTS

At inclusion, 74.3% of 881 outpatients with FF were untreated. Followup at 12 months was completed in 92.3% of patients. Up to 90% of patients treated at inclusion remained treated at 12 months. Among patients who initially were untreated, 18.8% in the SC group, 40.4% in the MIN, and 53.2% in the INT groups were treated at 12 months. Change in treatment rates (adjusted for age and initial treatment) increased significantly after both MIN and INT. Only the INT intervention significantly increased treatment rates in patients with previous fractures. Negative predictors of change in treatment status included non-major FF, age younger than 65 years, and male sex.

CONCLUSION

Both interventions significantly increased initiation of osteoporosis treatment. Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized resources. Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term.

Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis

Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures, despite the availability of effective treatments. We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures. We searched eight medical literature databases to identify reports published between 1996 and 2011, describing models of care for secondary fracture prevention. Information extracted from each publication included study design, patient characteristics, identification strategies, assessment and treatment initiation strategies, as well as outcome measures (rates of bone mineral density (BMD) testing, osteoporosis treatment initiation, adherence, re-fractures and cost-effectiveness). Meta-analyses of studies with valid control groups were conducted for two outcome measures: BMD testing and osteoporosis treatment initiation. Out of 574 references, 42 articles were identified as analysable. These studies were grouped into four general models of care-type A: identification, assessment and treatment of patients as part of the service; type B: similar to A, without treatment initiation; type C: alerting patients plus primary care physicians; and type D: patient education only. Meta-regressions revealed a trend towards increased BMD testing (p = 0.06) and treatment initiation (p = 0.03) with increasing intensity of intervention. One type A service with a valid control group showed a significant decrease in re-fractures. Types A and B services were cost-effective, although definition of cost-effectiveness varied between studies. Fully coordinated, intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and/or education only.