Adherence to osteoporosis medications amongst Singaporean patients

Cost-effectiveness of selective bone densitometry using the osteoporosis self-assessment tool for Asians in multi-ethnic Asian population

Early detection and treatment of osteoporosis can help to prevent debilitating fractures in the elderly. The osteoporosis self-assessment tool for Asians can be used as a screening tool to stratify patients for bone densitometry. It is most cost-effective for post-menopausal women aged 70 and males aged 75.

PURPOSE

To determine the cost-effectiveness of selective bone densitometry (SBD) using the Osteoporosis Self-Assessment Tool for Asians (OSTA) as a risk-stratifying tool for the three predominant races (Chinese, Malay and Indian) in Singapore.

METHODS

Decision analytical models were developed using a Markov model. Three scenarios were compared: no bone densitometry, SBD using the OSTA as a pre-screening tool and universal bone densitometry. Those diagnosed with osteoporosis were treated with five years of alendronate therapy. Data sources were from Singapore epidemiological studies, healthcare cost figures and published literature. Measurements include life years, quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios (ICER).

RESULTS

Compared to no bone densitometry, SBD using the OSTA would cost between $40,679 and $73,909 per QALY gained for men aged 75-80 and $22,386 to $58,185 per QALY gained for post-menopausal women aged 70-80. Universal bone densitometry would cost $157,955 to $177,127 per QALY gained for men aged 75-80 and $40,179 to $66,112 per QALY gained for post-menopausal women aged 70 to 80 compared to SBD.

CONCLUSION

In general, osteoporosis screening was the most cost-effective for Malays and the least cost-effective for Indians. However, a general guideline should still be applied to the Singaporean population, as further explained later. Overall, the most cost-effective strategy for males would be using OSTA as a risk-stratifying tool at age 75. For post-menopausal women, SBD should be used for women aged 70, while universal bone densitometry should be used for women aged 75-80.

Adherence to dosing schedule of denosumab therapy for osteoporosis during COVID-19 lockdown: an electronic medical record and pharmacy claims database study from Asia

COVID-19 lockdowns have impacted management of chronic diseases such as osteoporosis. Adherence to the 6-monthly dosing schedule of denosumab, the parenteral anti-osteoporosis medication most often used in Singapore, was significantly reduced during the lockdown period compared to that during pre-COVID-19 times. Patients managed by endocrinologists were more likely to be adherent.

PURPOSE

No study thus far has quantified actual adherence rates to anti-osteoporosis therapy with denosumab during COVID-19 or explored factors associated with it. We aimed to estimate the adherence rates to denosumab in Singaporean men and women during COVID-19 lockdown and to compare it with those during the pre-COVID-19 period.

METHOD

We conducted this retrospective, electronic medical records, and pharmacy claims database study at Singapore General Hospital, the largest hospital in the country. Patients initiated on subcutaneous denosumab between August 2019 and December 2019 and were thus scheduled to receive the second dose during the COVID-19 first-wave period from February 2020 to June 2020 (lockdown group) were analyzed, as were patients initiated anytime on denosumab between September 2011 and December 2018 (pre-COVID-19 group). Data extracted from the hospital's electronic prescription platform and patients' pharmacy purchase records were matched. Adherence was defined as being punctual (with an allowable delay of up to 4 weeks) with the second dose scheduled 6 months from the 1st dose. A sensitivity analysis with an allowable delay up to 8 weeks was also performed. We compared the adherence rates between the two periods and explored factors associated with adherence.

RESULTS

A total of 768 and 1458 patients respectively during the lockdown and pre-COVID-19 periods were analyzed. The mean adherence rate during lockdown was 63.9%. The odds of being adherent during lockdown were higher if patients were managed by endocrinologists as opposed to those by other specialists [OR 2.516 (95% CI: 1.836-3.448); p < 0.001]. Adherence rates during the pre-COVID-19 period was 75.4%. Overall, the odds of being adherent to denosumab was significantly lower during lockdown than that during the pre-COVID-19 period [OR 0.525 (95% CI 0.430-0.640); p < 0.001], and odds of being adherent were higher if patients were managed by endocrinologists than if they were managed by other specialists (OR 1.765 (95% CI: 1.444-2.158; p < 0.001).

CONCLUSION

Adherence to denosumab was significantly lower during COVID-19 lockdown than the pre-COVID-19 period. The odds of being adherent were higher in patients managed by endocrinologists. Whether healthcare providers from certain specialties spend more time counselling and educating patients about the importance of adherence to osteoporosis medications needs to be explored further.

Cancer Screening Knowledge and Behavior in a Multi-Ethnic Asian Population: The Singapore Community Health Study

Background

Cancer has become the leading cause of mortality in Singapore and among other Asian populations worldwide. Despite the presence of National Cancer Screening programmes in Singapore, less than half of the population has had timely screening according to guidelines. The underlying factors of poor cancer screening rates and health outcomes among Asian ethnic groups remain poorly understood. We therefore examined cancer screening participation rates and screening behavior in a multi-ethnic Singapore population.

Methods

We collected data from 7,125 respondents of the 2015–2016 Singapore Community Health Study. Factors associated with cervical, breast, and colorectal cancer screening were evaluated using modified Poisson regression. Adjusted prevalence ratios were computed with 95% confidence intervals after adjusting for confounders.

Results

The mean age of the respondents was 57.7 ± 10.9 years; 58.9% were female and were predominately Chinese (73.0%), followed by Malay (14.2%), and Indian (10.9%). Less than half of the respondents in the recommended age groups had undergone cancer screening (cervical, 43%; breast, 35.1%; colorectal, 27.3%). Malay respondents were significantly less likely to screen as recommended for cervical (aPR = 0.75, CI = 0.65–0.86, p < 0.001), breast (aPR = 0.83, CI = 0.68–0.99, p = 0.045), and colorectal cancer (aPR = 0.55, CI = 0.44–0.68, p < 0.001), as compared to Chinese respondents. Respondents who had obtained lower secondary level education were 42% more likely to screen for cervical cancer (aPR = 1.42, CI = 1.23–1.64, p < 0.001), and 22% more likely to screen for breast cancer (aPR = 1.22, CI = 1.02–1.46, p = 0.032), compared to those with primary level education and below. Respondents with a household income ≥S$10,000/month were 71% more likely to screen for breast cancer (aPR = 1.71, CI = 1.37–2.13, p < 0.001), as compared with <$2,000/month.

Conclusions

Ethnicity and socio-economic status were significantly associated with lower uptake of cancer screening tests in Singapore. To improve the screening uptake among disadvantaged groups, a multi-faceted approach is needed that addresses the barriers to screening such as the adequacy of subsidy schemes and ethnic differences.

Comparing the efficacies of bisphosphonates' therapies for osteoporosis persistence and compliance: A Systematic Review

OBJECTIVES

Osteoporosis is the most prevalent metabolic bone disorder worldwide. This review was undertaken to compare the efficacies of bisphosphonates therapies for patient persistence and compliance for the treatment of osteoporosis.

METHODS

A systematic review was performed in accordance with the available reporting items. MEDLINE and Cochrane library databases were applied for literature searched up to January 2020. All major studies such as prospective, retrospective and reviews articles that examined patient persistence or compliance to bisphosphonates for osteoporosis were included.

RESULTS

Literature search found 656 relevant published reports, out of which 87 were included. The 10,712,176 osteoporotic patients were studied for patient persistence and 5,875,718 patients were studied for patient compliances. Analysis of all studied bisphosphonates showed almost similar patterns for patient persistence rates as it was decreased over the time following initial prescription but persistence length was found to be significantly high for alendronate therapy as compared to the other studied bisphosphonates (p<0.001), whereas the length of persistence of all other bisphosphonates (other than alendronate) were almost same (p>0.05). Analysis of patient compliances with etidronate therapy showed the highest percent medication possession ratio (MRP) at 12 months, followed by the MRPs of ibandronate, alendronate, risedronate, and clodronate.

CONCLUSIONS

This is the first systematic review that shows the comparison of the efficiencies of bisphosphonates for patient persistence and compliance for the treatment of osteoporosis. The data showed that the length of patient persistence was highest for alendronate therapy, whereas patient compliance was highest for etidronate therapy for the treatment of osteoporosis.

Cost-effectiveness of FRAX®-based intervention thresholds for management of osteoporosis in Singaporean women

Cost-effectiveness analysis of FRAX® intervention thresholds (ITs) in Singaporean women > 50 years of age showed that generic alendronate was cost-effective at age-dependent major osteoporotic fracture (MOF) IT from the ages of 65 years for both full and real-world adherence whilst hip fracture (HF) ITs were cost-effective from the ages of 60 and 65 years. Alendronate was cost-effective irrespective of age only at fixed MOF IT of 14% and HF IT of 3.5%.

INTRODUCTION

FRAX®-based intervention thresholds (ITs) were recently identified for osteoporosis management in Singapore. This study aimed to assess the cost-effectiveness of ITs in Singaporean women over the age of 50 years.

METHODS

A validated Markov microsimulation model was used to estimate the lifetime healthcare costs (SGD2019) per quality-adjusted life-years (QALY) of generic alendronate compared with no treatment. Cost-effectiveness of age-dependent FRAX® major osteoporotic fracture (MOF) and hip fracture (HF) ITs was explored. In addition, ITs that would lead to cost-effectiveness were computed. Fracture incidence and cost data were obtained from the Ministry of Health and a previously published Singaporean study. A cost-effectiveness threshold of SGD 62,500/QALY gained was used, based conservatively on 0.7 times the Singapore GDP per capita.

RESULTS

Generic alendronate was shown to be cost-effective at MOF ITs from the ages of 65 years, while HF ITs were cost-effective from the ages of 60 and 65 years, assuming full and real-world adherence, respectively. A 14% MOF and a 3.5% HF ITs were required for alendronate to be cost-effective above 50 years.

CONCLUSION

This study suggests that the treatment of Singaporean women with alendronate is cost-effective at age-dependant FRAX® intervention thresholds at 65 years and older. Furthermore, identifying women at any age above 50 years with a 10-year risk of MOF or HF of 14% or 3.5% would lead to efficient use of resources. Cost-effective access to therapy for patients at high fracture probability based on FRAX® could contribute to reduce the growing burden of osteoporotic fractures in Singapore.

Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore

Undertreatment of osteoporosis after hip fracture increases the risk of death, disability, recurrent osteoporotic fractures, and financial burden. Only half were compliant with osteoporosis medications. Elderly patients were less persistent and compliant to treatment. Denosumab was associated with a higher proportion of days covered by osteoporosis medications than oral bisphosphonates.

PURPOSE

The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications.

METHODS

Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated.

RESULTS

Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year.

CONCLUSION

Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.

Real-world persistence and adherence with oral bisphosphonates for osteoporosis: a systematic review

OBJECTIVES

This study examined patient adherence and persistence to oral bisphosphonates for the treatment of osteoporosis in real-world settings.

METHODS

A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) and National Health Service Economic Evaluation Database NHS EED) databases were searched for studies published in English language up to April 2018. Prospective and retrospective observational studies that used prescription claim databases or hospital medical records to examine patient adherence and persistence to oral bisphosphonate treatment among adults with osteoporosis were included. The Newcastle-Ottawa quality assessment scale (NOS) was used to assess the quality of included studies.

RESULTS

The search yielded 540 published studies, of which 89 were deemed relevant and were included in this review. The mean age of patients included within the studies ranged between 53 to 80.8 years, and the follow-up varied from 3 months to 14 years. The mean persistence of oral bisphosphonates for 6 months, 1 year and 2 years ranged from 34.8% to 71.3%, 17.7% to 74.8% and 12.9% to 72.0%, respectively. The mean medication possession ratio ranged from 28.2% to 84.5%, 23% to 50%, 27.2% to 46% over 1 year, 2 years and 3 years, respectively. All studies included scored between 6 to 8 out of 9 on the NOS. The determinants of adherence and persistence to oral bisphosphonates included geographic residence, marital status, tobacco use, educational status, income, hospitalisation, medication type and dosing frequency.

CONCLUSIONS

While a number of studies reported high levels of persistence and adherence, the findings of this review suggest that patient persistence and adherence with oral bisphosphonates medications was poor and reduced notably over time. Overall, adherence was suboptimal. To maximise adherence and persistence to oral bisphosphonates, it is important to consider possible determinants, including characteristics of the patients.

Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium

Despite an increase in absolute numbers, the age-standardized incidence of hip fractures in Singapore declined in the period 2000 to 2017. Among the three major ethnic groups, Chinese women had the highest fracture rates but were the only group to show a temporal decline.

INTRODUCTION

A study published in 2001 predicted a 30-50% increase in Singapore hip fracture incidence rates over the ensuing 30 years. To test that prediction, we examined the incidence of hip fracture in Singapore from 2000 to 2017.

METHODS

We carried out a population-based study of hip fractures among Singapore residents aged ≥ 50 years. National medical insurance claims data were used to identify admissions with a primary discharge diagnosis of hip fracture. Age-adjusted rates, based on the age distribution of the Singapore population of 2000, were analyzed separately by sex and ethnicity (Chinese, Malay, or Indian).

RESULTS

Over the 18-year study period, 36,082 first hip fractures were recorded. Total hip fracture admissions increased from 1487 to 2729 fractures/year in the years 2000 to 2017. Despite this absolute increase, age-adjusted fracture rates declined, with an average annual change of - 4.3 (95% CI - 5.0, - 3.5) and - 1.1 (95% CI - 1.7, - 0.5) fractures/100,000/year for women and men respectively. Chinese women had 1.4- and 1.9-fold higher age-adjusted rates than Malay and Indian women: 264 (95% CI 260, 267) versus 185 (95% CI 176, 193) and 141 (95% CI 132, 150) fractures/100,000/year, respectively. Despite their higher fracture rates, Chinese women were the only ethnic group exhibiting a decline, most evident in those ≥ 85 years, in age-adjusted fracture rate of - 5.3 (95% CI - 6.0, - 4.5) fractures/100,000/year.

CONCLUSION

Although the absolute number of fractures increased, steep drops in elderly Chinese women drove a reduction in overall age-adjusted hip fracture rates. Increases in the older population will lead to a rise in total number of hip fractures, requiring budgetary planning and new preventive strategies.

A systematic review of factors affecting medication adherence among patients with osteoporosis

The aim of this review was to identify factors that influence patients' adherence to anti-osteoporotic therapy. Factors identified that were associated with poorer medication adherence included polypharmacy, older age, and misconceptions about osteoporosis. Physicians need to be aware of these factors so as to optimize therapeutic outcomes for patients.

INTRODUCTION

To identify factors that influence patients' adherence to anti-osteoporotic therapy.

METHODS

A systematic review of literature was performed for articles published up till January 2018 using PubMed®, PsychINFO®, Embase®, and CINAHL®. Peer-reviewed articles which examined factors associated with anti-osteoporotic medication adherence were included. Classes of anti-osteoporotic therapy included bisphosphonates, parathyroid hormone-related analogue, denosumab, selective estrogen receptor modulators, estrogen/progestin therapy, calcitonin, and strontium ranelate. Meta-analyses, case reports/series, and other systematic reviews were excluded. Identified factors were classified using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of 2404 articles reviewed, 124 relevant articles were identified. The prevalence of medication adherence ranged from 12.9 to 95.4%. Twenty-four factors with 139 sub-factors were identified. Bisphosphonates were the most well-studied class of medication (n = 59, 48%). Condition-related factors that were associated with poorer medication adherence included polypharmacy, and history of falls was associated with higher medication adherence. Patient-related factors which were associated with poorer medication adherence included older age and misconceptions about osteoporosis while therapy-related factors included higher dosing frequency and medication side effects. Health system-based factors associated with poorer medication adherence included care under different medical specialties and lack of patient education. Socio-economic-related factors associated with poorer medication adherence included current smoker and lack of medical insurance coverage.

CONCLUSION

This review identified factors associated with poor medication adherence among osteoporotic patients. To optimize therapeutic outcomes for patients, clinicians need to be aware of the complexity of factors affecting medication adherence.

Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12-month analysis

Fracture liaison service linked to an emergency department database effectively identifies patients with OP, improves best practice care, reduces recurrent fractures, and improves quality of life (QoL). The next step is to establish cost-effectiveness. This should be seen as the standard model of care.

INTRODUCTION

The Western Australian Osteoporosis Model of Care recommends implementation of a fracture liaison service (FLS) to manage patients with minimal trauma fractures (MTFs). This study evaluates the efficacy of a FLS linked to a tertiary hospital emergency department information system (EDIS) in reducing recurrent fractures.

METHODS

Patients aged ≥ 50 years with MTF identified from EDIS were invited to the FLS. Patient outcomes were compared to routine care (retrospective group-same hospital, and prospective group-other hospital) at 3- and 12-month follow-up.

RESULTS

Two hundred forty-one of 376 (64.1%) eligible patients participated in the FLS with 12 months of follow-up. Absolute risk of recurrent MTF at 12 months was reduced by 9.2 and 10.2% compared with the prospective and retrospective controls, respectively. After age/sex adjustment, FLS participants had less MTF at 12 months vs. the retrospective controls, OR 0.38 (95%CI 0.18-0.79), but not the prospective controls, OR 0.40 (95%CI 0.16-1.01). FLS patients were more likely to receive the 'best practice' care, i.e. awareness of osteoporosis, investigations, and treatment (all p < 0.05). 'Fallers' (OR 0.48 (95%CI 0.24, 0.96)) and fall rates were lower in the FLS (p = 0.001) compared to the prospective control. FLS experienced the largest improvement in QoL from 3 to 12 months as measured by the EuroQoL 5-domain (EQ-5D) UK weighted score (+ 15 vs. - 11 vs. - 16%, p < 0.001) and EQ-5D Health State visual analogue scale (+ 29 vs. - 2 vs. + 1%, p < 0.001).

CONCLUSION

Patients managed in a linked EDIS-FLS were more likely to receive the 'best practice' care and had lower recurrent MTF and improved QoL.

Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture

As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.

Compliance and persistence with oral bisphosphonates for the treatment of osteoporosis in female patients with rheumatoid arthritis

Background

Poor adherence with oral bisphosphonates (BPs) can mitigate their therapeutic benefit for osteoporosis and is a significant clinical burden. Most previous studies regarding adherence with oral BPs have focused on postmenopausal osteoporosis, but little attention has been given to patients with rheumatoid arthritis (RA). Thus, we investigated compliance and persistence with oral BPs in the treatment of osteoporosis and analyzed risk factors for poor adherence in female patients with (RA) in real setting.

Methods

This is a retrospective longitudinal study including 396 female patients with RA in whom oral BPs were newly initiated from Aug 2004 to Aug 2014 at a university rheumatology center in South Korea. Compliance was quantified using the 1-year medication possession ratio (MPR), while persistence was defined as duration from the initiation to the end of BPs therapy without interruption exceeding 56 days. Seropositve RA was defined as having a positive test result for the presence of either rheumatoid factor or anti-cyclic citrullinated peptide antibody.

Results

Of 396 RA patients, 221 (55.8%) were prescribed risedronate 35 mg weekly; 17 (4.3%) received alendronate 70 mg weekly; and 158 (39.9%) received ibandronate 150 mg monthly. The 1-year MPR was 70.1% and the proportion of RA patients with the 1-year MPR ≥ 0.8 was 60.1%. A total of 274 (69.2%) patients discontinued oral BPs during the study period and persistence with BPs was 63.3% at 1 year, 50.7% at 2 years and 33.3% at 3 years. The most common cause of non-persistence was adverse events (47.5%), followed by poor health literacy (40.5%) and cost (12%). Both compliance and persistence with monthly oral BPs were significantly lower than those with weekly regimens (OR: 2.48, 95% CI: 1.59–3.89, P < 0.001 and HR: 2.19, 95% CI: 1.69–2.83, P < 0.001, respectively). Additionally, patients with seropositive RA showed better compliance and persistence with BPs compared with their seronegative counterparts.

Conclusions

Compliance and persistence with oral BPs in RA patients were suboptimal in real practice, thereby limiting the efficacy of osteoporosis treatment. Extending the dosing interval of BPs may improve medication adherence in RA patients.

Colorectal cancer screening: Barriers to the faecal occult blood test (FOBT) and colonoscopy in Singapore

Introduction:

This study aims to identify the barriers to adopting faecal occult blood test (FOBT) and colonoscopy as colorectal cancer (CRC) screening methods among the eligible target population of Singapore.

Materials and methods:

This study was previously part of a randomised controlled trial reported elsewhere. Data was collected from Singapore residents aged 50 and above, via a household sample survey. The study recruited subjects who were aware of CRC screening methods, and interviewed them about the barriers to screening that they faced. Collected results on barriers to each screening method were analysed separately.

Results:

Out of the 343 subjects, 85 (24.8%) recruited knew about FOBT and/or colonoscopy. Most of the respondents (48.9%) cited not having symptoms as the reason for not using the FOBT. This is followed by inconvenience (31.1%), not having any family history of colon cancer (28.9%), lack of time (28.9%) and lack of reminders/recommendation (28.9%). Of the respondents who indicated not choosing colonoscopy as a screening method, more than one-half (54.8%) identified not having any symptoms as the main barrier for them, followed by not having any family history (38.7%) and having a healthy/low-risk lifestyle (29.0%). There was no difference between the reported barriers to each of the screening methods and the respondents’ dwelling types.

Conclusions:

Lack of knowledge, particularly the misconceptions of not having symptoms and being healthy, were identified as the main barriers to FOBT and colonoscopy as screening methods. Interventions to increase the uptake of CRC screening in this population should be tailored to address this misconception.

Non-adherence with bisphosphonates among patients with osteoporosis: impact on fracture risk and healthcare cost‏

Osteoporosis-related fractures at the spine and hip have a substantial impact on mortality, morbidity, and quality of life in older adults worldwide. Adherence to bisphosphonates is essential for effective treatment and fracture prevention. Nevertheless, numerous studies from various populations and study designs clearly indicated that adherence and persistence are poor with more than 50% of patients discontinuing therapy within one year. This is primarily explained by mild adverse effects, dosing regimens, and costs. Studies have also shown that good adherence is associated with reduced osteoporosis-related and non-related healthcare costs as soon as 2 years from therapy initiation. Nonetheless, we found only little improvement in adherence rates over the years. In light of the importance of medication adherence and the limited success of previous programs, other than reducing dosing frequency, new directions should be explored to engage patients and care givers in order to improve adherence and prevent fractures.

Utility of the Morisky Medication Adherence Scale in gout: a prospective study

BACKGROUND

The outcomes of any chronic illness often depend on patients' adherence with their treatment. A tool is lacking to assess adherence in gout that is standardized, allows real-time feedback, and is easy to understand.

OBJECTIVE

We set out to evaluate the utility of the 8-item Morisky Medication Adherence Scale (MMAS-8) in monitoring medication adherence in a multiethnic Asian gout cohort on urate-lowering therapy (ULT).

METHODS

This cohort study recruited patients with gout where baseline and 6-monthly clinical data, self-report of adherence, and health status by Gout Impact Scale (GIS) and EuroQoL-5 dimension 3 levels were collected. Those who received at least 9 months of ULT were analyzed. Convergent and construct validities of MMAS-8 were evaluated against medication possession ratio (MPR) and known groups, clinical outcomes, and patient-reported outcomes. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively.

RESULTS

Of 91 patients, 92.3% were male, 72.5% Chinese with mean age 53.5 years. MMAS-8 (mean 6.17) and MPR (mean 96.3%) were poorly correlated (r=0.069, P=0.521). MMAS-8 did not differ between those who did or did not achieve target serum urate (SU) <360 µmol/L (P=0.852); or among those whose SU improved, stagnated, or worsened during follow-up (P=0.777). Adherence was associated with age (β=0.256, P=0.015) and education level (P=0.011) but not comorbidities, polypharmacy, or flare frequency. Concerns for medication side effects and anxiety or depression were associated with lower MMAS-8 (P<0.005). Internal consistency was acceptable (α=0.725) and test-retest reliability was satisfactory (ICC =0.70, 95% confidence interval [CI] 0.36-0.88).

CONCLUSION

MMAS-8 had limited construct validity in assessing medication adherence to ULT in our gout patients. Nevertheless, it identified patients bothered or worried about ULT side effects, and those with underlying anxiety or depression, for whom targeted education and coping support may be useful.

Dropping the Ball and Falling Off the Care Wagon. Factors Correlating With Nonadherence to Secondary Fracture Prevention Programs

Health care systems and hospitals in several countries have implemented Fracture Liaison Services (FLSs). Success rates of FLSs with regard to osteoporosis assessment and treatment, fracture reduction, and adherence to osteoporosis medications have been reported by several groups including ours. A significant drop-out rate among patients in these programs may occur. This has not been evaluated before. We explored the factors correlating with nonadherence among a multiethnic population of patients in the FLS at our institution, the largest tertiary teaching hospital in South East Asia. Our secondary objective was to explore whether patients who defaulted follow-up visits continued to be compliant with medications. A retrospective analysis of our FLS's computerized database was performed. Of 938 patients followed up more than 2 years, 237 defaulted at various time points. A significant percentage of patients who dropped out of the program opined that it was because the follow-up visits were too time consuming. Non-Chinese patients were more likely than Chinese (adjusted hazard ratio [aHR] = 1.98, 1.33-2.94), patients with primary school education and below were more likely than those with secondary school and above education (aHR = 1.65, 1.11-2.45) and those with nonvertebral and/or multiple fractures were more likely than those with spine fractures (aHR = 1.38, 1.06-1.81) to be nonadherent. A fraction of patients who defaulted continued to fill osteoporosis medication prescriptions. Median medication possession ratio among the patients who defaulted was 12.3% (interquartile range: 4.1%-36.7%) at 2 years. Persistence ranged from 15.1% to 20.8% and from 1.9% to 7.5% at 1 and 2 years, respectively after defaulting from the program. Our study, which to the best of our knowledge is the first of its kind, provides insight into the factors correlating with nonadherence to FLSs. Knowledge of the challenges faced by patients may be of help to health care providers interested in developing FLSs.

Persistence with denosumab and persistence with oral bisphosphonates for the treatment of postmenopausal osteoporosis: a retrospective, observational study, and a meta-analysis

The objectives of this study were to estimate persistence with denosumab and put these results in context by conducting a review of persistence with oral bisphosphonates. Persistence with denosumab was found to be higher than with oral bisphosphonates.

PURPOSE

This study had two objectives: to analyse persistence in Swedish women initiating denosumab for treatment of postmenopausal osteoporosis (PMO) and to put these findings in context by conducting a literature review and meta-analysis of persistence data for oral bisphosphonates.

METHODS

The study used the Swedish Prescribed Drug Register and included women aged at least 50 years initiating denosumab between May 2010 and July 2012. One injection of denosumab was defined as 6-month persistence. Women were considered persistent for another 6 months if they filled their next prescription within 6 months + 56 days and survival analysis applied to the data. A literature search was conducted in PubMed to identify retrospective studies of persistence with oral bisphosphonates and pooled persistence estimates were calculated using a random-effects model.

RESULTS

The study identified 2,315 women who were incident denosumab users. Mean age was 74 years and 61% had been previously treated for PMO. At 12 and 24 months, persistence with denosumab was 83% (95% CI, 81-84%) and 62% (95% CI, 60-65%), respectively. The literature search identified 40 articles for inclusion in the meta-analysis. At 12 and 24 months, persistence with oral bisphosphonates ranged from 10% to 78% and from 16% to 46%, with pooled estimates of 45% and 30%, respectively.

CONCLUSION

These data from the Swedish Prescribed Drug Register and literature review suggest that persistence was higher with denosumab than with oral bisphosphonates.

Adherence to premixed insulin in a prefilled pen compared with a vial/syringe in people with diabetes in Singapore

BACKGROUND

The real-world clinical effectiveness of exogenous insulin is limited by nonadherence. Various insulin delivery systems have been developed to help improve adherence, with prefilled pens gaining popularity among adult Singaporeans with diabetes. However, adherence to insulin in people with diabetes in Singapore and most of Asia has not been studied.

OBJECTIVES

This study aimed to compare adherence to premixed insulin formulated in a prefilled pen versus a vial/syringe and to identify predictors of adherence in 955 patients managed at the outpatient clinics of the largest acute care hospital in Singapore.

METHODS

In this retrospective longitudinal study, electronic medical and pharmacy refill records were used to determine adherence to insulin over 24 months, measured in terms of compliance and persistence. Compliance is expressed as the medication possession ratio (used as continuous and categorical variables), and persistence is reported as a dichotomous variable with a permissible refill gap of 30 days before discontinuation of therapy is considered. Multivariate linear or logistic regression analysis was used to identify predictors of adherence.

RESULTS

Compared with prefilled pen users, vial/syringe users were older (mean [SD] age, 64.1 [10.6] vs 62.4 [11.9] years; P = 0.032), and more were undergoing polypharmacy (69.6% vs 54.1%; P < 0.001). The mean (SD) medication possession ratio was comparable in vial/syringe versus prefilled pen users (83.8% [26.9%] vs 86.0% [23.2%]; P = 0.266). Prefilled pen users were more persistent with therapy compared with vial/syringe users (odds ratio = 1.36; 95% CI, 1.01-1.86) after adjusting for sociodemographic and clinical covariates. Median time to discontinuation of therapy was comparable (vial/syringe vs prefilled pen: 409 vs 532 days; P = 0.076). Being managed by an endocrinologist and not receiving government subsidies were significant predictors of persistence.

CONCLUSIONS

Compared with other studies that found strong associations between adherence and insulin devices, the findings of this study suggest that persistence but not compliance varies by insulin device. The willingness to pay for health care, in addition to affordability, may affect insulin therapy adherence. Patients with uncontrolled diabetes due to suspected nonadherence may benefit from referral to a multidisciplinary care team comprising endocrinologists, diabetes nurse educators, dietitians, and allied health professionals. These findings are applicable to outpatients with similar demographic features managed at other acute care hospitals in Singapore. The impact of insulin devices on glycemic control needs to be investigated in future larger studies.

Secondary prevention of osteoporotic fractures--an "OPTIMAL" model of care from Singapore

A significant care gap exists in the management of osteoporotic fractures. Osteoporosis Patient Targeted and Integrated Management for Active Living (OPTIMAL) is a secondary fracture prevention program instituted in the public hospitals of Singapore. We aim to describe the operational characteristics of OPTIMAL and initial audit data of patients who were recruited into the program at Singapore General Hospital.

INTRODUCTION

Fractures often represent the first opportunity for care of osteoporosis. However, a significant care gap still exists in the management of these sentinel events and underdiagnosis and undertreatment of osteoporotic fractures are prevalent worldwide. Fracture liaison services run by care coordinators have been shown to reduce the fracture care gap. OPTIMAL is a clinician champion-driven, case manager-run secondary fracture prevention program set up in the public hospitals of Singapore in 2008.

METHODS

We present the operational characteristics and initial audit data of OPTIMAL from the largest tertiary teaching hospital in Singapore.

RESULTS

One thousand and fourteen patients have been recruited into OPTIMAL at our hospital since 2008, and 476 patients are currently in active follow-up. Two hundred and eighty-seven patients had completed a 2-year follow-up at the hospital as of August 2012 and were evaluated; 97.5% of these patients had DXA evaluation upon enrollment into the program, and 62% of the patients reported compliance with an exercise program over the 2-year follow-up. Compliance to osteoporosis medications as estimated by the medication possession ratio (MPR) was 72.8 ± 34.5% at 2 years with patients maintaining good compliance (MPR ≥ 80%) for an average of 20.2 months (95% CI 19.3-21.1).

CONCLUSION

Our report provides the first compelling evidence of the potential success of a secondary fracture prevention program from an Asian country. The ultimate success of the program will be determined by fracture outcomes and cost effectiveness, but in the interim, clear evidence of enhanced assessment and treatment rates has been demonstrated.

Secondary Fracture Prevention: Plucking The Low Hanging Fruit

It is well known that one fragility fracture begets another. Fracture Liaison Services have been shown to narrow the care gap that exists in the care of patients with fragility fractures. A secondary fracture prevention programme “OPTIMAL” (Osteoporosis Patient Targeted and Integrated Management for Active Living) has been in existence in the public restructured hospitals and polyclinics of Singapore since 2008 and this is beginning to show significant beneficial results in terms of identification and management of fragility fractures. However, significant obstacles in the path of appropriate management of the patient with a fragility fracture still exist. A concerted, multipronged and interdisciplinary approach is needed to overcome these barriers. Keywords: Care Gap, Fracture Liaison Service, Osteoporosis, Singapore

Bisphosphonates adherence for treatment of osteoporosis

BACKGROUND

Osteoporosis is a disease of bone metabolism in which bisphosphonates (BPS) are the most common medications used in its treatment, whose main objective is to reduce the risk of fractures. The aim of this study was to conduct a systematic review on BPs adherence for treatment of osteoporosis.

METHODS

Systematic review of articles on BPs adherence for treatment of osteoporosis, indexed on MEDLINE (via PubMed) databases, from inception of databases until January 2013. Search terms were "Adherence, Medication" (MeSH term), "Bisphosphonates" (MeSH term), and "Osteoporosis" (MeSH term).

RESULTS

Of the 78 identified studies, 27 met the eligibility criteria. Identified studies covered a wide range of aspects regarding adherence and associated factors, adherence and fracture, adherence and BPs dosage. The studies are mostly observational, conducted with women over 45 years old, showing low rates of adherence to treatment. Several factors may influence adherence: socio-economic and cultural, participation of physicians when guidance is given to the patient, the use of bone turnover markers, and use of generic drugs. The monthly dosage is associated with greater adherence compared to weekly dosage.

CONCLUSIONS

Considering the methodological differences between the studies, the results converge to show that adherence to treatment of osteoporosis with BPs is still inadequate. Further experimental studies are needed to evaluate the adherence and suggest new treatment options.

The over time development of chronic illness self-management patterns: a longitudinal qualitative study

Background

There currently exists a vast amount of literature concerning chronic illness self-management, however the developmental patterns and sustainability of self-management over time remain largely unknown. This paper aims to describe the patterns by which different chronic illness self-management behaviors develop and are maintained over time.

Method

Twenty-one individuals newly diagnosed with chronic illnesses (e.g., diabetes, rheumatism, ischemic heart disease, multiple sclerosis, chronic renal disease, inflammatory bowel disease) were repeatedly interviewed over two-and-a-half years. The interviews were conducted in Sweden from 2006 to 2008. A total of 81 narrative interviews were analyzed with an interpretive description approach.

Results

The participants’ self-management behaviors could be described in four different developmental patterns: consistent, episodic, on demand, and transitional. The developmental patterns were related to specific self-management behaviors. Most participants took long-term medications in a consistent pattern, whereas exercise was often performed according to an episodic pattern. Participants managed health crises (e.g., angina, pain episodes) according to an on demand pattern and everyday changes due to illness (e.g., adaptation of work and household activities) according to a transitional pattern. All of the participants used more than one self-management pattern.

Conclusion

The findings show that self-management does not develop as one uniform pattern. Instead different self-management behaviors are enacted in different patterns. Therefore, it is likely that self-management activities require support strategies tailored to each behavior’s developmental pattern.

Non-adherence to anti-osteoporotic medications in Taiwan: physician specialty makes a difference

Adherence to anti-osteoporotic regimens gradually decreases over time. We hypothesized that the determinants of non-compliance or non-persistence at different times vary and identified these differences. We used an outpatient database to retrieve information on anti-osteoporotic medications prescribed by a medical centre in southern Taiwan during 2001-2007. Compliance was defined as a medication possession ratio (MPR) ≥80 %. Persistence was determined as continuous use, allowing for a refill gap of 30 days. A multivariate Cox regression model evaluated potential predictors of non-adherence. A total of 3589 patients were included. In the multivariate analyses, non-compliance for both year 1 and year 2 was more likely in patients with non-vertebral non-hip fractures, respiratory disorders, prescription of the first anti-osteoporotic regimen by an orthopedist; and less likely in patients with follow-up bone densitometry and switched regimens. Risks for non-persistence at year 1 and year 2 were generally similar to those for non-compliance; insurance coverage and malignancy were associated with a lower risk of non-persistence at year 1 and year 2, respectively. In the subgroup with an MPR ≥80 % at year 1, an index prescription by an orthopedist was the only independent predictor of non-compliance and non-persistence at year 2. In conclusion, the positive or negative determinants of non-adherence were different at year 1 and year 2, which indicated that clinicians might deliver effective interventions to improve adherence via different precautions annually. This study also provided evidence that physician specialty had a significant effect on adherence to osteoporosis care.