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Gates M, Pillay J, Thériault G, Limburg H, Grad R, Klarenbach S, Korownyk C, Reynolds D, Riva JJ, Thombs BD, Kline GA, Leslie WD, Courage S, Vandermeer B, Featherstone R, Hartling L. Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review. Syst Rev 2019; 8:216. [PMID: 31443711 PMCID: PMC6706906 DOI: 10.1186/s13643-019-1094-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making. METHODS A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force. DISCUSSION Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.
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Affiliation(s)
- Michelle Gates
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Jennifer Pillay
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | | | - Heather Limburg
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Canada
| | | | | | - Donna Reynolds
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - John J. Riva
- Department of Family Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Brett D. Thombs
- Faculty of Medicine, McGill University and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | | | - William D. Leslie
- Department of Medicine (Endocrinology), University of Manitoba, Winnipeg, Canada
- Department of Radiology (Nuclear Medicine), University of Manitoba, Winnipeg, Canada
| | - Susan Courage
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
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Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study. PLoS One 2019; 14:e0219681. [PMID: 31310619 PMCID: PMC6634405 DOI: 10.1371/journal.pone.0219681] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Osteoporosis prevention, diagnosis and treatment remain suboptimal. Objectives We conducted a qualitative study to understand barriers towards care initiation and levers to improve awareness and management of osteoporosis among general practitioners (GPs). Methods Semi-structured face-to face interviews were conducted with 16 GPs in the Rhône area of France to explore their knowledge and representations regarding osteoporosis. A thematic analysis of transcripts was performed to identify GPs’ perceptions on osteoporosis diagnosis, prevention, treatment and patients’ expectations. Results Interviewed GPs considered osteoporosis far less important than other chronic diseases. They questioned whether osteoporosis was a disease or normal aspect of ageing. They associated osteoporosis with fragility fractures, female sex, menopause, and old age but rarely with male sex. They regarded bone mineral density as the reference diagnostic test, but certain GPs indicated that they had difficulties to interpret the results and to know when to prescribe. Biphosphonates were mentioned as the reference treatment but some GPs expressed distrust about osteoporosis medications. Most of them did not think to screen for osteoporosis risk factors in their patients in a preventive medical approach. They mentioned the lack of time to implement prevention and were expecting clear and pragmatic guidelines, as well as information campaigns in general population to increase awareness on osteoporosis. Conclusion GPs tended to underestimate the salience of osteoporosis. Clear recommendations, better awareness of GPs and the general population could improve osteoporosis prevention and treatment.
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Karahan AY, Kaya B, Kuran B, Altındag O, Yildirim P, Dogan SC, Basaran A, Salbas E, Altınbilek T, Guler T, Tolu S, Hasbek Z, Ordahan B, Kaydok E, Yucel U, Yesilyurt S, Polat AD, Cubukcu M, Nas O, Sarp U, Yasar O, Kucuksarac S, Turkoglu G, Karadag A, Bagcaci S, Erol K, Guler E, Tuna S, Yildirim A, Karpuz S. Common Mistakes in the Dual-Energy X-ray Absorptiometry (DXA) in Turkey. A Retrospective Descriptive Multicenter Study. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 59:117-123. [PMID: 28440214 DOI: 10.14712/18059694.2017.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Osteoporosis is a widespread metabolic bone disease representing a global public health problem currently affecting more than two hundred million people worldwide. The World Health Organization states that dual-energy X-ray absorptiometry (DXA) is the best densitometric technique for assessing bone mineral density (BMD). DXA provides an accurate diagnosis of osteoporosis, a good estimation of fracture risk, and is a useful tool for monitoring patients undergoing treatment. Common mistakes in BMD testing can be divided into four principal categories: 1) indication errors, 2) lack of quality control and calibration, 3) analysis and interpretation errors, and 4) inappropriate acquisition techniques. The aim of this retrospective multicenter descriptive study is to identify the common errors in the application of the DXA technique in Turkey. METHODS All DXA scans performed during the observation period were included in the study if the measurements of both, the lumbar spine and proximal femur were recorded. Forearm measurement, total body measurements, and measurements performed on children were excluded. Each examination was surveyed by 30 consultants from 20 different centers each informed and trained in the principles of and the standards for DXA scanning before the study. RESULTS A total of 3,212 DXA scan results from 20 different centers in 15 different Turkish cities were collected. The percentage of the discovered erroneous measurements varied from 10.5% to 65.5% in the lumbar spine and from 21.3% to 74.2% in the proximal femur. The overall error rate was found to be 31.8% (n = 1021) for the lumbar spine and 49.0% (n = 1576) for the proximal femur. CONCLUSION In Turkey, DXA measurements of BMD have been in use for over 20 years, and examination processes continue to improve. There is no educational standard for operator training, and a lack of knowledge can lead to significant errors in the acquisition, analysis, and interpretation.
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Affiliation(s)
- Ali Yavuz Karahan
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey.
| | - Bugra Kaya
- Department of Nuclear Medicine of Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey
| | - Banu Kuran
- Department of Physical Medicine and Rehabilitation, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ozlem Altındag
- Department of Physical Medicine and Rehabilitation, Gaziantep University Sahinbey Research and Training Hospital, Gaziantep, Turkey
| | - Pelin Yildirim
- Department of Physical Medicine and Rehabilitation, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Sevil Ceyhan Dogan
- Department of Physical Medicine and Rehabilitation, Cumhuriyet University, Faculty of Medicine, Sivas, Turkey
| | - Aynur Basaran
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey
| | - Ender Salbas
- Department of Physical Medicine and Rehabilitation, State Hospital of Agri, Agri, Turkey
| | - Turgay Altınbilek
- Department of Physical Medicine and Rehabilitation, Physical therapy High school of Health Sciences of University of Halic, Istanbul, Turkey
| | - Tuba Guler
- Department of Physical Medicine and Rehabilitation, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Sena Tolu
- Department of Physical Medicine and Rehabilitation, Medipol University, Faculty of Medicine, Istanbul, Turkey
| | - Zekiye Hasbek
- Department of Nuclear Medicine, Cumhuriyet University, Faculty of Medicine, Sivas, Turkey
| | - Banu Ordahan
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey
| | - Ercan Kaydok
- Department of Physical Medicine and Rehabilitation, State Hospital of Nevsehir, Nevsehir, Turkey
| | - Ufuk Yucel
- Department of Physical Medicine and Rehabilitation, State Hospital of Nevsehir, Nevsehir, Turkey
| | - Selcuk Yesilyurt
- Department of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Hospital of Yoncali, Kutahya, Turkey
| | - Almula Demir Polat
- Department of Physical Medicine and Rehabilitation, State Hospital of Afyon, Afyon, Turkey
| | - Murat Cubukcu
- Department of Physical Medicine and Rehabilitation, State Hospital of Denizli, Denizli, Turkey
| | - Omer Nas
- Department of Physical Medicine and Rehabilitation, State Hospital of Yozgat, Yozgat, Turkey
| | - Umit Sarp
- Department of Physical Medicine and Rehabilitation, State Hospital of Yozgat, Yozgat, Turkey
| | - Ozan Yasar
- Department of Physical Medicine and Rehabilitation, Amasya University Sabuncuoglu Serefeddin Research and Training Hospital, Amasya, Turkey
| | - Seher Kucuksarac
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey
| | - Gozde Turkoglu
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey
| | - Ahmet Karadag
- Department of Physical Medicine and Rehabilitation, State Hospital of Sivas, Sivas, Turkey
| | - Sinan Bagcaci
- Department of Physical Medicine and Rehabilitation, State Hospital of Hakkari, Hakkari, Turkey
| | - Kemal Erol
- Department of Physical Medicine and Rehabilitation, State Hospital of Nigde, Nigde, Turkey
| | - Emel Guler
- Department of Physical Medicine and Rehabilitation, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Serpil Tuna
- Department of Physical Medicine and Rehabilitation, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Ahmet Yildirim
- Department of Orthopedics and Traumatology, Beyhekim State Hospital of Konya, Konya, Turkey
| | - Savas Karpuz
- Department of Physical Medicine and Rehabilitation, Beyhekim State Hospital of Konya, Konya, Turkey
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Munce SEP, Butt DA, Anantharajah R(S, Huang S, Allin S, Bereket T, Jaglal SB. Acceptability and Feasibility of an Evidence-Based Requisition for Bone Mineral Density Testing in Clinical Practice. J Osteoporos 2016; 2016:6967232. [PMID: 28050306 PMCID: PMC5168451 DOI: 10.1155/2016/6967232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction. The purpose of this study is to understand the experience of primary care providers (PCPs) using an evidence-based requisition for bone mineral density (BMD) testing. Methods. A qualitative descriptive approach was adopted. Participants were given 3 BMD Recommended Use Requisitions (RUR) to use over a 2-month period. Twenty-six PCPs were interviewed before using the RUR. Those who had received at least one BMD report resulting from RUR use were then interviewed again. An inductive thematic analysis was performed. Results. We identified four themes in interview data: (1) positive and negative characteristics of the RUR, (2) facilitators and barriers for implementation, (3) impact of the RUR, and (4) requisition preference. Positive characteristics of the RUR related to both its content and format. Negative characteristics related to the increased amount of time needed to complete the form. Facilitators to implementation included electronic availability and organizational endorsement. Time constraints were identified as a barrier to implementation. Participants perceived that the RUR would promote appropriate referrals and the majority of participants preferred the RUR to their current requisition. Conclusions. Findings from this study provide support for the RUR as an acceptable point-of-care tool for PCPs to promote appropriate BMD testing.
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Affiliation(s)
- Sarah E. P. Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Debra A. Butt
- Department of Family and Community Medicine, University of Toronto, Research Department, Toronto, ON, Canada
- Family and Community Medicine, The Scarborough Hospital, Scarborough, ON, Canada
| | | | - Susana Huang
- Family and Community Medicine, The Scarborough Hospital, Scarborough, ON, Canada
| | - Sonya Allin
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Tarik Bereket
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Susan B. Jaglal
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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Allin S, Bleakney R, Zhang J, Munce S, Cheung AM, Jaglal S. Evaluation of Automated Fracture Risk Assessment Based on the Canadian Association of Radiologists and Osteoporosis Canada Assessment Tool. J Clin Densitom 2016; 19:332-9. [PMID: 27067299 DOI: 10.1016/j.jocd.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 02/09/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
Fracture risk assessments are not always clearly communicated on bone mineral density (BMD) reports; evidence suggests that structured reporting (SR) tools may improve report clarity. The aim of this study is to compare fracture risk assessments automatically assigned by SR software in accordance with Canadian Association of Radiologists and Osteoporosis Canada (CAROC) recommendations to assessments from experts on narrative BMD reports. Charts for 500 adult patients who recently received a BMD exam were sampled from across University of Toronto's Joint Department of Medical Imaging. BMD measures and clinical details were manually abstracted from charts and were used to create structured reports with assessments generated by a software implementation of CAROC recommendations. CAROC calculations were statistically compared to experts' original assessments using percentage agreement (PA) and Krippendorff's alpha. Canadian FRAX calculations were also compared to experts', where possible. A total of 25 (5.0%) reported assessments did not conform to categorizations recommended by Canadian guidelines. Across the remainder, the Krippendorff's alpha relating software assigned assessments to physicians was high at 0.918; PA was 94.3%. Lower agreement was associated with reports for patients with documented modifying factors (alpha = 0.860, PA = 90.2%). Similar patterns of agreement related expert assessments to FRAX calculations, although statistics of agreement were lower. Categories of disagreement were defined by (1) gray areas in current guidelines, (2) margins of assessment categorizations, (3) dictation/transcription errors, (4) patients on low doses of steroids, and (5) ambiguous documentation of modifying factors. Results suggest that SR software can produce fracture risk assessments that agree with experts on most routine, adult BMD exams. Results also highlight situations where experts tend to diverge from guidelines and illustrate the potential for SR software to (1) reduce variability in, (2) ameliorate errors in, and (3) improve clarity of routine adult BMD exam reports.
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Affiliation(s)
- Sonya Allin
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
| | - Robert Bleakney
- Department of Medical Imaging, Mount Sinai Hospital and the University Health Network, Toronto, ON, Canada; Joint Department of Medical Imaging (JDMI), University Health Network, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, ON, Canada
| | - Julie Zhang
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Sarah Munce
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Angela M Cheung
- Department of Medical Imaging, Mount Sinai Hospital and the University Health Network, Toronto, ON, Canada; Joint Department of Medical Imaging (JDMI), University Health Network, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, ON, Canada; University Health Network Osteoporosis Program, Toronto General Hospital, Toronto, ON Canada
| | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Osteoporosis Research Program, Women's College Research Institute, Toronto, ON, Canada
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Seuffert P, Sagebien CA, McDonnell M, O'Hara DA. Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice. Arch Osteoporos 2016; 11:10. [PMID: 26847628 DOI: 10.1007/s11657-016-0262-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/12/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to assess whether education and referral by a nurse practitioner could improve treatment adherence in patients with low bone mineral density in the orthopedic office. Our customized project did show some improvement but resistance to care continues in this unique population of patients. INTRODUCTION Osteoporosis and osteopenia are significant clinical problems. Nearly 50% of adults over the age of 50 are osteopenic (Looker et al. in Osteoporos Int 22:541-549, 2011). Many patients with osteoporosis are not taking calcium or vitamin D, or any active treatment, even after dual energy X-ray absorptiometry (DXA) and demonstration of low bone mineral density (Dell et al. in J Bone Joint Surg Am 91(Suppl 6):79-86, 2009). One hypothesis to explain low adherence with osteoporosis treatment is lack of patient education. This study was designed to compare a control group with an education-intervention group (receiving patient education from a nurse practitioner) to determine any effect of education on treatment adherence. METHODS A total of 242 females and 105 males were studied as a control: a total of 292 females and 155 male were studied in the education group. Patients in the education group received educational materials and were counseled by a single nurse practitioner. Patients had a DXA performed and patients with osteoporosis or osteopenia were followed to assess treatment. At 12 months, patients received follow-up phone calls to determine patient use of calcium, vitamin D, and/or an active treatment. Results between the groups were compared. RESULTS Significantly more patients began calcium and vitamin D after education (p = 0.04); significantly more patients were taking or were recommended for an active treatment after education (p = 0.03). Thirty percent of patients either did not follow up or refused active treatment for osteoporosis. Approximately 50% of patients with osteoporosis were not taking an FDA-approved pharmacologic agent for osteoporosis treatment, despite education. CONCLUSION After patient education and referral to endocrinology, significantly more patients began calcium and vitamin D supplementation. However, up to 50% of patients with osteoporosis would not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.
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Affiliation(s)
- Patricia Seuffert
- University Orthopaedic Associates, LLC, 2 World's Fair Drive, Somerset, NJ, 08873, USA.
| | - Carlos A Sagebien
- University Orthopaedic Associates, LLC, 2 World's Fair Drive, Somerset, NJ, 08873, USA
| | - Matthew McDonnell
- University Orthopaedic Associates, LLC, 2 World's Fair Drive, Somerset, NJ, 08873, USA
| | - Dorene A O'Hara
- University Orthopaedic Associates, LLC, 2 World's Fair Drive, Somerset, NJ, 08873, USA
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Claesson A, Toth-Pal E, Piispanen P, Salminen H. District nurses' perceptions of osteoporosis management: a qualitative study. Osteoporos Int 2015; 26:1911-8. [PMID: 25792490 DOI: 10.1007/s00198-015-3086-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 02/20/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED Underdiagnosis of osteoporosis is common. This study investigated Swedish district nurses' perceptions of osteoporosis management. They perceived the condition as having low priority, and the consequences of this perception were insufficient awareness of the condition and perceptions of bone-specific medication as unsafe. They perceived, though, competency when working with fall prevention. INTRODUCTION Undertreatment of patients with osteoporosis is common. Sweden's medical care strategy dictates prioritisation of various conditions; while guidelines exist, osteoporosis is not prioritised. The aim of this study was to investigate district nurses' perceptions of osteoporosis management within Sweden's primary health care system. METHODS Four semi-structured focus group interviews were conducted with 13 female district nurses. The interviews were analysed using thematic analysis. RESULTS The overall theme was perceiving osteoporosis management as ambiguous. The themes were perceiving barriers and perceiving opportunities. These subthemes were linked to perceiving barriers: (i) insufficient procedures, lack of time and not aware of the condition; (ii) insufficient knowledge about diagnosis and about fracture risk assessment tools; (iii) low priority condition and unclear responsibility for osteoporosis management; and (iv) bone-specific medication was sometimes perceived to be unsafe. These subthemes were linked to perceiving opportunities: (i) professional competency when discussing fall prevention in home visit programs, (ii) willingness to learn more about osteoporosis management, (iii) collaboration with other professionals and (iv) willingness to identify individuals at high risk of fracture. CONCLUSIONS Osteoporosis was reported, by the district nurses, to be a low-priority condition with consequences being unawareness of the condition, insufficient knowledge about bone-specific medications, fracture risk assessment tools and procedures. These may be some of the explanations for the undertreatment of osteoporosis. At the same time, the district nurses described competency performing the home visits, which emerged as an optimal opportunity to discuss fall prevention and to introduce FRAX with the aim to identify individuals at high risk of fracture.
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Affiliation(s)
- A Claesson
- Unit of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden,
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Sale JEM, Bogoch E, Meadows L, Gignac M, Frankel L, Inrig T, Beaton D, Jain R. Bone Mineral Density Reporting Underestimates Fracture Risk in Ontario. Health (London) 2015; 7:566-571. [PMID: 26523215 PMCID: PMC4623753 DOI: 10.4236/health.2015.75067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective Analysis of clinical documents such as bone mineral density (BMD) reports is an important component of program evaluation because it can provide insights into the accuracy of assessment of fracture risk communicated to patients and practitioners. Our objective was to compare fracture risk calculations from BMD test reports to those based on the 2010 Canadian guidelines. Methods We retrieved BMD reports from fragility fracture patients screened through a community hospital fracture clinic participating in Ontario’s Fracture Clinic Screening Program. Fracture risk was determined according to the 2010 Canadian guidelines using age, sex, and T-score at the femoral neck, in addition to three clinical factors. Three researchers classified patients’ fracture risk until consensus was achieved. Results We retrieved reports for 17 patients from nine different BMD clinics in the Greater Toronto Area. Each patient had a different primary care physician and all BMD tests were conducted after the 2010 Canadian guidelines were published. The fracture risk of 10 patients was misclassified with 9 of the 10 reports underestimating fracture risk. Nine reports acknowledged that the prevalence of a fragility fracture raised the risk category by one level but only four of these reports acknowledged that the patient had, or may have sustained, a fragility fracture. When we raised fracture risk by one level according to these reports, eight patients were still misclassified. Fracture risk in the majority of these patients remained underestimated. Inconsistent classification was found in the majority of cases where reports came from the same clinic. Four reports described risk levels for two different types of risk. Conclusions More than half of patients received BMD reports which underestimated fracture risk. Bone health management recommendations based on falsely low fracture risk are likely to be sub-optimal.
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Affiliation(s)
- Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada ; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Earl Bogoch
- Mobility Program, St. Michael's Hospital, Toronto, Canada ; Department of Surgery, University of Toronto, Toronto, Canada
| | - Lynn Meadows
- Community Health Sciences, University of Calgary, Calgary, Canada
| | - Monique Gignac
- Toronto Western Research Institute, University Health Network, Toronto, Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Lucy Frankel
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Dorcas Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ravi Jain
- Osteoporosis Canada, Toronto, Canada
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Sale JEM, Bogoch E, Hawker G, Gignac M, Beaton D, Jaglal S, Frankel L. Patient perceptions of provider barriers to post-fracture secondary prevention. Osteoporos Int 2014; 25:2581-9. [PMID: 25082555 DOI: 10.1007/s00198-014-2804-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 07/01/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED We examined patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after being screened through Ontario's Fracture Clinic Screening Program. Provider-level barriers to testing and treatment appeared to be as significant as patient-level barriers and potentially had more of an impact on treatment than on testing. INTRODUCTION Post-fracture secondary prevention programs have had modest effects on bone densitometry rates and osteoporosis (OP) treatment initiation. Few studies have examined in depth the reasons that patients choose to seek or avoid investigation and treatment after screening through such a program. Our purpose was to examine patients' experiences regarding bone mineral density (BMD) testing and bone health treatment after screening through Ontario's Fracture Clinic Screening Program (FCSP). METHODS We conducted a prospective qualitative study in fragility fracture patients screened through one site of the FCSP. Eligible patients not on antiresorptive medication at the time of fracture were assessed by an osteoporosis screening coordinator and advised to follow up with their primary care physician for a BMD test and appropriate treatment. Participants were interviewed within 6, and within 18, months of their clinic visit. Fracture risk was assessed by the study team. Interviews were transcribed verbatim and analyzed by two researchers. RESULTS We conducted 51 interviews with 25 patients (22 females, 3 males) aged 50-79 years old, of whom 8 were deemed high risk for future fracture. Eighteen participants had a BMD test between baseline and follow-up and three reported receiving a prescription for pharmacotherapy. We categorized 21 participants as experiencing at least one barrier to BMD testing and appropriate treatment including health care providers telling participants that the fracture was not a fragility fracture, using participants' appearance/demographic information and X-rays to judge bone density, telling participants that a BMD test was not appropriate, failing to discuss fracture risk status, and giving unclear or incorrect information about treatment. CONCLUSION We identified modifiable barriers to post-fracture secondary prevention from the patient's perspective. Provider-level barriers appeare to be as significant as patient-level barriers and potentially had more of an impact on treatment than on BMD testing.
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Affiliation(s)
- J E M Sale
- Mobility Program Clinical Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada,
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