Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials

Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry

Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.

Pharmacist interventions in osteoporosis management: a systematic review

Internationally, there is an osteoporosis treatment gap, which pharmacists may assist in closing. This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness. Pharmacist interventions are shown to improve osteoporosis management in terms of increasing investigation and treatment commencement and osteoporosis therapy adherence.

INTRODUCTION

This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness.

METHODS

A literature search using PubMed, Embase, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was undertaken from database inception to June 2022. Randomised controlled trials were eligible, if they included adults diagnosed with or at risk of osteoporosis and assessed pharmacist interventions to improve osteoporosis management. Outcomes regarding investigation, treatment, adherence and patient knowledge were evaluated using qualitative analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration tool to assess the risk of bias (Rob 2.0).

RESULTS

Sixteen articles (12 different studies) with a total of 16,307 participants, published between 2005 and 2018 were included. Pharmacist interventions were classified into two categories, those targeting investigation and treatment (n = 10) and those targeting adherence (n = 2). The impact of the intervention on patient knowledge was considered by studies targeting both investigation and treatment (n = 2) and adherence (n = 1). Pharmacist interventions demonstrated benefit for all outcomes; however, the extent to which conclusions can be drawn on their effectiveness is limited by the heterogeneity of interventions employed and methodological issues identified. Patient education and counselling were identified as a cornerstone of pharmacist interventions targeting both investigation and treatment and adherence, along with the importance of pharmacist and physician collaboration.

CONCLUSION

Pharmacist interventions show promise for improving osteoporosis management. The potential for pharmacists to contribute to closing the osteoporosis treatment gap through undertaking population screening has been identified.

Ten-year fracture risk predicted by proximal femur Hounsfield units

Colon cancer screening occurs at younger ages than osteoporosis screening. Bone density measurements using virtual colonoscopy performed for colon cancer screening can provide an early warning sign of patients at potential risk for osteoporosis-related fractures. Earlier identification may improve treatment and potentially fracture prevention.

INTRODUCTION

Opportunistic osteoporosis screening with computed tomography colonography (CTC) offers an opportunity to capitalize on earlier colorectal cancer screening to identify patients at risk of future fractures. The purpose of this study is to evaluate 10-year fracture and specifically hip fracture risk based on Hounsfield units (HU) obtained from CTC.

METHODS

We identified all CTC scans between 2004 and 2007 of patients 40 years and older with 10 years minimum follow-up. Hounsfield units were measured within the proximal femur and fractures identified via worldwide military records. Patients were stratified into two cohorts based on the presence or lack of a fracture in the wrist, spine, hip, or proximal humerus. Hounsfield unit measurements were compared between groups using Student's t test and the HU threshold was calculated that best approximated an 80% sensitivity to optimally screen patients for fracture risk. The odds ratio, negative predictive value, 10-year incidence of fracture, and survival curves were calculated.

RESULTS

We identified 3711 patients with 183 fractures over 10 years. The HU threshold that corresponded with an 80% sensitivity to identify fractures was 112 HU. The negative predictive value (NPV) for overall fractures and hip fractures was over 97%. The 10-year fracture incidence was higher in patients below 112 HU compared to those above for both overall fractures (6.3% vs 1.7%) and hip fractures (2.7% vs 0.07%). The 112 HU threshold corresponds with an odds ratio for overall fracture and hip fractures of 2.5 (95% confidence interval (CI), 1.7-3.6) and 24.5 (95% CI, 3.3-175.5), respectively.

CONCLUSION

In the 10 years following CTC, patients who experienced a fracture had lower hip HU. Decreasing HU on CTC may be an early warning sign of fracture potential.

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.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF)

Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions.

INTRODUCTION

Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication.

METHODS

A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken.

RESULTS

Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it.

CONCLUSION

These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.

[Hounsfield units as a measure of bone density-applications in spine surgery]

Despite today's good diagnostic and therapeutic options for osteoporosis, the number of unidentified cases is very high and therapy is therefore usually inadequate. Frequently, the diagnosis of osteoporosis is made only after the occurrence of a fracture. The reason for this, apart from the costs incurred as well as the additional radiation exposure of the diagnostics, is certainly the limited availability of dual energy X‑ray absorptiometry (DEXA) as well as quantitative computed tomography (q-CT). In search of an alternative technique, Hounsfield units (HU) of the clinical CT examination proved to be ground-breaking: the results of previous investigations demonstrated a reliable correlation between the T values of the DEXA measurement and the HU of the same vertebral body. Due to the widespread use of clinical CT scans of the thorax and the abdomen for a variety of indications, it is expected that the number of unidentified cases of osteoporosis can be significantly reduced-without additional costs and radiation exposure associated with osteoporosis screening. In addition to osteoporosis diagnostics, the calculated HU may also provide better preoperative planning as well as predicting the further course of the disease. Thus, the risk for vertebral body fractures, screw loosening and cage sintering after ventral fusion operations can be sufficiently predicted. In this way, preoperative modifications to the surgical procedure can be made to reduce the risk of implant failure.

Identifying and Addressing Barriers to Osteoporosis Treatment Associated with Improved Outcomes: An Observational Cohort Study

OBJECTIVE

To identify and address patient-reported barriers in osteoporosis care after a fracture.

METHODS

A longitudinal cohort of fragility fracture patients over 50 years of age was seen in a provincewide fracture liaison service. Followup interviews were done at 6 months for osteoporosis care indicators. Univariate statistics were used to describe baseline characteristics, osteoporosis-related outcomes, and reasons cited for not achieving them. Two phases of this program were compared (Phase I: education and communication, and Phase II: risk assessment education and communication). Phase II was further divided into those who fully participated and those who declined.

RESULTS

Phase I (n = 3997) had lower testing and treatment rates than Phase II (n = 1363). Rates were highest in those confirmed as having participated in Phase II (n = 569). Phase II nonparticipants (n = 794) had results as in Phase I. In Phase I, the main patient-reported barriers for not visiting their physician or not having a bone mineral density (BMD) test were patient- and physician-oriented (e.g., being instructed by their physician to not have the BMD test). In Phase II, BMD testing was part of the program, thus the main barriers were around treatment choices. Phase II eligible nonparticipants experienced many of the same barriers as Phase I patients, with lower BMD testing rates (54.9% and 65.4%, respectively).

CONCLUSION

Evaluating and addressing barriers to guideline implementation reduced those barriers and was associated with higher downstream treatment rates. Monitoring barriers in a program like this provides useful insights for program changes and research interventions.

Frequency of Bone Health Presentations at National Hand Meetings

PURPOSE

The purpose of this study was to determine the frequency with which osteoporosis topics (screening, medical treatment, and fracture prevention) are presented at national hand surgery meetings. This was compared with the frequency of the same topics presented at the Orthopaedic Trauma Association (OTA) annual meetings.

METHODS

The annual meeting programs for the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the OTA from the previous 10 years (2007-2016) were searched for presentations that covered bone health at each of these meetings. We categorized the presentations as either instructional or research.

RESULTS

There were 2 bone health instructional presentations at hand surgery meetings in contrast to 13 presentations at OTA meetings over the last 10 years. For the last 9 years, the OTA has featured at least 1 instructional presentation on bone health every year. We identified 11 research presentations at the hand surgery meetings compared with 16 at the OTA meetings.

CONCLUSIONS

Osteoporosis and bone health are infrequently presented instructional topics at national hand meetings compared with OTA meetings. The cause of the difference is unclear and likely multifactorial, varying each year with different program chairs and committees. The level of involvement of hand surgeons in osteoporosis management is controversial; however, incorporation of this topic may stimulate discussion and help identify solutions for this controversy.

CLINICAL RELEVANCE

It may benefit hand surgeons to place more importance on osteoporosis screening and treatment. We believe that there should be an annual instructional course on this topic at the ASSH and AAHS meetings.

Osteoporosis: a discussion on the past 5 years

PURPOSE OF THE REVIEW

The purposes of this study are to examine the literature within the past 5 years regarding osteoporosis and offer a discussion on new topics and controversies.

RECENT FINDINGS

Patient compliance with therapy remains an issue. The effectiveness of Vitamin D and calcium are being called into question Atypical femur fractures have been associated with bisphosphonate and denosumab use. Treatment is both surgical and pharmaceutical. A multidisciplinary approach to osteoporotic fractures is important and having some form of fracture liaison service (FLS) improves the efficacy of osteoporotic care and decreases secondary fractures. Screening for osteoporosis remains low. Ultrasound may be cost-effective for diagnosis. Understanding of osteoporosis has come a long way in the medical community, but the translation to the lay community has lagged behind. Patients often take a laissez-faire attitude toward osteoporosis that can affect compliance. Information read by patients often focuses on complications, such as atypical femur fractures and myocardial infarctions. It is essential for providers to be able to discuss these issues with patients. Newer medications and more cost-effective diagnostic tests exist, but availability may be limited. FLS are effective, but the most cost-effective model for therapy still eludes us. Areas for further investigation include FLS models, the effectiveness of vitamin supplementation, and more ubiquitous and cost-effective diagnostic tools.

Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced.

INTRODUCTION

Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year.

METHODS

We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison.

RESULTS

We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time.

CONCLUSIONS

The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.

Men's health-seeking behaviours regarding bone health after a fragility fracture: a secondary analysis of qualitative data

In our qualitative study, men with fragility fractures described their spouses as playing an integral role in their health behaviours. Men also described taking risks, preferring not to dwell on the meaning of the fracture and/or their bone health. Communication strategies specific to men about bone health should be developed.

INTRODUCTION

We examined men's experiences and behaviours regarding bone health after a fragility fracture.

METHODS

We conducted a secondary analysis of five qualitative studies. In each primary study, male and female participants were interviewed for 1-2 h and asked to describe recommendations they had received for bone health and what they were doing about those recommendations. Maintaining the phenomenological approach of the primary studies, the transcripts of all male participants were re-analyzed to highlight experiences and behaviours particular to men.

RESULTS

Twenty-two men (50-88 years old) were identified. Sixteen lived with a wife, male partner, or family member and the remaining participants lived alone. Participants had sustained hip fractures (n = 7), wrist fractures (n = 5), vertebral fractures (n = 2) and fractures at other locations (n = 8). Fourteen were taking antiresorptive medication at the time of the interview. In general, men with a wife/female partner described these women as playing an integral role in their health behaviours, such as removing tripping hazards and organizing their medication regimen. While participants described giving up activities due to their bone health, they also described taking risks such as drinking too much alcohol and climbing ladders or deliberately refusing to adhere to bone health recommendations. Finally, men did not dwell on the meaning of the fracture and/or their bone health.

CONCLUSIONS

Behaviours consistent with those shown in other studies on men were described by our sample. We recommend that future research address these findings in more detail so that communication strategies specific to men about bone health be developed.

Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial

Background

Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge.

Methods

The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates.

Results

At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point.

Conclusions

A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care.

Trial registration

Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.

Barriers to Effective Postmenopausal Osteoporosis Treatment: A Qualitative Study of Patients' and Practitioners' Views

BACKGROUND

Only a minority of patients at high risk for osteoporotic fracture receive treatment.

OBJECTIVE

Study patients' and physicians' views regarding postmenopausal osteoporosis (PMO) to identify impediments to good care.

METHODS

A qualitative study involving 18 physicians and 37 women (age 57-87) with PMO.

RESULTS

All women interviewed considered PMO to be somewhat normal wear-and-tear associated with old age. The women identified a large number of "causes" for osteoporosis but finally viewed it as chance. They all described its progression as slow. Three representations of PMO severity were identified: some women tended to interpreted it as benign (21), others tended to dramatize it (11), and the rest were uncertain (5). These representations did not appear linked to age or fracture. Even the women who associated fracture and PMO were uncertain of the link between them. Fractures were considered to be random events, independent of osteoporosis. Women received general life-style recommendations from their physicians positively, but did not connect them specifically to osteoporosis. Indeed, these recommendations, along with the fear of side effects, the absence of tangible results of treatments, the view of PMO as a natural process, and the representations of PMO severity are factors that may deter treatments and impact compliance. As for the physicians, they identified eight risk factors, recognizing menopause as central to PMO and recognized the link between risk of fracture and PMO. However, some considered the impact of fractures to be limited in time, and viewed PMO as a "benign" disease. Seeing the progression of PMO as slow and inevitable reduced their urgency to diagnose and treat it as compared to other diseases. Some physicians acknowledged limited mastery of the existing therapeutic arsenal and unsuccessful handling of patient compliance.

CONCLUSION

Women's and physicians' perspectives on PMO converged to trivialize postmenopausal osteoporosis and thus disqualify it as a legitimate disease. A better understanding of women's and physicians' views, practices, and concerns related to PMO can improve osteoporosis management.

Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice

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.