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Wingood M, Criss MG, Irwin KE, Freshman C, Phillips EL, Dhaliwal P, Chui KK. Screening for Osteoporosis Risk Among Community-Dwelling Older Adults: A Scoping Review. J Geriatr Phys Ther 2023; 46:E137-E147. [PMID: 36827688 DOI: 10.1519/jpt.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND AND PURPOSE Due to potential health-related consequences of osteoporosis (OP), health care providers who do not order imaging, such as physical therapists, should be aware of OP screening tools that identify individuals who need medical and rehabilitation care. However, current knowledge and guidance on screening tools is limited. Therefore, we explored OP screening tools that are appropriate and feasible for physical therapy practice, and evaluated tools' effectiveness by examining their clinimetric properties. METHODS A systematic search of the following databases was performed: PubMed, PEDro, PsycINFO, CINAHL, and Web of Science. Articles were included if the study population was 50 years and older, had a diagnosis of OP, if the screening tool was within the scope of physical therapy practice, and was compared to either a known diagnosis of OP or bone densitometry scan results. Included articles underwent multiple reviews for inclusion and exclusion, with each review round having a different randomly selected pair of reviewers. Data were extracted from included articles for participant demographics, outcome measures, cut-off values, and clinimetric properties. Results were categorized with positive and negative likelihood ratios (+LR/-LR) based on the magnitude of change in the probability of having or not having OP. RESULTS +LRs ranged from 0.15 to 20.21, with the Fracture Risk Assessment Tool (FRAX) and Study of Osteoporotic Fractures (SOF) having a large shift in posttest probability. -LRs ranged from 0.03 to 1.00, with the FRAX, Male Osteoporosis Risk Estimation Scores, Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation having a large shift in posttest probability. CONCLUSION Tools with moderate-large shift for both +LR and -LR recommended for use are: (1) OST; (2) FRAX; and (3) SOF. The variability in cut-off scores and clinimetric properties based on gender, age, and race/ethnicities made it impossible to provide one specific recommendation for an OP screening tool. Future research should focus on OP risk prediction among males and racial and ethnic groups.
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Affiliation(s)
- Mariana Wingood
- Department of Rehabilitation and Movement Sciences, University of Vermont, Burlington
| | - Michelle G Criss
- School of Health Sciences, Chatham University, Pittsburgh, Pennsylvania
| | - Kent E Irwin
- Department of Physical Therapy, Midwestern University, Downers Grove, Illinois
| | - Christina Freshman
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania
| | | | - Puneet Dhaliwal
- Department of Physical Therapy, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Kevin K Chui
- Department of Physical Therapy, Radford University, Roanoke, Virginia
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Gregor RA, Sebach AM. Nurse Practitioner–Led Vitamin D Screening and Supplementation Program in Rural Primary Care. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wopat M, Breslow R, Chesney K, McCauley M, Van Gysel R, Gray A, Hilsenhoff J, Edwardson G, Nachreiner J, Hoff L, Gruber S, Shattuck P, Portillo E. Implementation of a pharmacist and student pharmacist-led primary care service to identify and treat rural veterans at risk for osteoporotic fracture. J Am Pharm Assoc (2003) 2021; 61:e105-e112. [PMID: 34393078 DOI: 10.1016/j.japh.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/03/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop and implement a pharmacist and student pharmacist-led osteoporosis service to increase dual-energy x-ray absorptiometry (DXA) screening rates among rural veterans and treat those at high risk of osteoporotic fractures. PRACTICE DESCRIPTION Pharmacists are uniquely positioned to provide direct patient care in the Department of Veterans Affairs ambulatory care setting owing to their broad scope of practice. Clinical Pharmacy Specialists (CPSs) have the authority to order laboratory tests and imaging, prescribe medications, refer patients to specialty services, and monitor patients along with the primary care team. PRACTICE INNOVATION The implementation of a pharmacist-led osteoporosis primary prevention service using student pharmacists to identify and treat patients has not been previously described in the literature to the authors' knowledge. EVALUATION METHODS Student pharmacists in their third year contacted veterans who met the inclusion criteria for osteoporosis screening. The veterans were offered DXA scans and provided education on the risk factors for osteoporosis. After the DXA scans were completed, the students and the CPS reviewed the results to determine treatment strategies. The primary objective was evaluated by comparing the pre- and post-implementation rates of DXA screening. The other process markers that were evaluated included (1) completed DXA scans, (2) new diagnoses of osteoporosis or osteopenia, (3) patients eligible for treatment on the basis of the DXA screening results, and (4) patients who started oral bisphosphonate therapy. RESULTS Of the 232 rural veterans evaluated, 36 had completed DXA scans before this service was implemented. After the service was implemented, 115 veterans completed DXA scans. A total of 57 patients received a new diagnosis, 33 were eligible for therapy, and 12 started oral bisphosphonate therapy after intervention by the CPS. CONCLUSION The implementation of a pharmacist-driven osteoporosis screening and treatment service demonstrated an increase in the rate of DXA screening among rural veterans.
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Miller KL, Steffen MJ, McCoy KD, Cannon G, Seaman AT, Anderson ZL, Patel S, Green J, Wardyn S, Solimeo SL. Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation. Arch Osteoporos 2021; 16:27. [PMID: 33566174 PMCID: PMC7875846 DOI: 10.1007/s11657-021-00882-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting. PURPOSE An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility. METHODS For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. RESULTS Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success. CONCLUSION The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.
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Affiliation(s)
- Karla L. Miller
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Melissa J. Steffen
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
| | - Kimberly D. McCoy
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
| | - Grant Cannon
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Aaron T. Seaman
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Division of Genera l Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242 Iowa City, IA USA
| | - Zachary L. Anderson
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Anesthesiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Shardool Patel
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Anesthesiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Janiel Green
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Shylo Wardyn
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
| | - Samantha L. Solimeo
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
- Division of Genera l Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242 Iowa City, IA USA
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Abstract
PURPOSE OF REVIEW Identifying individuals at high fracture risk can be used to target those likely to derive the greatest benefit from treatment. This narrative review examines recent developments in using specific risk factors used to assess fracture risk, with a focus on publications in the last 3 years. RECENT FINDINGS There is expanding evidence for the recognition of individual clinical risk factors and clinical use of composite scores in the general population. Unfortunately, enthusiasm is dampened by three pragmatic randomized trials that raise questions about the effectiveness of widespread population screening using clinical fracture prediction tools given suboptimal participation and adherence. There have been refinements in risk assessment in special populations: men, patients with diabetes, and secondary causes of osteoporosis. New evidence supports the value of vertebral fracture assessment (VFA), high resolution peripheral quantitative CT (HR-pQCT), opportunistic screening using CT, skeletal strength assessment with finite element analysis (FEA), and trabecular bone score (TBS). The last 3 years have seen important developments in the area of fracture risk assessment, both in the research setting and translation to clinical practice. The next challenge will be incorporating these advances into routine work flows that can improve the identification of high risk individuals at the population level and meaningfully impact the ongoing crisis in osteoporosis management.
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Affiliation(s)
- William D Leslie
- Departments of Medicine and Radiology, University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - Suzanne N Morin
- Department of Medicine, McGill University- McGill University Health Center, Montreal, Quebec, Canada
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Leslie WD, Crandall CJ. Population-Based Osteoporosis Primary Prevention and Screening for Quality of Care in Osteoporosis, Current Osteoporosis Reports. Curr Osteoporos Rep 2019; 17:483-490. [PMID: 31673933 DOI: 10.1007/s11914-019-00542-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite the high prevalence and impact of osteoporosis, screening and treatment rates remain low, with few women age 65 years and older utilizing osteoporosis screening for primary prevention. RECENT FINDINGS This review examines opportunities and challenges related to primary prevention and screening for osteoporosis at the population level. Strategies on how to identify individuals at high fracture risk and target them for treatment have lagged far behind other developments in the osteoporosis field. Most osteoporosis quality improvement strategies have focused on patients with recent or prior fracture (secondary prevention), with limited attention to individuals without prior fracture. For populations without prior fracture, the only quality improvement strategy for which meta-analysis demonstrated significant improvement in osteoporosis care was patient self-scheduling of DXA plus education Much more work is needed to develop and validate effective primary screening and prevention strategies and translate these into high-quality guidelines.
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Affiliation(s)
- William D Leslie
- Departments of Medicine and Radiology, University of Manitoba, C5121 - 409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
| | - Carolyn J Crandall
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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Rubin KH, Möller S, Holmberg T, Bliddal M, Søndergaard J, Abrahamsen B. A New Fracture Risk Assessment Tool (FREM) Based on Public Health Registries. J Bone Miner Res 2018; 33:1967-1979. [PMID: 29924428 DOI: 10.1002/jbmr.3528] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/25/2018] [Accepted: 06/06/2018] [Indexed: 12/25/2022]
Abstract
Some conditions are already known to be associated with an increased risk of osteoporotic fractures. Other conditions may also be significant indicators of increased risk. The aim of the current study was to identify conditions for inclusion in a fracture prediction model (fracture risk evaluation model [FREM]) for automated case finding of high-risk individuals of hip or major osteoporotic fractures (MOFs). We included the total population of Denmark aged 45+ years (N = 2,495,339). All hospital diagnoses from 1998 to 2012 were used as possible conditions; the primary outcome was MOFs during 2013. Our cohort was split randomly 50/50 into a development and a validation dataset for deriving and validating the predictive model. We applied backward selection on ICD-10 codes (International Classification of Diseases and Related Health Problems, 10th Revision) by logistic regression to develop an age-adjusted and sex-stratified model. The FREM for MOFs included 38 and 43 risk factors for women and men, respectively. Testing FREM for MOFs in the validation cohort showed good accuracy; it produced receiver-operating characteristic (ROC) curves with an area under the ROC curve (AUC) of 0.750 (95% CI, 0.741 to 0.795) and 0.752 (95% CI, 0.743 to 0.761) for women and men, respectively. The FREM for hip fractures included 32 risk factors for both genders and showed an even higher accuracy in the validation cohort as AUCs of 0.874 (95% CI, 0.869 to 0.879) and 0.851 (95% CI, 0.841 to 0.861) for women and men were found, respectively. We have developed and tested a prediction model (FREM) for identifying men and women at high risk of MOFs or hip fractures by using solely existing administrative data. The FREM could be employed either at the point of care integrated into electronic patient record systems to alert physicians or deployed centrally in a national case-finding strategy where patients at high fracture risk could be invited to a focused DXA program. © 2018 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Katrine Hass Rubin
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Sören Möller
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Mette Bliddal
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark
| | - Jens Søndergaard
- The Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Bo Abrahamsen
- OPEN-Odense Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, and Odense University Hospital, Odense, Denmark.,Department of Medicine, Holbaek Hospital, Holbaek, Denmark
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Khatib J, Stote K, Gosmanov AR. Utility of DXA screening for diagnosis of osteoporosis in US veterans aged 70 years and older. J Investig Med 2017; 66:298-303. [DOI: 10.1136/jim-2017-000557] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 11/04/2022]
Abstract
Dual energy X-ray absorptiometry (DXA) is recommended for osteoporosis screening in men aged 70 years and older but supportive data is limited. The aim of this study was to determine the efficacy of DXA for the diagnosis of increased fragility in this group of subjects. We retrospectively identified men aged 70 years and older without prior history of fracture and/or conditions predisposing to low bone mineral density (BMD) who attended the VA endocrinology clinic and performed DXA for osteoporosis screening. We analyzed the relationship between BMD and demographic, anthropometric data and biochemical parameters using linear regression models. Out of 55 subjects identified, 13 (24%) men had normal BMD, 30 (54%) had osteopenia and 12 (22%) had a diagnosis of osteoporosis based on the femoral neck (FN) T-score. Lumbar spine T-scores were normal in all three groups. Weight and body mass index (BMI) were significantly higher in the normal BMD group compared with the osteopenia and osteoporosis groups (p<0.001). After adjustments for age, weight, BMI, vitamin D concentrations, and diabetes status, differences in the FN BMD among the groups remained significant (p<0.001). Based on the Fracture Risk Assessment Tool (FRAX) score calculations in 43 non-osteoporotic patients, 15 patients with osteopenia had a 10-year hip fracture probability ≥3%. Screening with DXA in male US veterans aged 70 years and older without known osteoporosis risk factors revealed that up to 50% of men may qualify for diagnostic workup to determine the etiology of low BMD and/or to meet criteria to initiate pharmacological therapy to reduce future fracture risk.
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