Perception, knowledge, and use by general practitioners of Belgium of a new WHO tool (FRAX) to assess the 10-year probability of fracture

High rates of undiagnosed and untreated osteoporosis in postmenopausal women receiving medical services in the area of Upper Silesia

Introduction

High social cost and high risk of disability make postmenopausal osteoporosis one of major public health problem in the 21^st century. The aim of this study was to assess frequency of undiagnosed and untreated osteoporosis in postmenopausal women in the Upper Silesia Region of Poland. Additionally, we compare estimation of the 10-year probability of major osteoporotic fractures (MOF) and hip fractures (HF) based on fracture risk assessment tool (FRAX) with and without bone mineral density (BMD).

Material and methods

The survey included 450 postmenopausal women (age 65 ±11 years). A detailed questionnaire included demographic and anthropometric data, comorbidity, history of previous low-energy fractures, family medical history, and treatment for osteoporosis. The FRAX calculator was used to estimate the risk of MOF and HF.

Results

Osteoporosis was previously diagnosed in 23.7% women. Of those 70.2% were receiving vitamin D, 27% calcium preparations, 33% bisphosphonates, and 22% were untreated. Only 42.2% women with previous fractures had been diagnosed with osteoporosis and 42.8% received any treatment. 12.5% women with FRAX-BMD ≥ 10% had no risk factors of osteoporosis and < 10% risk of MOF and HF in FRAX without BMD.

Conclusions

Osteoporosis often remains undiagnosed and untreated in postmenopausal women. There is a great need to popularize FRAX without BMD calculator among physicians, especially GPs, as the risk calculation justify the implementation of antiosteoporotic therapy. Women with burden of risk factors of fractures and borderline FRAX without BMD values, should be referred to a densitometry examination, as having greater risk of fracture than shown by FRAX without BMD.

Primary care physicians' views on osteoporosis management: a qualitative study

Osteoporosis is an under-diagnosed condition; only around 14% of patients in Sweden receive bone-specific treatment after a fragility fracture. This qualitative interview study found that primary care physicians perceive osteoporosis as a silent disease that is overshadowed by other conditions and is complicated to manage.

PURPOSE

To explore primary care physicians' views on managing osteoporosis.

METHODS

A total of 17 primary care physicians in Stockholm participated in four focus group interviews. Interview transcripts were analysed with thematic analysis.

RESULTS

One main theme was found: Osteoporosis-a silent disease overshadowed by other conditions. The main theme contained five sub-themes. Physicians perceived osteoporosis as a low-priority issue. They described uncertainty about managing it and insufficient awareness of the condition in primary healthcare (PHC). Physicians had differing opinions about who is responsible for managing osteoporosis. They reported that the health care system regulated their work such that they gave low priority to the condition. They were uncertain about the value of the Fracture Risk Assessment Tool (FRAX). The physicians thought that financial incentives, education, and increased collaboration with other relevant health care professionals and with patients were needed to increase the priority of osteoporosis in PHC.

CONCLUSION

Physicians perceived osteoporosis as a silent disease that is complicated to manage. They gave low priority to osteoporosis and thought their patients shared this view. The physicians saw other issues and medical conditions as more important than osteoporosis. They wanted better collaboration at their PHC centres and with hospitals. They also wanted district nurses to be more involved in managing osteoporosis and especially in assessing fracture risk.

Selective serotonin re-uptake inhibitor sertraline inhibits bone healing in a calvarial defect model

Bone wound healing is a highly dynamic and precisely controlled process through which damaged bone undergoes repair and complete regeneration. External factors can alter this process, leading to delayed or failed bone wound healing. The findings of recent studies suggest that the use of selective serotonin reuptake inhibitors (SSRIs) can reduce bone mass, precipitate osteoporotic fractures and increase the rate of dental implant failure. With 10% of Americans prescribed antidepressants, the potential of SSRIs to impair bone healing may adversely affect millions of patients' ability to heal after sustaining trauma. Here, we investigate the effect of the SSRI sertraline on bone healing through pre-treatment with (10 mg·kg-1 sertraline in drinking water, n = 26) or without (control, n = 30) SSRI followed by the creation of a 5-mm calvarial defect. Animals were randomized into three surgical groups: (a) empty/sham, (b) implanted with a DermaMatrix scaffold soak-loaded with sterile PBS or (c) DermaMatrix soak-loaded with 542.5 ng BMP2. SSRI exposure continued until sacrifice in the exposed groups at 4 weeks after surgery. Sertraline exposure resulted in decreased bone healing with significant decreases in trabecular thickness, trabecular number and osteoclast dysfunction while significantly increasing mature collagen fiber formation. These findings indicate that sertraline exposure can impair bone wound healing through disruption of bone repair and regeneration while promoting or defaulting to scar formation within the defect site.

Time to Clinically Relevant Fracture Risk Scores in Postmenopausal Women

BACKGROUND

Clinical practice guidelines recommend use of fracture risk scores for screening and pharmacologic treatment decisions. The timing of occurrence of treatment-level (according to 2014 National Osteoporosis Foundation guidelines) or screening-level (according to 2011 US Preventive Services Task Force guidelines) fracture risk scores has not been estimated in postmenopausal women.

METHODS

We conducted a retrospective competing risk analysis of new occurrence of treatment-level and screening-level fracture risk scores in postmenopausal women aged 50 years and older, prior to receipt of pharmacologic treatment and prior to first hip or clinical vertebral fracture.

RESULTS

In 54,280 postmenopausal women aged 50 to 64 years without a bone mineral density test, the time for 10% to develop a treatment-level FRAX score could not be estimated accurately because of rare incidence of treatment-level scores. In 6096 women who had FRAX scores calculated with bone mineral density, the estimated unadjusted time to treatment-level FRAX ranged from 7.6 years (95% confidence interval [CI], 6.6-8.7) for those aged 65 to 69, to 5.1 years (95% CI, 3.5-7.5) for those aged 75 to 79 at baseline. Of 17,967 women aged 50 to 64 with a screening-level FRAX at baseline, 100 (0.6%) experienced a hip or clinical vertebral fracture by age 65 years.

CONCLUSIONS

Postmenopausal women with sub-threshold fracture risk scores at baseline were unlikely to develop a treatment-level FRAX score between ages 50 and 64 years. After age 65, the increased incidence of treatment-level fracture risk scores, osteoporosis, and major osteoporotic fracture supports more frequent consideration of FRAX and bone mineral density testing.

How General Practitioners and Their Patients Adhere to Osteoporosis Management: A Follow-Up Survey among Czech General Practitioners

Introduction: General practitioners (GPs) are key participants in osteoporosis (OP) management. The aim was to evaluate their adherence to lege artis management of the disease, potential barriers, and to discuss differences observed in comparison with the baseline survey carried out in 2007; the focus was on secondary prevention.

Methods: On behalf of two professional associations, 2-round postal survey among randomly selected GPs (>1/4 of all Czech GPs) was performed in 2014. The questionnaire covered areas concerning GP's role in the fight against OP, knowledge about OP, management of OP-related fractures, barriers to the management of OP, system- and patient-related in particular, and availability and use of information sources.

Results: The overall questionnaire return rate was 37% (551 respondents); mean age of the respondents was 53 year (37% men). The GP's role in the treatment of OP was rated as essential in 28 and 37% of men and women, respectively (P = 0.012). The guideline for diagnosis and treatment of OP for GPs was considered accessible by 92% of respondents. As much as 60% of the respondents were adherent to the guideline, i.e., used it repeatedly. The knowledge of several risk factors was very good, however, recommended daily intake of calcium was stated correctly by only 41% of respondents, and daily intake of vitamin D by only 40%. Three quarters reported active steps after a fracture: referral to a specialist, life-style recommendations, prescription of calcium/vitamin D supplements. Half of the respondents focus on fall prevention. System-related barriers, such as lack of possibility to prescribe selected drugs (61%) and financial limits set by health insurance company (44%) were most frequently reported. Patient-related barriers were also common, patient's non-adherence (reported by 29%) and patient's reluctance to go to a specialist (18%).

Conclusion: GPs adhered to OP management more than in 2007. Knowledge of risk factors and involvement in post-fracture care was relatively high. Compared to baseline survey, patient-related barriers, patient non-adherence in particular, were more common. Prescribing conditions are still an important issue. Among GPs, education should be focused on calcium and vitamin D intake, doses, sources, and supplements.

External validation and comparison of three prediction tools for risk of osteoporotic fractures using data from population based electronic health records: retrospective cohort study

OBJECTIVE

 To directly compare the performance and externally validate the three most studied prediction tools for osteoporotic fractures-QFracture, FRAX, and Garvan-using data from electronic health records.

DESIGN

 Retrospective cohort study.

SETTING

 Payer provider healthcare organisation in Israel.

PARTICIPANTS

 1 054 815 members aged 50 to 90 years for comparison between tools and cohorts of different age ranges, corresponding to those in each tools' development study, for tool specific external validation.

MAIN OUTCOME MEASURE

 First diagnosis of a major osteoporotic fracture (for QFracture and FRAX tools) and hip fractures (for all three tools) recorded in electronic health records from 2010 to 2014. Observed fracture rates were compared to probabilities predicted retrospectively as of 2010.

RESULTS

 The observed five year hip fracture rate was 2.7% and the rate for major osteoporotic fractures was 7.7%. The areas under the receiver operating curve (AUC) for hip fracture prediction were 82.7% for QFracture, 81.5% for FRAX, and 77.8% for Garvan. For major osteoporotic fractures, AUCs were 71.2% for QFracture and 71.4% for FRAX. All the tools underestimated the fracture risk, but the average observed to predicted ratios and the calibration slopes of FRAX were closest to 1. Tool specific validation analyses yielded hip fracture prediction AUCs of 88.0% for QFracture (among those aged 30-100 years), 81.5% for FRAX (50-90 years), and 71.2% for Garvan (60-95 years).

CONCLUSIONS

 Both QFracture and FRAX had high discriminatory power for hip fracture prediction, with QFracture performing slightly better. This performance gap was more pronounced in previous studies, likely because of broader age inclusion criteria for QFracture validations. The simpler FRAX performed almost as well as QFracture for hip fracture prediction, and may have advantages if some of the input data required for QFracture are not available. However, both tools require calibration before implementation.