Osteoporosis management by primary care physicians in Singapore: a survey on osteoporosis guidelines utilisation and barriers to care

Secondary fracture prevention in primary care: a narrative review

The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.

Barriers to osteoporosis management and adherence to Clinical Practice Guideline: a comparative study between tertiary East Coast hospitals and a Fracture Liaison Services (FLS)-accredited hospital in Malaysia

This study compares osteoporosis management between tertiary East Coast hospitals and a FLS-accredited hospital in Malaysia. It identifies significant barriers and highlights the superior performance of FLS in areas like timely treatment initiation and treatment monitoring. The insights are crucial for improving osteoporosis management strategies.

INTRODUCTION

Osteoporosis management poses a substantial healthcare challenge, necessitating effective strategies and Clinical Practice Guidelines (CPG) adherence.

METHODS

The study employed a self-administered online questionnaire via Google Forms. Orthopedic clinicians from all study sites were invited to participate via messaging platforms. A total of 135 participants completed the questionnaire and the data was proceeded to statistical analyses.

RESULTS

The study identified significant barriers, including inadequate knowledge of current osteoporosis guidelines and medications (p = 0.014), limited choice of anti-osteoporosis medication (p < 0.001), insufficient post-fracture care staff (p < 0.001), patients' financial constraints due to socioeconomic status (p = 0.027), and lack of doctor-patient time (p = 0.042). FLS demonstrated superior performance in CPG adherence in areas such as clinical diagnosis of osteoporosis without BMD assessment (p = 0.046), timely treatment initiation (p < 0.001), treatment monitoring using BMD (p = 0.004), reassessment treatment after 3-5 years of bisphosphonate therapy (p = 0.034) and considering anabolic agents in very high-risk patients (p = 0.018).

CONCLUSION

The findings highlight an essential opportunity for improvement and emphasize the necessity for robust strategies and strict adherence to Clinical Practice Guidelines (CPG), especially within tertiary East Coast hospitals. The exemplary efficacy demonstrated by the FLS model strongly advocates for its broader integration across multiple hospitals, promising substantial advancements in osteoporotic patient care outcomes throughout Malaysia.

Evaluating compliance with the care standard of proactively assessing bone health in patients with diabetes: a pilot audit of practice across Asia by the Asia Pacific Consortium on Osteoporosis (APCO)

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area.

PURPOSE

The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit.

METHODS

Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively.

RESULTS

The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients.

CONCLUSION

Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study

BACKGROUND

Over half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care.

METHODS

A qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12.

RESULTS

Thirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels.

CONCLUSION

The intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed.

TRIAL REGISTRATION

Approval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).

The relationship between weight-adjusted-waist index and total bone mineral density in adults aged 20-59

Introduction

According to reports, obesity has a significant impact on bone health. And the weight-adjusted-waist index (WWI), superior to BMI and waist circumference (WC), is a new obesity indicator arising in recent years. This research investigated the relationship between WWI and total bone mineral density (BMD) for adults aged 20 to 59.

Methods

Using data from the 2011-2018 NHANES, we looked into the independent link between WWI and total BMD as well as its nonlinearity using weighted multiple linear regression and smooth curve fitting. Two-stage linear regression models were employed to calculate the threshold effects. There were additional subgroup analyses and testing for interactions.

Results

Multiple linear regression studies on a total of 10,372 individuals showed a significant inverse link between WWI and total BMD in adults between 20 and 59 [β = -0.04, 95% CI: (-0.04, -0.03), P<0.0001]. And smoking, race, and chronic kidney disease (CKD) had no significant effect on this negative connection (P for interaction >0.05). In addition, we found a nonlinear relationship between WWI and total BMD in diabetic and CKD patients, for which the saturation point was 11.38 cm/√kg in the CKD patient group and 10.29 cm/√kg in the diabetic patient group.

Conclusion

Our analysis demonstrated a significant inverse association between WWI and total BMD in adults aged 20-59.