Patient Perceptions and Preferences for Osteoporosis Treatment

Disparities in Dual-energy X-ray Absorptiometry Scan Utilization Across Race/Ethnic Groups Before and After Hip Fractures

BACKGROUND

Geriatric hip fractures are common and important sentinel events regarding bone health. Although dual x-ray absorptiometry (DEXA) scans are a standard method for determining bone density, differences in use among various race/ethnic groups around the time of hip fracture may reveal disparities within the healthcare system.

METHODS

The 2014 to 2016 Medicare Standard Analytic Files PearlDiver data set was used to identify geriatric patients sustaining hip fracture. From that cohort, those who had a DEXA scan before or after their fracture were defined. For the defined cohorts, patient age, sex, Elixhauser Comorbidity Index, race/ethnicity, and income (based on zip code) were defined and compared with univariate and multivariate analyses.

RESULTS

Of 58,099 hip fracture patients, only 19.8% had had a DEXA scan before fracture and 3.9% of the remaining group had the DEXA scan after fracture. Of the hip fracture population, 91.0% identified as White and 9.0% as non-White (Native American, Black, Hispanic, Asian, or Other). Before hip fracture, controlling for other variables and compared with White patients, all non-White categories were at lesser odds of having had the DEXA scan. After hip fracture, Black, Hispanic, and other patients were also at lesser odds of having the DEXA scan.

DISCUSSION

Using a large Medicare data set, controlling for patient age, sex, Elixhauser Comorbidity Index, and income marker, this study revealed disparities in DEXA scan utilization across race/ethnic groups before and after presenting with a hip fragility fracture. Identification of such disparities highlights the needs for improved medical access and care for this at-risk hip fracture population.

Impact of an Outpatient Fracture Liaison Service on Osteoporosis Evaluation Among Patients With Upper Extremity Fragility Fracture

BACKGROUND

The purpose of this study was to assess the impact of implementation of an outpatient fracture liaison service (FLS) on completion rates of dual-energy x-ray absorptiometry (DXA) and screening labs including 25-OH vitamin D and parathyroid hormone (PTH) in patients with upper extremity (UE) fragility fractures.

METHODS

At our institution, 367 patients were treated in 2014-2015 for UE fragility fractures of the distal radius and proximal humerus before implementation of our outpatient FLS and 395 patients in 2017-2018 after implementation. Retrospective chart review was conducted to identify completed DXA scans within 2 years of fracture treatment and completed 25-OH vitamin D and PTH labs within 1 year of fracture treatment.

RESULTS

There were no statistical differences in the demographics of patients treated for distal radial and proximal humeral fragility fractures during the 2014-2015 and 2017-2018 time periods. Implementation of the FLS resulted in a 9.9% increase (P value = .021) in completed DXA scans within 2 years of fracture treatment. Completed 25-OH vitamin D and PTH labs saw a significant increase of 17.1% and 23.8%, respectively (P values < .001).

CONCLUSIONS

Implementation of an outpatient FLS can help to improve osteoporosis evaluation with completed DXA scans and 25-OH vitamin D and PTH labs.

Osteoporosis care through an Integrated, People-Centred Health Services framework lens: a hybrid qualitative analysis of international patient experiences

OBJECTIVES

Globally, patients with osteoporosis have unmet needs in terms of care accessibility, patient-centredness and care comprehensiveness. The WHO developed the Integrated, People-Centred Health Services (IPCHS) framework to reorient and integrate healthcare systems using 5 interdependent strategies and 20 substrategies. Patients' perspectives with regard to these strategies are poorly understood. We sought to relate patient-experienced gaps in osteoporosis care to the IPCHS strategies and identify key strategies to guide osteoporosis care reforms.

DESIGN, SETTING AND PARTICIPANTS

Qualitative online study of the experiences of international patients with osteoporosis.

PROCEDURE

Two researchers conducted semi-structured interviews in English, Dutch, Spanish and French that were recorded and transcribed verbatim. Patients were categorised according to their countries' healthcare systems (universal, public/private and private) and fracture status. A hybrid (sequential theory-driven and data-driven) analysis was performed, with the IPCHS framework used for the theory-driven analysis.

RESULTS

Thirty-five patients (33 women) from 14 countries participated. Twenty-two patients had universal healthcare and 18 had experienced fragility fractures. Prioritised substrategies overlapped among healthcare systems, with reported shortcomings related primarily to 'empowering and engaging individuals and families' and 'coordinating care' (at varying levels). Patients with all healthcare types prioritised 'reorienting care', with different substrategies prioritised. Patients with private healthcare called for 'improving funding and reforming payment systems'. Substrategy prioritisation did not differ between those receiving primary and secondary fracture prevention.

CONCLUSION

Patients' experiences with osteoporosis care are universal. Given the current care gaps and associated patient burdens, policymakers should make osteoporosis a(n) (inter)national health priority. Integrated osteoporosis care reforms should focus on patient-reported experiences with and be guided by priorities in IPCHS strategies, taking into account the healthcare system context.

Geriatric fracture program centering age-friendly care associated with lower length of stay and lower direct costs

OBJECTIVE

To evaluate outcomes associated with an integrated inpatient and outpatient program aimed at optimizing the care of geriatric fracture patients in a mixed community and academic health system setting.

DATA SOURCES AND STUDY SETTING

This study took place at a tertiary-care, 886-bed hospital system. The Geriatric Fracture Program (GFP) was designed in 2018 using the 4Ms Framework (What Matters, Medication, Mentation, and Mobility). Patients ≥65 years old with non-spine fractures managed by orthopedic faculty surgeons and participating hospitalist groups were included. A fracture liaison team educated patients regarding bone health and ensured ambulatory geriatrics follow-up. Outpatient geriatric visits focused on mobility, fall risk, bone health imaging, and medications.

STUDY DESIGN

We compared GFP-enrolled patients (n = 746) to patients seen by non-GFP-participating physicians (n = 852) and used a generalized estimating equations approach and Poisson models to analyze associations between participation in the GFP program and four inpatient outcomes (time to surgery, length of stay, Vizient length of stay index, and total direct costs). We examined outcomes across all fractures and also stratified them by fracture type (hip vs. non-hip). We descriptively examined post-discharge care outcomes: fall, gait, and balance assessments; bone health imaging; and medications.

DATA COLLECTION/EXTRACTION METHODS

We collected data through chart reviews/electronic health record extracts from July 2018 to June 2021.

PRINCIPAL FINDINGS

GFP-enrolled patients with all fracture types had a significantly lower length of stay (marginal effect [ME]: -2.12, 95%CI: -2.61, -1.63), length of stay index (ME: -0.33, 95%CI: -0.42, -0.25), and total direct costs (ME: -$5316, 95%CI: -$6806, -$3826); the magnitude of the effects was greater for non-hip fractures. There was no significant difference in time to surgery. Of 746 GFP patients, 170 (23%) had a post-discharge visit with a participating geriatrician ≥6 months.

CONCLUSIONS

A systematic approach to improving care for older adults with fractures improved length of stay and total direct costs.