Predictors of Screening and Treatment of Osteoporosis

Factors affecting willingness to get assessed and treated for osteoporosis

Individuals with poor knowledge of osteoporosis and lower socioeconomic status, including being single and having a lower level of annual income, are less likely to be assessed or treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

INTRODUCTION

Despite the negative health consequences of osteoporosis and the availability of effective treatment, a pervasive and persistent prevention care gap for osteoporosis remains present throughout the world. We attempted to identify the factors affecting the willingness of patients to either undergo or avoid assessment and treatment for osteoporosis.

METHODS

A nationwide online survey was conducted in 926 Korean women over age 50. The survey included questions addressing three domains: (1) clinical and socio-demographic characteristics, (2) questions concerning the reasons for undergoing or avoiding osteoporosis assessment or treatment, and (3) knowledge of osteoporosis as measured using the modified Korean version of Facts on Osteoporosis Quiz. The assessed and non-assessed participants were compared in terms of their clinical and socioeconomic statuses, reasons for undergoing or avoiding osteoporosis management, and levels of knowledge of osteoporosis.

RESULTS

The highest-ranked reason for undergoing osteoporosis assessment was fear of osteoporotic fracture, while the highest-ranked reason for avoiding osteoporosis assessment was not feeling a need to get tested for osteoporosis. Participants who sought assessment for osteoporosis were older and more likely to be married, and had greater knowledge of osteoporosis than those who did not seek assessment. The two groups were found to be similar in terms of tobacco use and daily alcohol use. Patients who had been diagnosed with osteoporosis but either did not initiate or discontinued osteoporosis treatment within 1 year were younger and had lower levels of annual income than those who began and continued treatment.

CONCLUSION

Individuals with poor knowledge of osteoporosis and those of lower socioeconomic status, including those who were single and had a lower level of annual income, were less likely to be assessed and treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

Patterns of Pharmacological Treatment for Osteoporosis Among Patients Qualified for Pharmacotherapy According to the National Osteoporosis Foundation Guidelines

Background: Whereas the National Osteoporosis Foundation (NOF) guidelines suggest pharmacological treatment for patients at high risk of fractures, little is known about the prevalence of osteoporosis treatment among those who met the NOF criteria for pharmacotherapy. Objective: To evaluate the prevalence of osteoporosis treatment among patients who met the NOF criteria and to assess factors associated with pharmacological treatment. Methods: The 2005-2010 National Health and Nutrition Examination Survey served as the data source. Using the Fracture Risk Assessment Tool, the study included postmenopausal women and men 50 years or older who met the NOF treatment criteria. Andersen’s Behavioral Model was used to select predisposing, enabling, and need factors that might predict osteoporosis treatment. A logistic regression was used to assess factors associated with osteoporosis treatment. Results: An estimated 16 million individuals qualified for osteoporosis treatment according to the NOF guidelines. Only 24% of them received pharmacological treatment, and 89% of the patients receiving treatment were women. Only 6% to 12% of men who were at high risk of osteoporosis or fracture received pharmacotherapy. Older age, long-term corticosteroid use, history of fractures, and T-score ≤−2.5 were associated with increased odds of osteoporosis treatment, whereas male gender and lack of a usual source of health care were associated with decreased odds of osteoporosis treatment. Conclusions: Less than one-fourth of the population who should be considered for pharmacotherapy received osteoporosis treatment. Clinicians should be more aware of the unmet need for medication treatment for osteoporosis.

Osteoporosis among older Saudis: risk of fractures and unmet needs

Using FRAX®, this study aimed at estimating 10-years probability of osteoporosis (OP)-related fractures and identifies those in need of OP treatment among primary care attendees in Saudi Arabia. Of those aged ≥ 60 years, 14.4 and 18.4 % scored probabilities for major and hip fractures respectively suggesting OP treatment. Predictors for receiving OP screening included the presence of multiple clinical risk factors, occurrence of fragility fractures and physicians recommendation.

PURPOSE

This study aimed at estimating the 10-years probability of osteoporosis (OP)-related fractures and identifying those in need of OP treatment among Saudi adults attending primary care centers (PHCs) in Al Hassa, Saudi Arabia, using FRAX® calculator and to determine factors possibly influence receiving of OP screening among them.

SUBJECTS AND METHODS

A total of 1,251 Saudi aged ≥ 40 years, of both genders, were recruited from four urban and three rural randomly selected PHCs. All were subjected to anthropometric measurements followed by a personal interview with structured questionnaire to asses OP clinical risk factors (CRFs) and possible correlates for receiving OP screening. Ten-year probabilities for major osteoporotic and hip fractures were calculated using the Lebanese version of FRAX® calculator.

RESULTS

Of participants aged ≥ 60 years, 14.4 and 18.4 % were identified with probability scores for major osteoporotic and hip fractures respectively, suggesting OP treatment. Out of sampled population, 16.1 % received OP screening. The presence of ≥two OP CRFs (odds ratio OR = 4.45), being aware of OP (OR = 2.89), physician recommendation of OP screening (OR = 2.01), and history of fragility fracture (OR = 1.92) were all possible positive predictors for receiving OP screening.

CONCLUSION

A sizable portion of the sampled older Saudis especially those aged ≥ 60 years are at high risk for OP-related fractures indicative to receive OP treatment. Occurrence of fragility fractures, multiplicity of CRFs and physician's recommendations are significant positive predictors to receive OP screening among them.

Role of physician gender in drug therapy

There is evidence that female patients receive less intensified drug therapy in many medical conditions than male patients. However, there are only limited data regarding the influence of physician gender on drug therapy. It has been shown, for example, that female physicians tend to adhere more closely to guideline-recommended pharmacotherapy compared to their male counterparts. In some medical conditions where drug therapy is only one among various components of a complex interplay of therapeutic regimes (e.g., diabetes, cardiovascular diseases, depression, pain management), female physicians seem to achieve better overall intermediate outcomes and some studies suggest that "better" drug therapy is provided by female compared to male physicians. The reasons for the overall better outcomes may be superior communication skills of female physicians, participatory decision making, and consequently improved drug adherence in addition to or in combination with more effective non-pharmacologic treatment results. It is impossible to distinguish between the individual contributions of drug- and nondrug-related influence on such improved outcomes and thus to determine whether they are due to unconfounded physician gender effects on drug therapy. There is until now in no area of medicine evidence to suggest that a patient will consistently receive higher quality of drug therapy by switching to a physician of a specific gender.

Factors associated with diagnosis and treatment of osteoporosis in older adults

Osteoporosis is often undiagnosed and untreated. We surveyed 1,830 adults and identified factors associated with osteoporosis diagnosis and treatment. Individuals with several risk factors, including older age, were not more likely to be diagnosed or treated. Measures should be taken to improve osteoporosis identification and treatment in high-risk patients.

INTRODUCTION

We aimed to identify patient characteristics associated with osteoporosis diagnosis and treatment.

METHODS

Survey was mailed to 1,830 women and men > or =60 years old in Pennsylvania. Multivariable logistic regression analyses were performed to determine odds ratios for osteoporosis diagnosis and treatment for individuals with established osteoporosis risk factors.

RESULTS

Surveys were completed by 1,268 adults (69.3%). Osteoporosis diagnosis was more commonly reported by participants with risk factors of female sex (OR, 3.60; 95% CI 2.31-5.61), prolonged oral steroid use (OR, 3.76, 95% CI 2.06-6.84), low-trauma fracture (OR, 2.14, 95% CI 1.44-3.17), height loss (OR, 1.83, 95% CI 1.28-2.64), and lower weight (OR, 1.35 per 11.4 kg decrease in weight; 95% CI, 1.16-1.56). Age and family history of osteoporosis were not predictive of osteoporosis diagnosis, when adjusting for other risk factors. Osteoporosis treatment was more commonly reported by participants with risk factors of female sex (OR, 5.19; 95% CI, 3.31-8.13), family history (OR, 2.18; 95% CI, 1.55-3.06), height loss (OR, 1.79; 95% CI 1.29-2.49), low-trauma fracture (OR, 1.66; 95% CI, 1.14-2.42), and lower weight (OR, 1.45 per 11.4 kg decrease in weight; 95% CI, 1.27-1.67). Osteoporosis treatment was not significantly associated with age or prolonged oral steroid use.

CONCLUSIONS

Individuals with several established osteoporosis risk factors are more likely to be underdiagnosed or undertreated.

Factors associated with osteoporosis screening and recommendations for osteoporosis screening in older adults

BACKGROUND

Osteoporosis screening rates are low, and it is unclear which patient factors are associated with screening and physician recommendations for screening.

OBJECTIVE

To identify patient characteristics associated with osteoporosis screening recommendations and receipt of screening in older adults.

DESIGN

Cross-sectional mailed survey.

PARTICIPANTS

Women and men > or =60 years old living in or near western Pennsylvania.

MEASUREMENTS

Sociodemographic characteristics and osteoporosis-related data, including risk factors, physician recommendations for screening, and receipt of screening. Multivariable logistic regression analyses were performed to determine odds ratios for receipt of screening and screening recommendations for individuals with particular osteoporosis risk factors, adjusting for sociodemographic and other risk factors.

RESULTS

Surveys were completed by 1,268 of the 1,830 adults to whom surveys were mailed (69.3%). Most respondents were white (92.9%), female (58.7%), and believed they were in good to excellent health (88.2%). Only 47.6% said their physician recommended osteoporosis screening, and 62.6% of all respondents reported being screened. Screening recommendations were less likely for older respondents than younger ones (OR, 0.87 per 5-year increase in age; 95% CI, 0.77-0.97). Individuals with osteoporosis risk factors of a history of oral steroid use for >1 month, height loss >2.54 cm, or history of low-trauma fracture were no more likely to report screening recommendations than individuals without these characteristics. Receipt of screening was no more likely for more elderly respondents or respondents with a history of oral steroid use for >1 month than for respondents without these characteristics.

CONCLUSIONS

Individuals with several known osteoporosis risk factors are not being sufficiently targeted for screening.

Management of cancer treatment-induced bone loss in early breast and prostate cancer -- a consensus paper of the Belgian Bone Club

Cancer treatment-induced bone loss (CTIBL) is one of the most important side effects of adjuvant antineoplastic treatment in hormone-dependent neoplasms. Chemotherapy, GnRH analogs and tamoxifen can induce marked bone loss in premenopausal women with early breast cancer. Aromatase inhibitors (AIs) are replacing tamoxifen as the preferred treatment for postmenopausal women. As a class effect, steroidal (exemestane) and non-steroidal (anastrozole and letrozole) AIs increase bone turnover and cause bone loss (4%-5% over 2 years). When compared to tamoxifen, the risk of getting a clinical fracture under AI treatment is increased by 35%-50%. In patients with prostate cancer, androgen deprivation therapy (ADT) increases bone turnover, reduces bone mass (4%-5% per year) and increases the fracture rate depending on the duration of therapy. Zoledronic acid can prevent accelerated bone loss induced by goserelin in premenopausal women, by letrozole in postmenopausal women and by ADT in men. More limited data indicate that weekly alendronate or risedronate could also be effective for preventing CTIBL. Initiation of therapy early, prior to the occurrence of severe osteoporosis, rather than after, may be more effective. Bisphosphonate treatment should be considered in osteoporotic but also in osteopenic patients if other risk factor(s) for fractures are present.

Bone loss and fracture risk associated with cancer therapy

BACKGROUND

Cancer patients experience osteoporosis resulting from accelerated loss of bone mineral density (BMD) caused by their treatment. Such bone loss greatly increases the risk for fracture and can have other serious effects on quality of life.

METHODS

In the current report, the author focuses on studies of cancer therapy-associated bone loss, its prevalence and pathogenesis, and resulting clinical impact. Options for management and prevention are also reviewed, including treatment guidelines where available.

RESULTS

A variety of cancer therapies, including hormonal therapy, chemotherapy, and glucocorticoids, affect gonadal hormone production, which increases bone resorption and decreases BMD. Such bone loss occurs more rapidly and to a greater degree than normal age-related osteoporosis, increases the risk for fracture and other morbidities, and decreases survival. Regular BMD screening and early intervention can prevent further decline in bone density and bone quality. Pharmacologic therapy with oral and i.v. bisphosphonates has been shown to slow bone loss in patients receiving cancer therapy, and the i.v. bisphosphonate zoledronic acid can increase BMD in patients with cancer treatment-related bone loss. Lifestyle changes, including supplementation with calcium and vitamin D, diet, and proper exercise, can also slow the rate of bone loss.

CONCLUSIONS

Bone loss associated with various cancer therapies significantly affects bone health. Early initiation of bisphosphonates, when indicated, and lifestyle modification can improve patient outcomes. Education of patients and health care professionals regarding the importance of this complication and effective treatment options is essential.

Access to bone mineral density testing in patients at risk for osteoporosis

INTRODUCTION

Prior studies have documented suboptimal diagnosis and treatment for osteoporosis in many settings. Consistent predictors of suboptimal management include patient age, physician training, and physician gender. We assessed whether access to bone mineral density (BMD) testing was a predictor of osteoporosis management in an at-risk population of patients from New Jersey.

METHODS

Based on health care claims data, we identified three groups of at-risk beneficiaries, including women >or=65 (n=8,283), men and women >or=45 with a fracture (n=740), and men and women >or=45 taking chronic oral glucocorticoids (n=616). As the outcome of interest, we determined whether beneficiaries had undergone a BMD test and/or filled a prescription for a medicine used for osteoporosis (alendronate, calcitonin, hormone therapy, etidronate, risedronate, raloxifene, teriparatide) during the period 1 September 2002-31 August 2004. We assessed the relationship between this outcome and access to BMD testing. Access was characterized using two different measures: (1) the estimated driving time between each beneficiary's residence and the nearest BMD testing center ("driving time") and (2) the number of persons >or=65 years of age per BMD testing machine ("BMD scanner ratio") for each of the 21 counties in New Jersey.

RESULTS

Of the 9,640 beneficiaries, we found that 3,104 (32%) had undergone a BMD test, 2,893 (30%) had filled a prescription for an osteoporosis medication, and 4,364 (45%) had one or both. Across the 21 counties of New Jersey, the percentage of at-risk patients who had a BMD test and/or medication for osteoporosis ranged from 38 to 52%. In models adjusted for patient factors and the clustering of patients in counties, driving time was not associated with patients being screened or treated for osteoporosis. The BMD scanner ratio was a weak predictor of osteoporosis management.

CONCLUSION

Among beneficiaries of one large health insurer in New Jersey, two different measures of access to BMD testing were not important predictors of receiving testing and/or medications for osteoporosis.

Osteoporosis action: design of the healthy bones project trial

Although osteoporosis is common in older adults, it is often under-diagnosed and under-treated. We developed community-based patient- and physician-directed interventions for fracture prevention and compared them in a 2 x 2 factorial randomized controlled trial. The study population included older adults who were enrolled in a state-run pharmacy benefits program (The Pharmaceutical Assistance Contract for the Elderly in Pennsylvania) for Medicare beneficiaries. We randomly assigned 826 primary care physicians and their 31,715 patients to one of four trial arms--no patient and no physician intervention, patient but no physician intervention, physician but no patient intervention, both patient and physician interventions. The patient intervention consisted of targeted communication about fall and fracture prevention and osteoporosis diagnosis and treatment. It was delivered through several mailings. The physician intervention entailed one-on-one academic detailing encounters covering the same topics. The composite primary endpoint consisted of use of osteoporosis medication or a bone mineral density test. Other endpoints included patient's knowledge and attitudes towards fractures and osteoporosis, use of lower extremity strengthening to prevent falls, and the occurrence of fractures. All outcomes will be analyzed using random effects models accounting for clustering of subjects within physicians' practices.