Access to Osteoporosis Treatment is Critically Linked to Access to Dual-Energy X-ray Absorptiometry Testing

Osteoporosis management in adults with schizophrenia following index hip fracture event: a 10-year population-based retrospective cohort study, Ontario, Canada

Little is known about the incidence of osteoporosis testing and treatment in individuals with schizophrenia, who may be more likely to fracture. Using competing risk models, we found that schizophrenia was associated with lower incidence of testing or treatment. Implications are for understanding barriers and solutions for this disadvantaged group.

PURPOSE

Evidence suggests that individuals with schizophrenia may be more likely to experience hip fractures than the general population; however, little is known about osteoporosis management in this disadvantaged subpopulation. Our study objective was to compare bone mineral density (BMD) testing and pharmacologic treatment in hip fracture patients with versus without schizophrenia.

METHODS

This was a retrospective population-based cohort study leveraging health administrative databases, and individuals aged 66-105 years with hip fracture between fiscal years 2009 and 2018 in Ontario, Canada. Schizophrenia was ascertained using a validated algorithm. The outcome was a composite measure of (1) pharmacologic prescription for osteoporosis; or (2) a BMD test. Inferential analyses were conducted using Fine-Gray subdistribution hazard regression, with mortality as the competing event.

RESULTS

A total of 52,722 individuals aged 66 to 105 years who sustained an index hip fracture in Ontario during the study period were identified, of whom 1890 (3.6%) had schizophrenia. Hip fracture patients with vs without schizophrenia were more likely to be long-term care residents (44.3% vs. 18.1%; standardized difference, 0.59), frail (62.5% vs. 36.5%; standardized difference, 0.54) and without a primary care provider (9.2% vs. 4.8%; standardized difference, 0.18). In Fine-Gray models, schizophrenia was associated with a lower incidence of testing or treatment (0.795 (0.721, 0.877)).

CONCLUSIONS

In this population-based retrospective cohort study, a schizophrenia diagnosis among hip fracture patients was associated with a lower incidence of testing or treatment, after accounting for mortality, and several enabling and predisposing factors. Further research is required to investigate barriers to osteoporosis management in this disadvantaged population.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Cortical bone thickness of the distal radius predicts the local bone mineral density

AIMS

The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD).

METHODS

A total of 54 human cadaver forearms (ten singles, 22 pairs) (19 to 90 years) were systematically assessed by clinical radiograph (XR), dual-energy X-ray absorptiometry (DXA), CT, as well as high-resolution peripheral quantitative CT (HR-pQCT). Cortical bone thickness (CBT) of the distal radius was measured on XR and CT scans, and two cortical indices mean average (CBTavg) and gauge (CBTg) were determined. These cortical indices were compared to the BMD of the distal radius determined by DXA (areal BMD (aBMD)) and HR-pQCT (volumetric BMD (vBMD)). Pearson correlation coefficient (r) and intraclass correlation coefficient (ICC) were used to compare the results and degree of reliability.

RESULTS

The CBT could accurately be determined on XRs and highly correlated to those determined on CT scans (r = 0.87 to 0.93). The CBTavg index of the XRs significantly correlated with the BMD measured by DXA (r = 0.78) and HR-pQCT (r = 0.63), as did the CBTg index with the DXA (r = 0.55) and HR-pQCT (r = 0.64) (all p < 0.001). A high correlation of the BMD and CBT was observed between paired specimens (r = 0.79 to 0.96). The intra- and inter-rater reliability was excellent (ICC 0.79 to 0.92).

CONCLUSION

The cortical index (CBTavg) at the distal radius shows a close correlation to the local BMD. It thus can serve as an initial screening tool to estimate the local bone quality if quantitative BMD measurements are unavailable, and enhance decision-making in acute settings on fracture management or further osteoporosis screening. Cite this article: Bone Joint Res 2021;10(12):820-829.

Software for the Diagnosis of Sarcopenia in Community-Dwelling Older Adults: Design and Validation Study

BACKGROUND

The usual diagnosis of sarcopenia requires a dual-energy x-ray absorptiometry (DXA) exam, which has low accessibility in primary care for Latin American countries.

OBJECTIVE

The aim of this study is to design and validate software for mobile devices (Android, IOS) and computers, based on an adapted version of the diagnostic algorithm of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP).

METHODS

Follow-up exams were conducted on 430 community-dwelling Chileans 60 years and older (mean 68.2 years, SD 4.9) participating in the IsaMayor and Alexandros cohorts designed to study sarcopenia and disability associated with obesity, respectively. All the participants from the cohorts were randomly selected from the registries of primary health care centers and, for this study, must have a DXA scan at baseline. The software (HTSMayor) was designed according to an adapted version of the algorithm proposed by the EWGSOP and was divided into four phases: longitudinal validation of diagnostic algorithm of sarcopenia, alpha version, beta version, and release version. The software estimates appendicular skeletal muscle mass (ASM) using an anthropometric equation or DXA measurements with Chilean cut-off points. The predictive validation of the algorithm was estimated, comparing functional limitations (at least one activity of daily living, two instrumental activities of daily living, or three mobility limitations), falls, and osteoporosis at follow-ups in patients with and without sarcopenia at baseline, using adjusted logistic models.

RESULTS

After a median follow-up of 4.8 years (2078.4 person-years), 37 (9.9%) new cases of sarcopenia, out of the 374 patients without sarcopenia at baseline, were identified (incidence density rate=1.78 per 100 person-years). ASM estimated with the anthropometric equation showed both a high sensitivity and specificity as compared with those estimated by DXA measurements, yielding a concordance of 0.96. The diagnostic algorithm of sarcopenia considered in the software with the equation showed both a high sensitivity (82.1%) and specificity (94.9%) when compared with DXA (reference standard). Adults without sarcopenia (at baseline) showed better physical performance (after approximately 5 years) than adults with sarcopenia. Loss of functionality was greater in adults with sarcopenia (OR 5.0, 95% CI 2.2-11.4) than in adults without sarcopenia. In addition, the risks of falls (OR 2.2, 95% CI 1.1-4.3) and osteoporosis (OR 2.8, 95% CI 1.2-6.6) were higher in older persons with sarcopenia than those without sarcopenia. The measurements and results were completed for the beta and release tests with a mean time of 10 minutes and 11 minutes, respectively.

CONCLUSIONS

We developed and validated a software for the diagnosis of sarcopenia in older Chilean adults that can be used on a mobile device or a computer with good sensitivity and specificity, thus allowing for the development of programs for the prevention, delay, or reversal of this disease. To our knowledge, HTSMayor is the first software to diagnose sarcopenia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13657.

Management of osteoporosis in the Middle East and North Africa: a survey of physicians' perceptions and practices

We surveyed 573 physicians in the Middle East regarding osteoporosis management. Sixty percent had access to, but were not in charge of, densitometry reporting. Screening for secondary causes was common; 62% were aware of FRAX®; less than half used it. Medications were accessible, and most participants had concerns regarding bisphosphonates. Barriers to care were identified.

INTRODUCTION

The 2011 IOF Middle East Osteoporosis Audit highlighted major care gaps in osteoporosis care in the Middle East and North Africa (MENA) region. We investigated osteoporosis management practice patterns in this region.

METHODS

We mailed an electronic survey to a convenience sample of physicians, explaining the study rationale and methods. It gathered information on physicians' profiles, availability and utilization of resources, risk assessment, and management.

RESULTS

Five hundred seventy-three responses were obtained from the United Arab Emirates (UAE, 36%), Saudi Arabia (KSA, 25%), Lebanon (14%), and others (25%). Endocrinology was the single most represented specialty. Sixty percent of participants had access to densitometers, but treating physicians were not in charge of densitometry reading. Screening for vitamin D deficiency and secondary contributors to osteoporosis was frequently implemented. Although two-thirds of professionals were aware of FRAX®, only 42% used it, either because of lack of know how or of a country specific calculator. Almost all (96.0%) had access to oral and 68.9% to intravenous bisphosphonates, and over half to teriparatide (46.4%) and denosumab (45.0%). Most participants (92%) were aware of concerns regarding side effects of bisphosphonates, and this changed the management in the majority (73%). Important barriers to osteoporosis care were lack of osteoporosis awareness among physicians, patients, and cost of treatment.

CONCLUSIONS

This first look at physicians' practice patterns on the diagnosis and treatment of osteoporosis in the MENA region underscores the pressing need for an official call for action, at all levels, to address this large care gap.

Cost-effectiveness of fracture prevention in rural women with limited access to dual-energy X-ray absorptiometry

A reduced reimbursement for office-based dual-energy X-ray absorptiometry (DXA) is likely to exacerbate the burden of fractures in rural areas. Our cost-effective analysis suggests that, in areas where access to DXA is limited, treatment for women at high clinical risk for fractures could both improve health and save money.

INTRODUCTION

To evaluate the cost-effectiveness of various fracture prevention strategies for rural women with limited access to dual-energy X-ray absorptiometry (DXA).

METHODS

A Markov model was developed using data from the published literature and the Manitoba Bone Density Program. The participants were a simulated cohort of rural women aged 65 years with travel distance between 10 and 24 mi to the nearest DXA site. The evaluated strategies were (1) watchful waiting, (2) bone mineral density (BMD)-based strategy (i.e., DXA screening followed by pharmacotherapy based on BMD), and (3) clinical risk factor (CRF)-based strategy (i.e., pharmacotherapy for women at high risk for fractures by the World Health Organization Fracture Risk Assessment Tool [FRAX]). The outcome was an incremental cost-effectiveness ratio (ICER) measured by cost per quality-adjusted life-year (QALY) gained. The analysis was preformed from a societal perspective over a lifetime horizon.

RESULTS

In the base-case analysis, the BMD-based strategy had an ICER of $6000 per QALY gained. For those with travel distance between 25 and 39 mi, the BMD-based strategy would have an ICER of $140,800 per QALY gained. For those with travel distance greater than 40 mi, the CRF-based strategy would be more effective and less costly than other strategies.

CONCLUSIONS

In areas where DXA is readily available, DXA screening followed by pharmacotherapy guided by BMD would be preferred. In areas with more limited access to DXA, pharmacotherapy for women at high clinical risk for fractures based on FRAX could both improve health and save money from the societal perspective.

Osteoporosis management and fractures in the Métis of Ontario, Canada

Half of Métis citizens, compared to less than 10 % of the general population of Ontario, reside in northern regions, with little access to bone mineral density (BMD) testing. Métis citizens had lower sex-specific and age-standardized rates of BMD testing, yet similar rates of fracture (both sexes) and pharmacotherapy (women only).

PURPOSE

To examine osteoporosis management and common osteoporosis-related fractures among Métis citizens compared to the general population of older adults residing in Ontario.

METHODS

We linked healthcare (medical and pharmacy) utilization and administrative (demographic) databases with the Métis Nation of Ontario citizenship registry to estimate osteoporosis management (bone mineral density [BMD] testing, pharmacotherapy) and fractures (hip, humerus, radius/ulna) among adults aged ≥50 years, from April 1, 2006 to March 31, 2011. Pharmacotherapy data were limited to residents aged ≥65 years. Sex-specific and age-standardized rates were compared between the Métis and the general population. Multivariable logistic regression was used to compare rates of BMD testing after controlling for differences in age and region of residence between the Métis and the general population.

RESULTS

We studied 4219 Métis citizens (55 % men), and 140 (3 %) experienced a fracture. Half of Métis citizens, compared to less than 10 % of the general population of Ontario, resided in northern regions. We identified significantly lower sex-specific and age-standardized rates of BMD testing among Métis compared to the general population, yet found little difference in fracture rates (both sexes) or pharmacotherapy (women only). Differences in BMD testing disappeared after adjusting for region of residence among women yet remained significant among men.

CONCLUSIONS

Despite finding significantly lower rates of osteoporosis management among men, Métis men and women were found to have similar age-standardized fracture rates to the general population.

Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials

Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers.

INTRODUCTION

In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors.

METHODS

Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year.

RESULTS

Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment.

CONCLUSIONS

The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.

Factors influencing the pharmacological management of osteoporosis after fragility fracture: results from the Ontario Osteoporosis Strategy's fracture clinic screening program

Potential mediating factors in the pathway to initiation of osteoporosis treatment following a fragility fracture were evaluated. Patients' perceived need for treatment, mediated by their perception of bone density test results, was central to treatment initiation. Interventions focusing on patients' perceptions of need and test results may improve treatment rates.

INTRODUCTION

We tested a hypothesized pathway to osteoporosis (OP) pharmacotherapy initiation in fragility fracture patients. We hypothesized that bone mineral density (BMD) testing is strongly associated with treatment initiation and perception of BMD test results would inform patients' perceived need for treatment, which would mediate the effect between BMD testing and treatment initiation.

METHODS

A longitudinal cohort study followed patients, ≥50 years of age, screened for fragility fracture in 31 fracture clinics in Ontario, Canada who had no prior diagnosis of or treatment for OP. At screening, OP risk factors, baseline-patient perception of OP risk, OP knowledge, and perceived benefits of medication were reported by patients. Patients were followed up within 6 months of fracture to determine BMD testing and prescription of and adherence to first-line OP pharmacotherapy. Structural equation modeling tested the hypothesized pathway. Significance and magnitude of the coefficients and indicators of overall model fit were used to test our model.

RESULTS

The direct path from BMD testing to OP treatment initiation was non-significant. The pathway to treatment initiation was mediated by patients' perception of their need, which was influenced by their self-reported BMD results. Baseline fracture risk factors, knowledge of OP, and perceived benefits of treatment-predicted patient-perceived need for treatment at follow-up and initiation of OP treatment.

CONCLUSIONS

Patient perceptions were central factors in the path to initiation of OP pharmacotherapy. Interventions to facilitate accurate patient perceptions of BMD test results and OP risk status could prove helpful in improving OP treatment initiation.

Examining the impact of reimbursement on referral to bone density testing for older adults: 8 years of data from the Barwon Statistical Division, Australia

In 2007, Medicare Australia revised rei:mbursement guidelines for dual energy X-ray absorptiometry (DXA) for Australians aged ≥70 years; we examined whether these changes increased DXA referrals in older adults. Proportions of DXA referrals doubled for men and tripled for women from 2003 to 2010; however, rates of utilization remained low.

INTRODUCTION

On April 1, 2007 Medicare Australia revised reimbursement guidelines for DXA for Australians aged ≥70 year; changes that were intended to increase the proportion of older adults being tested. We examined whether changes to reimbursement increased DXA referrals in older adults, and whether any sex differences in referrals were observed in the Barwon Statistical Division.

METHODS

Proportions of DXA referrals 2003-2010 based on the population at risk ascertained from Australian Census data and annual referral rates and rate ratios stratified by sex, year of DXA, and 5-year age groups. Persons aged ≥70 years referred to the major public health service provider for DXA clinical purposes (n = 6,096; 21 % men).

RESULTS

DXA referrals. Proportions of DXA referrals for men doubled from 0.8 % (2003) to 1.8 % (2010) and tripled from 2.0 to 6.3 % for women (all p < 0.001). For 2003-2006, referral ratios of men/women ranged between 1:1.9 and 1:3.0 and for 2007-2010 were 1:2.3 to 1:3.4. Referral ratios <2007:≥2007 were 1:1.7 for men aged 70-79 years (p < 0.001), 1:1.2 for men aged 80-84 years (p = 0.06), and 1:1.3 for men 85+ years (p = 0.16). For women, the ratios <2007:≥2007 were 1:2.1 (70-79 years), 1.1.5 (80-84 years), and 1:1.4 (85+ years) (all p < 0.001).

CONCLUSIONS

DXA referral ratios were 1:1.6 (men) and 1:1.8 (women) for 2007-2010 vs. 2003-2006; proportions of referrals doubled for men and tripled for women from 2003 to 2010. Overall, rates of DXA utilization remained low. Policy changes may have had minimal influence on referral; thus, ongoing evaluation over time is warranted.

Digital X-ray radiogrammetry of hand or wrist radiographs can predict hip fracture risk--a study in 5,420 women and 2,837 men

OBJECTIVES

To assess whether digital X-ray radiogrammetry (DXR) analysis of standard clinical hand or wrist radiographs obtained at emergency hospitals can predict hip fracture risk.

METHODS

A total of 45,538 radiographs depicting the left hand were gathered from three emergency hospitals in Stockholm, Sweden. Radiographs with insufficiently included metacarpal bone, fractures in measurement regions, foreign material or unacceptable positioning were manually excluded. A total of 18,824 radiographs from 15,072 patients were analysed with DXR, yielding a calculated BMD equivalent (DXR-BMD). Patients were matched with the national death and inpatient registers. Inclusion criteria were age ≥ 40 years, no prior hip fracture and observation time > 7 days. Hip fractures were identified via ICD-10 codes. Age-adjusted hazard ratio per standard deviation (HR/SD) was calculated using Cox regression.

RESULTS

8,257 patients (65.6 % female, 34.4 % male) met the inclusion criteria. One hundred twenty-two patients suffered a hip fracture after their radiograph. The fracture group had a significantly lower DXR-BMD than the non-fracture group when adjusted for age. The HR/SD for hip fracture was 2.52 and 2.08 in women and men respectively. The area under the curve was 0.89 in women and 0.84 in men.

CONCLUSIONS

DXR analysis of wrist and hand radiographs obtained at emergency hospitals predicts hip fracture risk in women and men.

KEY POINTS

• Digital X-ray radiogrammetry of emergency hand/wrist radiographs predicts hip fracture risk. • Digital X-ray radiogrammetry (DXR) predicts hip fracture risk in both women and men. • Osteoporosis can potentially be identified in patients with suspected wrist fractures. • DXR can potentially be used for selective osteoporosis screening.

Hip fracture and other predictors of anti-osteoporosis drug use in Norway

This study aims to find predictors of anti-osteoporosis drug (AOD) use. Known risk factors of osteoporosis, i.e., age, hip fracture, and corticosteroid use were found to be predictors of AOD use, in addition to a number of other drugs used. Higher socioeconomic position did not favor the use of AOD.

INTRODUCTION

This study deals with studying predictors of anti-osteoporosis drug treatment in Norwegian women and men.

METHODS

All Norwegian women and men≥50 years were included (n=1,407,392). Data were taken from different data sources, (1) the Norwegian Prescription Database (drug use in 2004-2005); (2) the Nationwide Census 2001 (marital status, education and resident county); (3) the National Hip Fracture Database (hip fractures 2003-2005); and (4) the National Population Register (date of death/emigration). We estimated the hazard ratios (HR) for incident treatment by Cox proportional hazard regression.

RESULTS

In 2005, 10,332 women (1.5%) and 1,387 men (0.2%) were new users of anti-osteoporosis drugs (incident treatment). Age was a statistically significant predictor of incident treatment in both women and men, with HR ranging from 1.7 to 3.2 (per 10 years). A middle educational level in men strongly predicted incident treatment [HR 2.0 (CI 1.1-3.8)], but not in women after full adjustment. A previous hip fracture, increasing number of drugs used and use of corticosteroids were all predictors of incident treatment in both genders after adjustments. Corticosteroid use [HRwomen=4.0 (CI 3.8-4.2)] had a higher HR for incident treatment than hip fracture [HRwomen=2.0 (CI 1.8-2.3)]. Marital status and area of residency were not predictors of incident treatment in either gender, after adjustments. The predictors of prevalent treatment were only slightly different from incident treatment in 2005.

CONCLUSIONS

Age, previous hip fracture, number of drugs used, and use of corticosteroids were positively related to treatment in both genders. In men, a middle educational level predicted treatment.

Patient perceptions of the path to osteoporosis care following a fragility fracture

Coordinator-based osteoporosis (OP) screening programs for fragility-fracture patients in orthopedic environments improve rates of OP testing and care, but there are still gaps in care. The purpose of this study was to understand the process by which patients decided whether to proceed with OP testing or care within these programs. Twenty-four fragility-fracture patients in the OP screening program at a large, urban, university hospital in Canada participated in one of five focus groups. Focus group transcripts were sorted and coded. Links between themes were developed to generate a description of the process leading to successful initiation of OP care after a fragility fracture. To initiate OP testing and care, patients had to both comprehend the link between their fragility fracture and OP, and make an action-oriented appraisal of what action to take. Several modifiable facilitators and barriers influenced the process between screening and undergoing OP testing and initiating treatment.

The effect modification of supplemental insurance on the relationship between race and bone mineral density screening in female Medicare beneficiaries

To determine the effect modification of supplemental insurance on the relationship between race and bone mineral density (BMD) in female Medicare beneficiaries. Retrospectively analyzing hospital administrative claim and clinical data of female Medicare beneficiaries (n = 1,398), we performed multivariate logistic regressions of BMD testing including data from all study participants and the subsets of health insurance. Significantly fewer Black than White female Medicare beneficiaries received the BMD testing in the overall sample (odds ratio, OR = 0.63; p = 0.02) and those without supplementary health insurance (n = 709; OR = 0.38; p = 0.004). By contrast, the magnitude of this racial disparity in the BMD testing was diminished among those with supplementary private health insurance (n = 689). We found a significant racial disparity in BMD testing for Black and White female Medicare beneficiaries. This disparity became more pronounced among those without supplementary private health insurance.

Effect of reimbursement reductions on bone mineral density testing for female Medicare beneficiaries

BACKGROUND

We examined whether the recent reimbursement reductions on the bone mineral density (BMD) test affected BMD testing in female Medicare beneficiaries with or without supplemental private health insurance.

METHODS

Retrospectively analyzing hospital administrative and clinical data on female Medicare beneficiaries (n=1320), we reviewed whether participants received BMD testing before (January 2004-December 2006) or after (January 2007-December 2009) reimbursement reductions for BMD testing. After adjusting for demographics and clinical characteristics, we performed Cox proportional hazard regression analyses of the BMD test including data from all study participants; we then performed separate regression analyses using data with or without supplemental private health insurance.

RESULTS

In those without supplemental private health insurance (n=421), less frequent BMD testing occurred after reimbursement reductions for BMD testing (hazard ratio [HR] 0.67, 95% confidence intervals [CI] 0.34-0.98; p=0.03). By contrast, in the overall participants (n=1320) and those with supplemental private health insurance (n=899), the number of BMD tests did not change significantly after reimbursement reductions for BMD testing.

CONCLUSIONS

We found a significant association between reimbursement reductions and decrease in BMD tests in female Medicare beneficiaries without supplemental private health insurance.

Osteoporosis management and the utilization of FRAX®: a survey amongst health care professionals of the Asia-Pacific

This survey investigated osteoporosis management practices in the Asia-Pacific region. While access to anti-osteoporotic medication is reasonable, screening for secondary contributors is performed insufficiently. FRAX® is well-known, but not used by many physicians. High costs of medication and unawareness about the disease are the biggest barriers to osteoporosis care.

PURPOSE

Osteoporosis is an increasing burden amongst countries of the Asia-Pacific. The fracture risk assessment tool FRAX® has recently been introduced in some Asian countries. This study aimed to identify attitudes about osteoporosis management in general and the utilization of FRAX® in particular amongst physicians in the Asia-Pacific region.

METHODS

A 26-item questionnaire was distributed to the participants of the first Asian regional osteoporosis meeting of the IOF in 2010. In total, 247 valid questionnaires representing 17 countries from the Asia-Pacific region were analyzed.

RESULTS

Most physicians make use of bone densitometry devices (94 %) and have access to at least one type of anti-osteoporotic medication (100 %). Central dual-energy X-ray absorptiometry was the most accessible device (87 %). Oral bisphosphonates were the only medication that was available to health care professionals in all surveyed Asia-Pacific countries. Seventy-six percent were aware of FRAX®; however, among these only 62 % used it. The main reason for not using FRAX® was the lack of country-specific models (46 %). Screening for secondary osteoporosis was performed by 36 % of the respondents. The high costs of medication and lack of awareness amongst physicians and patients about the disease were perceived as the most important barriers to osteoporosis care.

CONCLUSION

More FRAX® models should be established and implemented into the local guidelines. The necessity of screening for secondary contributors to osteoporosis should be emphasized, as easily treatable causes might be identified. To further improve osteoporosis diagnosis and treatment, the awareness of osteoporosis among doctors as well as patients needs to be raised.

Social determinants of bone densitometry uptake for osteoporosis risk in patients aged 50yr and older: a systematic review

The World Health Organization identifies that osteoporosis is one of the leading health problems in the Western world. An increased risk of fragility fracture is observed in more socially disadvantaged individuals in most Western countries. Dual-energy X-ray absorptiometry (DXA) is currently the procedure of choice to diagnose osteoporosis and assess fracture risk. We systematically reviewed the literature regarding social determinants of DXA utilization for osteoporosis detection in patients aged 50yr and older using a computer-aided search of MEDLINE, EMBASE, CINAHL, and PsychINFO from January 1994 to December 2010. Five cross-sectional studies, incorporating 16 separate analyses, were identified for inclusion in this review. The best evidence analysis identified limited evidence for a positive association between either income or education with DXA utilization; furthermore, the best evidence analysis found no evidence for an association between either marital status or working status and DXA utilization. Further research is required to identify whether a relationship exists and elucidate reasons for disparities in DXA utilization between different social groups, such as choice and referral processes, as a necessary precursor in identifying modifiable determinants and appropriate strategies to promote preventive screening to identify fracture risk.

The post-fracture care gap among Canadian First Nations peoples: a retrospective cohort study

Despite targeted attempts to reduce post-fracture care gaps, we hypothesized that a larger care gap would be experienced by First Nations compared to non-First Nations people. First Nations peoples were eight times less likely to receive post-fracture care compared to non-First Nations peoples, representing a clinically significant ethnic difference in post-fracture care.

INTRODUCTION

First Nations peoples are the largest group of aboriginal (indigenous or native) peoples in Canada. Canadian First Nations peoples have a greater risk of fracture compared to non-First Nations peoples. We hypothesized that ethnicity might be associated with a larger gap in post-fracture care.

METHODS

Non-traumatic major osteoporotic fractures for First Nations and non-First Nations peoples aged ≥ 50 years were identified from a population-based data repository for Manitoba, Canada between April 1996 and March 2002. Logistic regression analysis was used to examine the probability of receiving a BMD test, a diagnosis of osteoporosis, or beginning an osteoporosis-related drug in the 6 months post-fracture.

RESULTS

A total of 11,234 major osteoporotic fractures were identified; 502 occurred in First Nations peoples. After adjustment for confounding covariates, First Nations peoples were less likely to receive a BMD test [odds ratio (OR) 0.1, 95% confidence interval (CI), 0.0-0.5], osteoporosis-related drug treatment (OR, 0.5; 95% CI, 0.3-0.7), or a diagnosis of osteoporosis (OR, 0.5; 95% CI, 0.3-0.7) following a fracture compared to non-First Nations peoples. Females were more likely to have a BMD test (OR, 5.0; 95% CI, 2.6-9.3), to be diagnosed with osteoporosis (OR, 1.7; 95% CI, 1.5-2.0), and to begin drug treatment (OR, 4.1; 95% CI, 2.7-6.4) compared to males.

CONCLUSIONS

An ethnicity difference in post-fracture care was observed. Further work is needed to elucidate underlying mechanisms for this difference and to determine whether failure to initiate treatment originates with the medical practitioner, the patient, or a combination of both. It is imperative that all residents of Manitoba receive efficacious and equal care post-fracture, regardless of ethnicity.

Predictors of bone mineral density testing in patients at high risk of osteoporosis: secondary analyses from the OSTEOPHARM randomized trial

In a randomized trial, we demonstrated that a community pharmacist osteoporosis screening intervention doubled the rates of bone mineral density (BMD) testing in high-risk patients. The purpose of this secondary analysis was to evaluate the potentially modifiable factors associated with BMD testing. From 2005 to 2007, 15 pharmacies randomized 262 patients to intervention (education, pamphlets, point-of-care quantitative heel ultrasound [QUS]) or usual care. The main outcome was BMD testing within 4mo. Multivariate regression was used to determine independent correlates of BMD testing. The median age of the cohort was 62yr, 65% were women, and 49% (n=129) were randomized to intervention. Compared with patients who were not tested, those with BMD were more likely to be women (p=0.007) and have excellent or very good health (p<0.001). Postrandomization correlates of BMD test were intervention (p=0.017), greater osteoporosis knowledge (p=0.004), and osteoporosis-specific physician visits (p<0.001). In adjusted analyses, only female sex (adjusted odds ratio [aOR]: 3.0; 95% confidence interval [CI]: 1.3-7.4) and osteoporosis-specific visits (aOR: 3.2; 95% CI: 1.4-7.8) were independently associated with BMD testing. In analyses restricted to intervention patients, abnormal QUS (aOR: 3.7, 95% CI: 1.4-9.1) was the only independent predictor of BMD test. Future interventions should incorporate the finding that osteoporosis-specific visits and abnormal QUS results were strongly associated with getting a BMD testing and should give greater attention to men.

Osteoporosis onset differences between rural and metropolitan populations: correlation to fracture type, severity, and treatment efficacy

Osteoporosis is the prevalent cause of fractures in an ever-aging population, with an established correlation between daily activities and way of life. We aimed to delineate differences in onset of osteoporosis, T-score progression, quality of life, and correlation to prevalence, types, and severity of fractures in age-comparable populations of rural and metropolitan habitats in this multicenter, retrospective double-blind study. We evaluated data derived from the medical files of two comparable groups of osteoporotic patients: group A (n = 530, rural area) and group B (n = 171, metropolitan area). Both groups received comparable treatment for osteoporosis. Comparison was performed on the basis of osteoporosis onset, T-score in a maximum of 8 years follow-up, fracture types [American Academy of Orthopaedic Surgeons (AO) categorization], and type of treatment followed. Quality of life was assessed by use of specialized questionnaires. From the minimum 4-year follow-up of all patients included in the research, there was a statistically significant difference in favor of the rural population in all research parameters. Rural populations presented with osteoporosis at a later age than their metropolitan counterparts, exhibiting favorable T-scores with comparable treatments and simpler fractures (AO categorization). Metropolitan habitats and life therein have a deleterious effect on osteoporosis onset and response to treatment. Rural populations are diagnosed with osteoporosis on a later age, with better compliance and improved treatment outcome. Fracture categorization shows increased severity in the metropolitan populace and a suggested correlation between a poor-quality way of life and decreased activity levels.

Bone density, health beliefs, and osteoporosis preventing behaviors in men

PURPOSE

To examine the effect of bone mineral density (BMD) screening via dual-energy x-ray absorptiometry (DXA) results on osteoporosis preventing behaviors (OPB), knowledge of osteoporosis, and health beliefs of men aged 50 years or older (N = 196) was evaluated.

DESIGN

An experimental, 2-group longitudinal design was used. The independent variable was DXA, dependent variables were osteoporosis preventing behaviors, and mediating variables were general knowledge of osteoporosis and Health Belief variables. Half of the men had low bone density. Men diagnosed to be osteoporotic increased their calcium intake.

FINDINGS

Health belief variables predicted calcium intake and/or exercise. In addition, 9 men in the experimental group were taking medications to prevent/restore bone loss at Time 3. Healthcare providers play a significant role in assessing bone loss and preventing and treating osteoporosis in men.

IMPLICATIONS

The cost of a DXA screen is far less than financial and social costs due to osteoporotic fractures.

Phalangeal densitometry compared with dual energy X-ray absorptiometry for assessment of bone mineral density in elderly women

BACKGROUND

Reduced bone mineral density (BMD) is identified as a major risk factor for fracture. The World Health Organization criterion for diagnosis of osteoporosis (T-score ≤-2.5 SD) is based on dual energy X-ray absorptiometry (DXA) measurements. However DXA availability may be limited in some regions. In this study the ability of the phalangeal radiographic absorptiometry (RA) device, MetriScan, to identify women with reduced BMD at the femoral neck assessed by DXA was evaluated.

METHODS

The study population contained women with recent low-energy distal radius fracture and women recruited from the general population, all aged ≥50 years. A triage approach was applied in which two cut-offs for RA T-score were defined at which individuals with 90% sensitivity and 90% specificity could be identified to have or not have reduced BMD at the femoral neck defined as T-score ≤-2.5 SD.

RESULTS

The correlation between phalangeal RA BMD and femoral neck DXA BMD was r=0.65 (p<0.001). The upper and lower RA T-score cut-off was -1.5 SD and -2.9 SD. With the triage approach being used for the whole cohort, 34% would require a central DXA assessment to determine if the femoral neck T-score is below or above -2.5 SD.

CONCLUSION

The application of the RA MetriScan device can reduce the number of DXA assessments needed to detect reduced BMD. The device may thus be of clinical value if access to DXA is limited, as well as for screening purposes.

Secondary osteoporosis in men and women: clinical challenge of an unresolved issue

OBJECTIVE

To evaluate the clinical and etiological factors of osteoporosis. We also tested the FRAX algorithm to compare the assessment of fracture risk in patients with primary or secondary osteoporosis.

METHODS

A prospective study carried out in a large sample of 123 men and 246 women. All subjects had a biochemical, densitometric, and radiological examination of thoracic and lumbar spine.

RESULTS

The prevalence of primary (men 52.9% vs women 50%; p = nonsignificant) and secondary (men 21.1% vs women 17.5%; p = nonsignificant) osteoporosis did not differ between the sexes. In contrast, the prevalence of primary osteoporosis was significantly higher than secondary causes (p < 0.0001) in both men and women. While women came to our attention for prevention of osteoporosis, men sought help because of clinical symptoms or disease-related complications, such as fractures. As evaluated by the FRAX tool, patients with osteopenia do not need treatment, in agreement with Italian guidelines. The estimated risk of major osteoporotic and hip fractures was significantly higher in women with secondary osteoporosis compared to men and also compared to women with primary osteoporosis.

CONCLUSION

The prevalence of secondary osteoporosis in men is similar to that in women and it is less frequent than commonly reported. In patients with secondary osteoporosis, FRAX calculation may provide an estimate of a particularly high fracture risk in patients whose bone fragility is usually attributed to another disease.

Osteoporosis pharmacotherapy following bone densitometry: importance of patient beliefs and understanding of DXA results

SUMMARY

Persistence with osteoporosis therapy remains low and identification of factors associated with better persistence is essential in preventing osteoporosis and fractures. In this study, patient understanding of dual energy X-ray absorptiometry (DXA) results and beliefs in effects of treatment were associated with treatment initiation and persistence.

INTRODUCTION

The purpose of this study is to examine patient understanding of their DXA results and evaluate factors associated with initiation of and persistence with prescribed medication in first-time users of anti-osteoporotic agents. Self-reported DXA results reflect patient understanding of diagnosis and may influence acceptance of osteoporosis therapy. To improve patient understanding of DXA results, we provided written information to patients and their referring general practitioner (GP), and evaluated factors associated with osteoporosis treatment initiation and 1-year persistence.

METHODS

Information on diagnosis was mailed to 1,000 consecutive patients and their GPs after DXA testing. One year after, a questionnaire was mailed to all patients to evaluate self-report of DXA results, drug initiation and 1-year persistence. Quadratic weighted kappa was used to estimate agreement between self-report and actual DXA results. Multivariable logistic regression was used to evaluate predictors of understanding of diagnosis, and correlates of treatment initiation and persistence.

RESULTS

A total of 717 patients responded (72%). Overall, only 4% were unaware of DXA results. Agreement between self-reported and actual DXA results was very good (κ = 0.83); younger age and glucocorticoid use were associated with better understanding. Correctly reported DXA results was associated with treatment initiation (OR 4.3, 95% CI 1.2-15.1, p = 0.02), and greater beliefs in drug treatment benefits were associated with treatment initiation (OR 1.4, 95%CI 1.1-1.9, p = 0.006) and persistence with therapy (OR 1.8, 95% CI 1.2-2.7, p = 0.006).

CONCLUSION

Our findings suggest that written information provides over 80% of patients with a basic understanding of their DXA results. Communicating results in writing may improve patient understanding thereby also improve osteoporosis management and prevention.

Osteoporosis quality indicators using healthcare utilization data

SUMMARY

Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying dual-energy X-ray absorptiometry (DXA) testing (sensitivity = 98%, specificity = 93%) and osteoporosis pharmacotherapy (κ = 0.81) with minimal measurement error.

INTRODUCTION

In osteoporosis, key quality indicators among older women include risk assessment by DXA and/or pharmacotherapy within 6 months following fracture.

METHODS

The purpose of this study was to examine healthcare utilization data for use as quality indicators of osteoporosis management. We linked data from 858 community-dwelling women aged over 65 years who completed a standardized telephone interview about osteoporosis management to their healthcare utilization (medical and pharmacy claims) data. Agreement between self-report of osteoporosis pharmacotherapy and pharmacy claims was examined using kappa statistics. We examined the sensitivity and specificity of medical claims to identify DXA testing as well as the sensitivity and specificity of medical and pharmacy claims to identify those with DXA-documented osteoporosis (T-score ≤ -2.5).

RESULTS

Participants were aged 75 (SD = 6) years on average; 96% were Caucasian. Agreement between self-report and claims-based osteoporosis pharmacotherapy was very good (κ = 0.81; 95% CI = 0.76, 0.86). The sensitivity of medical claims to identify DXA testing was 98% (95% CI = 95.9, 99.1), with estimated specificity of 93% (95% CI = 89.8, 95.4). We abstracted DXA results from test reports of 359 women, of whom 114 (32%) were identified with osteoporosis. Medical (osteoporosis diagnosis) and pharmacy (osteoporosis pharmacotherapy) claims within a year after DXA testing had a sensitivity of 80% (95% CI = 71.3, 86.8) and specificity of 72% (95% CI = 66.2, 77.8) to identify DXA-documented osteoporosis.

CONCLUSION

Healthcare utilization data may be used to examine the quality of osteoporosis management by identifying DXA testing and osteoporosis pharmacotherapy (care processes) with minimal measurement error. However, medical and pharmacy claims alone do not provide a good means for identifying women with underlying osteoporosis.

The effect of the addition of osteoporosis education to a bone health screening program for older adults

Osteoporosis affects approximately 26% of women and 4% of men after the age of 65 years. However, the diffusion of knowledge about osteoporosis risk factors, prevention and treatment remains low. The purpose of this longitudinal study was to investigate the value of adding initial and refresher osteoporosis education classes to a bone health screening program. A convenience sample of 376 men (n = 62) and women (n = 314) over the age of 62 years was assigned randomly to the Screening plus Education (n =193) or Screening only (n = 183) groups. Participants in both study groups demonstrated an increase in knowledge about osteoporosis, regardless of group assignment and other factors, over the two years of the study. Self-reported calcium use increased for all women and for men in the education group from baseline to year one, with a decline thereafter. There was no effect on exercise behaviors. This study points out the critical need for a more comprehensive and personalized bone health program that includes more than classroom-based education.

The ability of hand digital X-ray radiogrammetry to identify middle-aged and elderly women with reduced bone density, as assessed by femoral neck dual-energy X-ray absorptiometry

In this study, we evaluate the ability of digitized digital X-ray radiogrammetry (DXR) bone mineral density (BMD) to identify women with reduced BMD at femoral neck, assessed by dual-energy X-ray absorptiometry (DXA). The study population contained women with recent low-energy distal radius fracture and women recruited from the general population, all aged 50 yr or older. The correlation between hand BMD and femoral neck BMD was r=0.65 (p<0.001). We used a triage approach where 2 cutoffs for DXR T-score were defined at which patients with 90% sensitivity and 90% specificity could be identified to have or not have reduced BMD at femoral neck, defined as T-score ≤-2.5 standard deviation (SD). The upper and lower DXR T-score cutoffs were -1.2 and -2.7, respectively. Applying the triage approach in the whole cohort, 32% would require a central DXA assessment to determine the presence or absence of femoral neck T-score ≤-2.5 SD. Our data suggest that DXR can be used to reduce the numbers of patients in need of DXA femoral neck and may, thus, be of clinical value where access to DXA is limited.

Has reimbursement of bone mineral density testing and anti-osteoporotic treatments improved management of osteoporosis in France?

BACKGROUND

Since July 1, 2006 bone mineral density (BMD) testing has been reimbursed for osteoporosis screening under specific clinical conditions in France. Concurrently, drug coverage has been extended to all anti-osteoporotic treatments in women with low BMD. It was thus expected that the utilisation of BMD testing and subsequent treatment would increase significantly.

OBJECTIVE

To examine the pattern of use of BMD testing following reimbursement by the French National Health Insurance and subsequent prescriptions reimbursed for anti-osteoporotic treatment in the general population of the Rhone-Alpes area, France.

METHODS

Time trends, age and sex distribution of the population, and specialty of the physicians who performed the test were examined from all physicians' claims for BMD testing between 2006 and 2009 in Rhone-Alpes. A prospective inception cohort of all women aged 50 years and older, without prior reimbursement for anti-osteoporotic treatment and who had a BMD test between January 1, 2007 and March 31, 2007, was then created. Women were followed for 1 year for their reimbursements of estrogen or other anti-osteoporotic treatment (bisphosphonates, raloxifene, teriparatide and strontium ranelate) after their initial BMD test.

RESULTS

Between July 2006 and August 2009, 140,038 BMD tests were reimbursed in Rhone-Alpes, France, among which 94.8% were performed in women aged 50 years and older. In women, the number of BMD tests tended to significantly decrease during the study period (p for trend=0.047). The inception cohort was composed of 9635 women without prior anti-osteoporotic treatment. Among women without prior estrogen treatment, 27.3% (n=2339) initiated an anti-osteoporotic treatment within 4 months after a BMD test, mostly with bisphosphonates (16.8% n=1441), followed by strontium ranelate (5.8% n=498) and raloxifene (3.4% n=290). At 1 year 1702 women (71.7%) were still on treatment.

CONCLUSION

Following the decision by the French National Health Insurance of repayment of BMD measurement, the proportion of women who had BMD testing tended to decrease instead of increase over the time period. Although BMD screening is focused in France on high risk women, only 25% of those who had an initial BMD test were subsequently treated with an anti-osteoporotic medication.

A postfracture initiative to improve osteoporosis management in a community hospital in ontario

BACKGROUND

Screening programs to manage osteoporosis in fracture clinic environments have had varying success in terms of increasing rates of investigation and initiation of treatment for the disease.

METHODS

We determined rates of postfracture investigation and care for osteoporosis in patients screened through a coordinator-based initiative in a community hospital fracture clinic. A coordinator screened outpatients, educated them about osteoporosis, advised them to see their family physician for assessment and/or treatment, and performed follow-up at six months. Men who were fifty years of age or older and women who were forty years of age or older and had a fragility fracture were eligible.

RESULTS

Of 505 patients enrolled at baseline, 332 (66%) returned the follow-up questionnaire; 51% of those patients reported having had a bone mineral density test after screening and 26% had initiated first-line treatment (35% if the patients who had already initiated treatment at baseline were excluded) and an additional 23% were continuing treatment since baseline. After adjustment for demographic and baseline variables, patients who had initiated first-line treatment after screening were 4.15 times more likely to have had a bone mineral density test after screening than patients who had never initiated treatment and 11.67 times more likely to have had a bone mineral density test after screening than patients who had continued treatment since baseline.

CONCLUSIONS

A coordinator-based osteoporosis screening program was associated with osteoporosis investigation and treatment. A postfracture bone mineral density test was highly associated with treatment initiation.

'If it was osteoporosis, I would have really hurt myself.' Ambiguity about osteoporosis and osteoporosis care despite a screening programme to educate fragility fracture patients

RATIONALE, AIMS AND OBJECTIVES

Behaviour change models suggest that people need clear information about their susceptibility to disease and knowledge of treatment recommendations in order to change their behaviour. The purpose of this qualitative study was to examine fracture patients' understanding of osteoporosis (OP) and OP care after being screened for, and educated about, OP in a fracture clinic.

METHODS

We conducted five focus groups with 24 patients (18 women, six men) aged 47-80 years old who were screened for OP through an urban fracture clinic. Participants were asked about their awareness of OP and their status of bone mineral density (BMD) testing and OP treatment.

RESULTS

Twenty participants vocalized at least one expression of ambiguity regarding OP and/or treatment recommendations conveyed by the screening programme staff. Participants were ambiguous about the cause of their fracture, the BMD test process and results, and the presentation of OP. They were also ambiguous about the amount and type of medication and supplements recommended.

CONCLUSIONS

Despite a standardized screening programme in which OP was addressed in fragility fracture patients, ambiguity about diagnosis, testing and treatment were described. Efforts to clarify information relayed to fracture patients about their condition and recommended care need to extend beyond the fracture clinic so that health care providers can promote long-term adherence to these recommendations.

A perspective on male osteoporosis

Osteoporosis and fragility fracture become common with advancing age in men. The incidence of osteoporosis-related fracture is similar to myocardial infarction and exceeds that of lung and prostate carcinoma combined. These fractures cause substantial morbidity, and the mortality following hip fracture is greater in men than in women. A decline in sex steroids and glucocorticoid and alcohol use, among other factors, contribute to bone loss and fracture risk. Approaches to reduce fracture risk in men are very similar to that in women - recognising and addressing muscle weakness/falls risk and optimising nutrition, with emphasis on calcium and vitamin D and medications when appropriate. Despite the high prevalence, osteoporosis remains largely undiagnosed and undertreated. Hopefully, increased recognition of male osteoporosis by health-care providers and the men themselves, in combination with recent consensus recommendations for treatment based on fracture-risk estimation, will reduce the burden of fragility fracture in men.

Prescription of anti-osteoporosis drugs during 2004-2007-a nationwide register study in Norway

PURPOSE

To assess 1-year prevalence, incidence rates and minimum refill of anti-osteoporosis drug use in Norway by age, gender and place of residence during 2004-2007.

METHODS

Data from patients aged > or = 40 years receiving anti-osteoporosis drugs (AOD) were retrieved from the Norwegian Prescription Database (NorPD). AOD were defined as bisphosphonates (alendronate with or without cholecalciferol, risedronate, ibandronate and etidronate with or without calcium), raloxifene, teriparatide and nasal calcitonin. The NorPD covers the total Norwegian population in ambulatory care. Key measurements were 1-year prevalence, incidence rate and minimum refill.

RESULTS

Among Norwegian women and men > or = 40 years, 4.3 and 0.45% respectively used AOD in 2004. In 2007, the prevalence of AOD use had slightly increased to 4.6% in women and to 0.52% in men. In 2007, 90% of users were women. The use of alendronate, representing 88% of all AOD use in 2007, increased from 2004 to 2007 while the use of other bisphosphonates decreased. The counties with highest overall bisphosphonate use were the counties with the historically lowest incidence of osteoporotic fractures. The incidence rate of overall bisphosphonate use decreased from 2005 to 2007. Among those patients who were dispensed a bisphosphonate in 2005, 72% refilled at least one prescription both in 2006 and 2007.

CONCLUSION

There was an increasing prevalence and a decreasing incidence of AOD use over this limited time period. There was substantial geographical variation in the prevalence of anti-osteoporosis drugs. We also observed a high minimum refill rate.

High-risk patients' readiness to undergo BMD testing for osteoporosis diagnosis in Pennsylvania

The objective of this study was to better understand high-risk patients' readiness to engage in bone mineral density (BMD) testing to diagnose osteoporosis. Six hundred thirty-six participants in a randomized control trial for patients at high-risk for osteoporosis were surveyed. BMD screening readiness was measured by a three-item summative index. Multivariable linear regression examined the relationship between patients' scores on the index and constructs of osteoporosis and BMD testing knowledge, concern for developing osteoporosis and self-efficacy to engage in fall prevention behaviors. Participants had a mean age of 79 years, 96% were female and 80% were white. Greater concern for developing osteoporosis and better knowledge about BMD testing were significant predictors of a higher score on the index. Improving high-risk patients' knowledge about osteoporosis and the importance of BMD testing may enhance patients' readiness to undergo BMD testing. We found several correlates of readiness to undergo BMD screening that may be used to design effective interventions.

The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States

Using national Medicare data from 1999-2006, we evaluated the relationship between travel distance and receipt of dual-energy X-ray absorptiometry (DXA). After adjusting for potentially confounding factors, travel distance was strongly associated with DXA testing. Rural residents were most strongly dependent on the availability of DXAs performed in physician offices.

INTRODUCTION

Medicare reimbursement for DXAs performed in non-facility settings (e.g., physician offices) decreased in 2007. With declining reimbursement, some DXA providers may cease providing this service, which would increase travel distance for some people. The impact of travel distance on access to DXA is unclear.

METHODS

Using national Medicare data, we identified claims for DXA to evaluate trends in the number and locations of DXAs performed. Travel distance was the distance from beneficiaries' residence and the nearest DXA provider. Binomial regression evaluated the relationship between travel distance and receipt of DXA.

RESULTS

In 2006, 2.9 million DXAs were performed, a 103% increase since 1999. In 2005-2006, 8.0% of persons were tested at non-facility sites versus 4.2% at facility sites. The remainder (88%) had no DXA. Persons traveling 5-9, 10-24, 25-39, and 40-54, and > or = 55 miles were less likely to receive DXA (adjusted risk ratios = 0.92, 0.79, 0.43, 0.32, and 0.26, respectively, < 5 miles referent). Rural residents were more dependent than urban residents on the availability of DXA from non-facility providers.

CONCLUSION

Approximately two-thirds of DXAs in 2005-2006 were performed in non-facility settings (e.g., physician offices). Rural residents would have preferentially reduced access to DXA if there were fewer non-facility sites.

Measuring patient perceptions about osteoporosis pharmacotherapy

Background

Adherence to osteoporosis pharmacotherapy is poor, and linked with patient perceptions of the benefits of, and barriers to taking these treatments. To better understand the association between patient perceptions and osteoporosis pharmacotherapy, we generated thirteen items that may tap into patient perceptions about the benefits of, and barriers to osteoporosis treatment; and included these items as part of a standardized telephone interview of women aged 65–90 years (n = 871). The purpose of this paper is to report the psychometric evaluation of our scale.

Findings

Upon detailed analysis, six of the thirteen items were omitted: four redundant, one did not correlate well with any other item and one factorial complex. From the remaining seven items, two distinct unidimensional domains emerged (variance explained = 78%). Internal consistency of the 5-item osteoporosis drug treatment benefits domain was good (Cronbach's alpha = 0.88), and was supported by construct validity; women reporting a physician-diagnosis or taking osteoporosis pharmacotherapy had higher osteoporosis treatment benefit scores compared to those reporting no osteoporosis diagnosis or treatment respectively. Because only two items were identified as tapping into treatment barriers, we recommend they each be used as a separate item assessing potential barriers to adherence to osteoporosis pharmacotherapy, rather than combined into a single scale.

Conclusion

The 5-item osteoporosis drug treatment benefits scale may be useful to examine perceptions about the benefits of osteoporosis pharmacotherapy. Further research is needed to develop scales that adequately measure perceived barriers to osteoporosis pharmacotherapy.

Trend in incidence of osteoporosis-related fractures among 40- to 69-year-old women: analysis of a large insurance claims database, 2000-2005

OBJECTIVE

To determine the trend in incidence of fractures among perimenopausal and postmenopausal women during the periods immediately before and after publication of the Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study (HERS) II data.

DESIGN

This was an ecological study using a claims database for multiple healthcare plans. The cohort of women aged 40 to 69 years was included. Diagnostic codes for fractures likely to be osteoporosis related and prescriptions for hormone therapy and other bone-modifying medications were identified. Annual incidence rates and trends in incidence over time for fractures and prescriptions were determined for the period 2000 through 2005.

RESULTS

Enrollment among women aged 40 to 69 years increased from 919,389 in 2000 to 2,872,372 in 2005. A total of 43,017 new fractures were identified. There was a significant increasing trend in age-adjusted rates of radius and ulna, vertebra, ribs, hip, pelvis, multiple, and pathologic fractures during the period from 2003 through 2005 (P < 0.03). The incidence of each fracture type was significantly greater during 2004 to 2005 than 2000 to 2001 (P < 0.04). The use of estrogen, estrogen plus progestin, and other hormones declined over the period from 2000 to 2003, whereas the use of other bone-modifying drugs increased from 2003 through 2005.

CONCLUSIONS

The incidence of fractures among perimenopausal and postmenopausal women increased significantly in the 3 years after publication of Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study II results. This trend followed a decline in the use of hormone therapy, concurrent with an increase in the use of other bone-modifying agents.

Quality health care gaps in osteoporosis: how can patients, providers, and the health system do a better job?

A significant gap exists between evidence-based advances and real-world clinical practice in the diagnosis and prevention of osteoporosis. The goal of osteoporosis care is to prevent fractures and improve health-related quality of life, and ideally lower mortality. Despite recent advances in osteoporosis detection and treatment options, studies suggest underdiagnosis and undertreatment of osteoporosis, even among those who have already sustained fractures. The challenges in translating knowledge into practice are multifaceted, with efforts directed at the patient, provider, and health care system levels achieving variable success at the population level. Methods to improve quality of care in osteoporosis need to be multipronged, with emphasis on clinical process improvement and reliance on interdisciplinary teams. We review the growing literature on quality of care for osteoporosis.

A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial

In a cluster randomized trial, we evaluated the effect of a multifaceted intervention (directed at both patient and primary care physician) on the rates of testing and treatment of osteoporosis in postmenopausal women within six months of their wrist fracture. Compared to usual care, women in the intervention practices were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments.

INTRODUCTION

Postmenopausal women with wrist fractures are at increased risk of future fragility fractures, yet they frequently do not receive evaluation and treatment for osteoporosis. We set out to evaluate a multifaceted intervention designed to improve management of osteoporosis in older women with recent wrist fractures.

METHODS

Cluster randomized trial of 270 women cared for in 119 primary care practices. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario, Canada. Family practices were randomly assigned to either the intervention or usual care. The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician, in addition to an educational package and letter to the women. The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture.

RESULTS

The mean age of women was 69(10.9) years. The intervention increased the proportion of women started on osteoporosis medications (28% vs. 10%) of controls, adjusted OR 3.45, 95% CI, 1.58-7.56, p = 0.002) and the proportion who had a bone mineral density (BMD) test (53.3% vs. 26%) of controls, OR 3.38, 95% CI, 1.83-6.26, p < 0.001). In addition to the intervention, having a female physician was a predictor of increased testing and treatment rates.

CONCLUSION

A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures.

Patient and physician predictors of post-fracture osteoporosis management

BACKGROUND

Undertreatment of osteoporosis after hip or wrist fracture has been well documented, but the reasons for current patterns of care are poorly understood.

OBJECTIVE

We tested the role of physician and patient characteristics in predicting undertreatment when osteoporosis management was clearly indicated after a hip or wrist fracture in women over age 65.

METHODS

We assembled a cohort of 9,698 female Medicare beneficiaries aged > or = 65 years who experienced hip or wrist fracture between 2000 and 2004 and their prescribing physicians.

MEASUREMENTS

The dominant prescriber was identified as the physician prescribing at least 50% of patient prescriptions in the year after the fracture. Multivariate logistic regression estimated the role of physician and patient characteristics on osteoporosis management after hip or wrist fracture.

RESULTS

Patients older than 90 and black patients were less likely to be treated for osteoporosis relative to patients aged 65-69 and white patients. Female providers were more likely to manage osteoporosis. Models including patient characteristics discriminated well between managed and unmanaged patients (C statistic 0.81), while adding physician predictors to the model provided no additional discriminatory ability (C statistic 0.81).

CONCLUSIONS

Our findings highlight that osteoporosis management rates are similar across providers, but vary considerably by patient types.

Longitudinal trends in use of bone mass measurement among older americans, 1999-2005

Bone mass measurement (BMM) is useful to identify persons with low bone mass who are at increased risk for fracture. Given the increased emphasis that is being placed on preventive services such as screening for osteoporosis, we evaluated trends in BMM among Medicare beneficiaries. We studied a 5% sample of Medicare beneficiaries >or=65 yr of age in 1999-2005. We identified claims for BMM tests performed in both facility and nonfacility settings, evaluated temporal trends in use of these tests, and described the proportion of tests attributable to each specialty of physicians submitting claims. We also assessed patterns of serial testing among individuals who were tested more than once. Claims data from all years were pooled to describe the proportion of persons in the population ever tested. From 1999 to 2005, use of central DXA increased by approximately 50%, and use of peripheral DXA declined. The greatest increases in central DXA occurred among internists, family practitioners, and gynecologists. In 1999, the proportion of 65-yr-old women tested was 8.4%; this increased to 12.9% in 2005. Corresponding proportions for men were 0.6% and 1.7%, respectively. Between 40% and 73% of persons receiving central DXA were retested, most at approximately 2-yr intervals. Aggregating data across all years for whites and blacks, 30.0% of women and 4.4% of men underwent central DXA at least once. We conclude that, although use of DXA steadily increased from 1999 to 2005, only approximately 30% of women and 4% of men at least 65 yr old had a central DXA study. Given the importance of central DXA to assess the risk of osteoporotic fractures, strategies to increase central DXA use to test at-risk persons are warranted.

Minimal error in self-report of having had DXA, but self-report of its results was poor

OBJECTIVE

To examine the validity of both self-report of having had dual-energy x-ray absorptiometry (DXA) and self-reported DXA test results.

METHODS

Participants were recruited in 2003 and 2004 from a population-based study of women aged 65-90 years examining osteoporosis management in Ontario, Canada (N=871). Women reporting having had a DXA were eligible and asked to report the results of their most recent test. Participant responses were compared against DXA reports obtained from physicians.

RESULTS

We obtained 413 (81%) physician records among the 510 women who reported having had a DXA test. Of these, the positive predictive value for self-report of having had a DXA was 93%. The weighted kappa statistic for the agreement between self-report and actual DXA results was 0.42 (95% confidence interval=0.34-0.49). Although 84% of those with normal bone reported this, only 29% of those with osteopenia and 62% with osteoporosis reported their results correctly. Self-report of a clinical diagnosis of osteoporosis was better among those with a low trauma fracture, yet underestimated osteoporosis prevalence by 24%.

CONCLUSION

There is minimal measurement error in self-report of having had a DXA test. Self-report of DXA results will underestimate osteoporosis prevalence and is not a good proxy for clinical diagnosis.

Predictors of locating women six to eight years after contact: internet resources at recruitment may help to improve response rates in longitudinal research

BACKGROUND

The ability to locate those sampled has important implications for response rates and thus the success of survey research. The purpose of this study was to examine predictors of locating women requiring tracing using publicly available methods (primarily Internet searches), and to determine the additional benefit of vital statistics linkages.

METHODS

Random samples of women aged 65-89 years residing in two regions of Ontario, Canada were selected from a list of those who completed a questionnaire between 1995 and 1997 (n = 1,500). A random sample of 507 of these women had been searched on the Internet as part of a feasibility pilot in 2001. All 1,500 women sampled were mailed a newsletter and information letter prior to recruitment by telephone in 2003 and 2004. Those with returned mail or incorrect telephone number(s) required tracing. Predictors of locating women were examined using logistic regression.

RESULTS

Tracing was required for 372 (25%) of the women sampled, and of these, 181 (49%) were located. Predictors of locating women were: younger age, residing in less densely populated areas, having had a web-search completed in 2001, and listed name identified on the Internet prior to recruitment in 2003. Although vital statistics linkages to death records subsequently identified 41 subjects, these data were incomplete.

CONCLUSION

Prospective studies may benefit from using Internet resources at recruitment to determine the listed names for telephone numbers thereby facilitating follow-up tracing and improving response rates. Although vital statistics linkages may help to identify deceased individuals, these may be best suited for post hoc response rate adjustment.