Patient barriers to osteoporosis interventions after fracture

Treatment for older men with fractures

Less than 10% of men receive osteoporosis treatment, even after a fracture. A study of 17,683 men revealed that older men, those with spinal fractures, and those taking steroids or antidepressants are more likely to receive treatment after a fracture. Seeing a primary care physician also increases osteoporosis treatment rates.

INTRODUCTION

In 2000, the FDA approved bisphosphonates for the treatment of osteoporosis in men. The purpose of this study is to estimate the frequency of bisphosphonate therapy within 12 months following a fracture and describe patient/physician factors associated with treatment.

METHODS

Health insurance claims for 17,683 men ≥ 65 years of age, who had a claim for an incident fracture from 2000 to 2005, were followed for at least 6 months post-fracture for the initiation of treatment with a bisphosphonate. Patient characteristics, diagnostic procedures, therapies, co-morbidities, and provider characteristics were compared for men who received treatment with those who did not.

RESULTS

Eight percent of men (n = 1,434) received bisphosphonate therapy. Overall treatment increased from 7% in 2001 to 9% in 2005 (p < 0.001). Treatment for hip fractures remained at 7% (p = 0.747). Treatment increased with age: 6% in men aged 65-69 compared to 11.6% in men aged 85-89 (p < 0.001). Factors associated with treatment included: diagnosis of osteoporosis (OR = 8.8; 95% CI, 7.7, 10.4), glucocorticoid therapy (OR = 3.2; 95% CI, 2.4, 4.3), bone mineral density measurement (OR = 3.4; 95% CI, 2.9, 4.0), and antidepressant therapy with tricyclics (OR = 2.0; 95% CI, 1.2, 3.5) or selective serotonin reuptake inhibitors (OR = 1.7; 95% CI, 1.3, 2.4). Men with vertebral fractures (OR = 2.2; 95% CI, 1.8, 2.6) and men seen by primary physicians (OR = 2.6; 95% CI, 2.3, 3.1) were more likely to receive treatment.

CONCLUSIONS

Less than 10% of men received bisphosphonate therapy following a low-impact fracture. Men with a primary physician were more likely to receive bisphosphonate therapy; however, <25% of men were seen by a primary physician.

Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis

BACKGROUND CONTEXT

Osteoporosis and osteomalacia are significant risk factors for fracture and spine instrumentation failure. Low-energy fractures are becoming increasingly more common because of an increase in life expectancy and age of the population. Decreased bone density is an independent risk factor for instrumentation failure in spinal fusion operations.

PURPOSE

To assess the awareness and practice patterns of spine surgeons regarding metabolic bone disorders and osteoporosis with emphasis on fracture care and arthrodesis.

STUDY DESIGN/SETTING

Questionnaire study.

PATIENT SAMPLE

Spine surgeons attending the "Disorders of the Spine" conference (January 2007, Whistler, British Columbia, Canada).

OUTCOME MEASURES

Respondent reported frequencies of diagnostics, screening, and treatment methods for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

METHODS

A ten-question survey was administered to orthopedic surgeons and neurosurgeons who treated spine fractures and degenerative spine conditions in their practice. The survey was given to those who were attending a continuing medical education spinal disorders conference. The survey asked about treatment patterns with respect to osteoporosis and osteomalacia workup and treatment for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

RESULTS

Of the 133 surgeons to whom the questionnaire was distributed at this meeting, 114 questionnaires were returned that corresponds to a response rate of 86%. Twenty-one surveys were excluded because of incomplete biographical information, resulting in a total of 93 completed questionnaires that were available for analysis. When treating patients with low-energy spine fractures, 60% checked dual-energy X-ray absorptiometry (DEXA) and 39% checked metabolic laboratories (of those who did not order laboratories and DEXA about 63% refer for treatment). Before instrumented fusion, 44% of those queried checked DEXA and 12% checked metabolic laboratories (vitamin D, parathyroid hormone [PTH], and calcium [Ca]). Before noninstrumented fusion, 22% checked DEXA and 11% checked metabolic laboratories. Before addressing pseudoarthrosis, 19% checked DEXA and 20% checked metabolic laboratories.

CONCLUSIONS

Despite of the large number of elderly patients undergoing spine care and the high incidence of osteoporosis and/or osteomalacia in this population, a large portion of the spine surgeons who responded to the survey reported that they do not perform routine osteoporosis/osteomalacia workups. Of those who do perform workups, some commented that it will change their surgical plan or preoperative treatment. It appears that there is a need for increased awareness among spine specialists regarding osteoporosis screening and treatment. Osteoporosis practice patterns may also be affected with newly evolving government quality reporting regulations.

Glucocorticoids and the risk of osteoporosis

BACKGROUND

Glucocorticoid-induced osteoporosis (GIO) refers to a clinical condition in which a class of corticosteroids increases the susceptibility of bones to fracture. Numerous recent studies have improved our understanding of the underlying biology of this condition, whereas data from randomized controlled trials have provided clinicians with more options for prevention of GIO.

OBJECTIVE

To review the pathophysiology and epidemiology of GIO, as well as current pharmacologic treatment and prevention modalities available. To review the state of healthcare provider concordance with GIO prevention guidelines.

METHODS

Representative examples of various cellular and molecular processes underlying GIO were included, with an emphasis towards more recent discoveries. The data used to describe the epidemiology of GIO were derived from both randomized controlled studies and observational studies, framed through a discussion of known osteoporosis risk factors.

RESULTS/CONCLUSION

Progress has been made in clarifying the pathophysiologic mechanisms that result in GIO. Although the options for preventions and treatment of GIO continue to expand, provider compliance with preventive measures remains suboptimal.

Osteoporosis management in prostate cancer patients treated with androgen deprivation therapy

BACKGROUND

The use of androgen deprivation therapy (ADT) for prostate cancer has increased substantially in recent years, exposing more men to potential treatment complications, including osteoporosis and fractures.

OBJECTIVE

To determine whether men treated with ADT for prostate cancer received osteoporosis screening, prevention, or treatment.

DESIGN

Cross-sectional observational study using a retrospective review of electronic medical records.

SUBJECTS

One hundred seventy-four patients with prostate cancer on ADT or status-post orchiectomy enrolled in primary care at the New Mexico Veterans Affairs Health Care System as of July 2005.

MEASUREMENTS

Patient demographics, tumor characteristics (Gleason score, stage, last PSA value, documented bone metastases), history of hip or vertebral fracture, osteoporosis risk factors (number of ADT shots, diabetes, smoking, heavy alcohol use or prescriptions for corticosteroids, thyroid hormone or dilantin). We defined recommended management as performing DXA scans or prescribing bisphosphonates, calcitonin, calcium or vitamin D.

RESULTS

Just 60 of 174 (34%) patients received recommended osteoporosis management based on DXA scans (13%) or treatment with oral or IV bisphosphonates (21%), calcitonin (1%), calcium (16%) or vitamin D (10%). On multivariate analysis, bone metastases, higher last PSA, and younger age at diagnosis were associated with recommended management, whereas Hispanic race/ethnicity was inversely associated.

CONCLUSIONS

Most men treated with ADT for prostate cancer did not receive osteoporosis screening, prevention or treatment. Evidence for advanced cancer though not risk factors for osteoporosis or fracture-was associated with receiving osteoporosis management. Further research is needed to identify optimal strategies for screening, prevention, and treatment in this population.

Osteoporosis management in a Medicaid population after the Women's Health Initiative study

OBJECTIVE

Publication of the Women's Health Initiative (WHI) study has changed our understanding on the effects of hormone replacement therapy. This study was designed to evaluate patterns of antiosteoporosis medication (AOM) use in a Medicaid population before and after the release of the WHI study results.

METHODS

A descriptive time series analysis was conducted among women 50 years of age and older who were enrolled in the Pennsylvania Medicaid program from December 1, 2001, through December 31, 2002. All AOMs were identified, including estrogens, bisphosphonates, selective estrogen receptor modulators (SERMs), and calcitonin. The monthly prevalence of each AOM and drug class was estimated. Comparisons between pre-WHI (December 1, 2001-July 30, 2002) and post-WHI (August 1, 2002-December 31, 2002) study periods were made for overall AOM use by AOM drug class as well as by recipient characteristics.

RESULTS

The overall prevalence of AOM did not change between pre-WHI and post-WHI study publication. However, there were significant changes in the prevalence of certain AOM drug classes. Estrogen use decreased significantly after the WHI study release for all age and racial groups. The prevalence for bisphosphonates and SERM increased significantly in the post-WHI period.

CONCLUSIONS

The WHI study influenced patterns of use of all types of AOM, decreasing estrogen and increasing nonestrogen use among postmenopausal women in a Medicaid program. These results suggest that the WHI study affected patterns of use of bone protective pharmacotherapy, with a shift in bone protection therapy use from estrogen to nonestrogen AOMs.

A prospective clinical practice intervention to improve osteoporosis management following distal forearm fracture

Secondary prevention of osteoporosis after fracture is underutilized, despite cost-effective therapies. This clinical practice intervention aimed to improve osteoporosis care of the postfracture patient. Residents of Olmsted County, Minnesota, USA, > or = age 45 who sustained a moderate trauma distal forearm fracture were identified, and participants received educational materials, referral for bone densitometry and physician consultation to address osteoporosis in January 1999 through October 2000. Osteoporosis educational materials were provided to patients at the time of recruitment, and primary care physicians provided osteoporosis practice guidelines. Outcomes included: completion of bone densitometry, acceptance of interventions at the first postfracture primary care physician visit, and adherence to advice at 6 months. There were 105 patients identified (80% women), but only 58 agreed to participate (88% women). Women with lower T-scores (< -1.5) had an 89% initial treatment rate, and 67% were adherent to treatment at 6 months. All women with normal bone density (T-score above -1.5) were advised by their primary care physicians about antiresorptive treatment, and 100% adhered to these recommendations, even though they were not eligible for such treatment based on the National Osteoporosis Foundation (NOF) guidelines. None of the men accepted the treatments offered, despite T-scores that fell at or below the NOF treatment threshold. Bone densitometry and consultation improved osteoporosis interventions after index fracture from a 16% baseline rate in the population (1993-1997) to a 45% overall rate for the study population. In summary, while referral for bone densitometry and discussion by a physician about postfracture osteoporosis preventive treatments did increase treatment rate, the majority of patients at highest risk did not accept interventions. Further initiatives are needed to overcome both system and patient barriers.