Management of osteoporosis in primary care in Australia

Integrated model of secondary fracture prevention in primary care (INTERCEPT): protocol for a cluster randomised controlled multicentre trial

BACKGROUND

Osteoporotic fractures signal severely compromised bone strength and are associated with a greatly increased risk of refracture. Despite the availability of effective and safe medications that reduce fracture risk, 70-80% of patients are inadequately investigated or treated for osteoporosis following an initial fracture, constituting a significant 'osteoporosis care gap'. Optimal methods of bridging this gap with primary care at the forefront of secondary fracture prevention remain undetermined. This protocol describes a cluster randomised controlled trial to evaluate the effectiveness of a novel integrated model of secondary fracture prevention and management in primary care.

METHODS

The cluster randomised controlled trial involves multiple branches of a community-based radiology provider (CRP), a hospital-based secondary fracture prevention program (SFPP) and numerous primary care practices in metropolitan Sydney that refer to either the CRP or SFPP. Using natural language processing tools, patients diagnosed with a potential osteoporotic fracture will be identified by automatically screening radiology reports generated at the CRP or SFPP. The primary care practices that these patients attend will be randomised (1:1) to either the intervention or usual care. The intervention consists of (i) electronic and fax alerts informing the practice/primary care physician that their patient has been diagnosed with a potential osteoporotic fracture; (ii) provision of osteoporosis management guidelines and (iii) follow-up surveys at 4 weeks and 6 months. Practices in the usual care (control) group will receive no alerts and provide usual care. The primary outcome is the proportion of patients undergoing a bone density scan and/or filling a prescription for osteo-protective pharmacotherapy within 3 months of the initial diagnostic imaging report. Secondary outcomes are the proportion of patients: (i) undergoing an osteoporosis-related blood test within 3 months of the initial diagnostic imaging report; (ii) initiated on a chronic disease management plan within 3 months of the diagnostic report, and (iii) filling a second prescription for osteo-protective pharmacotherapy within 9 months post initial diagnostic imaging report. Outcomes will be obtained through de-identified linked data from Medical Benefits Schedule and Pharmaceutical Benefits Scheme held by the Australian Institute of Health and Welfare.

DISCUSSION

This is the first randomised trial to integrate case-detection of potential osteoporotic fractures in a hospital and community setting with direct alerts to the patient's primary care provider. This study will determine whether such an intervention is effective in improving investigation and/or treatment rates of osteoporosis in patients with a potential osteoporotic fracture.

TRIAL REGISTRATION

This study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000658617p.

Secondary fracture prevention in primary care: a narrative review

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

Establishing consensus recommendations for long-term osteoporosis care for patients who have attended an Australian fracture liaison service: a Delphi study

Coordinating healthcare activities between fracture liaison services (FLS) and primary care is challenging. Using a Delphi technique, we developed 34 consensus statements to support improved care coordination across this healthcare transition.

PURPOSE

Evidence supporting an optimal coordination strategy between fracture liaison services (FLS) and primary care is lacking. This study aimed to develop consensus statements to support consistency and benchmarking of clinical practice to improve coordination of care for patients transitioning from FLS to primary care following an osteoporotic fracture.

METHODS

A Delphi technique was used to develop consensus among a panel of experts, including FLS clinicians (medical and non-medical), general practitioners (GPs), and consumers.

RESULTS

Results of a preparatory questionnaire (n = 33) informed the development of 34 statements for review by expert panellists over two Delphi rounds (n = 25 and n = 19, respectively). The majority of participants were from New South Wales (82%), employed as FLS clinicians (78.8%) and working in metropolitan centres (60.6%). Consensus was achieved for 24/34 statements in round one and 8/10 statements in round two. All statements concerning patient education, communication, and the GP-patient relationship achieved consensus. Expert opinions diverged in some areas of clinician roles and responsibilities and long-term monitoring and management recommendations.

CONCLUSION

We found clear consensus among experts in many key areas of FLS integration with primary care. While experts agreed that primary care is the most appropriate setting for long-term osteoporosis care, overall confidence in primary care systems to achieve this was low. The role of (and responsibility for) adherence monitoring in a resource-limited setting remains to be defined.

Approach to the Patient With Bone Fracture: Making the First Fracture the Last

The global burden of osteoporosis and osteoporotic fractures will increase significantly as we enter a rapidly aging population. Osteoporotic fractures lead to increased morbidity, mortality, and risk of subsequent fractures if left untreated. However, studies have shown that the majority of patients who suffer an osteoporotic fracture are not investigated or treated for osteoporosis, leading to an inexcusable "osteoporosis care gap." Systematic and coordinated models of care in secondary fracture prevention known as fracture liaison services (FLS) have been established to streamline and improve the care of patients with osteoporotic fractures, and employ core principles of identification, investigation, and initiation of treatment. Our approach to the multifaceted care of secondary fracture prevention at a hospital-based FLS is illustrated through several case vignettes.

Integrating post-fracture care into the primary care setting (interFRACT): Protocol for a mixed-methods study to co-design a care program to improve rates of osteoporosis and fracture treatment

INTRODUCTION

Despite evidence showing that timely diagnosis and appropriate pharmacological treatment of osteoporosis reduces subsequent fracture rates, osteoporosis remains significantly underdiagnosed and undertreated. The large and ongoing treatment gap for osteoporosis and associated fragility fractures could be addressed by considering systematic approaches for post-fracture care in the primary care setting. This study will develop the Integrating Post-Fracture Care into Primary Care (interFRACT) care program that aims to enhance diagnosis and treatment of osteoporosis and improve initiation and adherence to fracture prevention strategies for older adults in the primary care setting.

METHODS AND ANALYSIS

This mixed-methods study will follow an established co-design approach that involves six steps; the first three aim to gain an understanding of the consumer experience and needs, while the latter three focus on how to improve that experience through design and action. This will include: development of a Stakeholder Advisory Committee to provide guidance on all aspects of study design, including implementation, evaluation and dissemination; interviews with primary care physicians to explore beliefs and attitudes towards osteoporosis and fracture treatment; interviews with consumers (older adults with a diagnosis of osteoporosis and/or fragility fracture) to identify current needs for osteoporosis treatment and fracture prevention; a series of co-design workshops to develop the components of the interFRACT care program based on published guidance and findings from interviews; and a feasibility study with primary care physicians to determine the usability and acceptability of the interFRACT care program.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Deakin University Human Research Ethics Committee (approval number: HEAG-H 56_2022). Study results will be published in peer-reviewed journals, presented at national and international conferences, and collated in reports for participating primary care practices.

An 11-year longitudinal analysis of refracture rates and public hospital service utilisation in Australia's most populous state

This detailed 11-year longitudinal analysis calculated the public health cost of managing refractures in people aged ≥ 50 years in Australia's most populous state. It provides current and projected statewide health system costs associated with managing osteoporosis and provides a foundation to evaluate a novel statewide model of fracture prevention.

PURPOSE

The purpose of this longitudinal analysis was to calculate current and projected refracture rates and associated public hospital utilisation and costs in New South Wales (NSW), Australia. These results will be used to inform scaled implementation and evaluation of a statewide Osteoporotic Refracture Prevention (ORP) model of care.

METHODS

Linked administrative data (inpatient admissions, outpatient attendances, Emergency Department presentations, deaths, cost) were used to calculate annual refracture rates and refracture-related service utilisation between 2007 and 2018 and healthcare costs between 2008 and 2019. Projections for the next decade were made using 'business-as-usual' modelling.

RESULTS

Between 2007 and 2018, 388,743 people aged ≥ 50 years experienced an index fracture and 81,601 had a refracture. Refracture was more common in older people (rising from a cumulative refracture rate at 5 years of 14% in those aged 50-64 years, to 44% in those aged > 90 years), women with a major index fracture (5-year cumulative refracture rate of 26% in females, compared to 19% for males) or minimal trauma index fracture and those with an osteoporosis diagnosis (5-year cumulative refracture rate of 36% and 22%, respectively in those with and without an osteoporosis diagnosis). Refractures increased from 8774 in 2008 to 14,323 in 2018. The annual cost of refracture to NSW Health increased from AU$130 million in 2009 to AU$194 million in 2019. It is projected that, over the next decade, if nothing changes, 292,537 refracture-related hospital admissions and Emergency Department presentations and 570,000 outpatient attendances will occur, at an estimated total cost to NSW Health of AU$2.4 billion.

CONCLUSION

This analysis provides a detailed picture of refractures and associated projected service utilisation and costs over the next decade in Australia's most populous state. Understanding the burden of refracture provides a foundation for evaluation of a novel statewide ORP model of care to prevent refractures in people aged ≥ 50 years.

Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture.

PURPOSE

To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance).

METHODS

Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital.

RESULTS

Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance).

CONCLUSIONS

An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

Osteoporosis and premature ovarian insufficiency: geographic variation in clinicians' and consumers' knowledge gaps and barriers to care

PURPOSE

To determine whether geographic variation exists in osteoporosis knowledge, management, and barriers to care in the setting of premature ovarian insufficiency (POI), among general practitioners (GPs) and women with POI.

METHODS

Australian GPs completed an online questionnaire regarding osteoporosis knowledge, barriers to care and educational preferences for managing osteoporosis in POI. Women with POI/early menopause (EM) completed an online questionnaire regarding osteoporosis knowledge, risk factors and health beliefs. Clinicians and consumers in metropolitan areas were compared to those in rural areas.

RESULTS

Of 688 GP respondents, 62.2% practised in major capital cities, 13.1% in major regional cities, 7.8% in regional centres, 8.7% in rural areas and 8.1% in remote areas. Mean ± SD osteoporosis knowledge score was 9.1 ± 1.5/13, with no difference by location. Forty-one percent of GPs reported barriers to care which varied by location. Of 316 women with POI/EM, 61.1% lived in metropolitan, 22.5% in regional, 11.7% in rural and 4.4% in remote locations. The mean osteoporosis knowledge score was 8.2 ± 3.1/20, with lower scores in women living in rural and remote versus metropolitan locations (difference - 1.3; 95% CI - 2.3, - 0.25; p = 0.02). Women in rural areas were less likely to use vitamin D supplements and more likely to have a family history of osteoporosis (both p < 0.05).

CONCLUSIONS

GP knowledge gaps and specific, location-dependent care barriers for osteoporosis in POI were identified. Geographic differences in osteoporosis knowledge and risk factors exist in women with POI/EM. These factors require consideration when designing programs to improve bone health in POI.

Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice

Background

Among Australians aged 50 and over, an estimated 1 in 4 men and 2 in 5 women will experience a minimal trauma fracture during their remaining lifetime. Effective fracture prevention is hindered by substantial undertreatment, even of patients who clearly warrant pharmacological therapy. Poor adherence to osteoporosis treatment is also a leading cause of repeat fractures and hospitalisation. The aim of this study was to identify current osteoporosis treatment patterns and gaps in practice in Australia, using general practice data, and to explore general practitioners’ (GPs’) attitudes to osteoporosis treatment and their views on patient factors affecting osteoporosis management.

Methods

The study was conducted in two phases. Phase 1 was a longitudinal retrospective cohort study which utilised data from MedicineInsight – a national general practice data program that extracts longitudinal, de-identified patient data from clinical information systems (CISs) of participating general practices. Phase 2 included semi-structured, in-depth telephone interviews with a sample of MedicineInsight practice GPs. Data were analysed using an inductive thematic analysis method informed by the theory of planned behaviour.

Results

A diagnosis of osteoporosis was recorded in 12.4% of patients over the age of 50 years seen in general practice. Of those diagnosed with osteoporosis, almost a quarter were not prescribed osteoporosis medicines. From 2012 to 17, there was a progressive increase in the number of denosumab prescriptions, while prescriptions for bisphosphonates and other osteoporosis medicines decreased. More than 80% of patients who ceased denosumab treatment had no subsequent bisphosphonate prescription recorded. Interviews with GPs revealed beliefs and attitudes that may have influenced their intentions towards prescribing and osteoporosis management.

Conclusions

This study suggests that within the Australian general practice setting, osteoporosis is underdiagnosed and undertreated. In addition, it appears that most patients who ceased denosumab treatment had no record of subsequent antiresorptive therapy, which would place them at risk of further fractures. The study supports the need for the development of clinical education programs addressing GP knowledge gaps and attitudes, and the implementation of specific interventions such as good reminder/recall systems to avoid delays in reviewing and treating patients with osteoporosis.

Identifying characteristics of an effective fracture liaison service: systematic literature review

Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.

Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review

The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.

Patient-specific prescriber feedback can increase the rate of osteoporosis screening and treatment: results from two national interventions

Osteoporosis interventions targeting older Australians and clinicians were conducted in 2008 and 2011 as part of a national quality improvement program underpinned by behavioural theory and stakeholder engagement. Uptake of bone mineral density (BMD) tests among targeted men and women increased after both interventions and sustained increases in osteoporosis treatment were observed among men targeted in 2008.

PURPOSE

Educational interventions incorporating patient-specific prescriber feedback have improved osteoporosis screening and treatment among at-risk patients in clinical trials but have not been evaluated nationally. This study assessed uptake of BMD testing and osteoporosis medicines following two national Australian quality improvement initiatives targeting women (70-79 years) and men (75-85 years) at risk of osteoporosis.

METHODS

Administrative health claims data were used to determine monthly rates of BMD testing and initiation of osteoporosis medicines in the 9-months post-intervention among targeted men and women compared to older cohorts of men and women. Log binomial regression models were used to assess differences between groups.

RESULTS

In 2008 91,794 patients were targeted and 52,427 were targeted in 2011. There was a twofold increase in BMD testing after each intervention among targeted patients compared to controls (p < 0.001). Initiation of osteoporosis medicines increased by 21% among men targeted in 2008 and 34% among men targeted in 2011 compared to older controls (p < 0.01). Initiation of osteoporosis medicines among targeted women was similar to the older controls.

CONCLUSION

Programs underpinned by behavioural theory and stakeholder engagement that target both primary care clinicians and patients can improve osteoporosis screening and management at the national level.

Barriers to secondary fracture prevention in primary care

This study of current osteoporosis management patterns in general practice found that the majority of patients presenting to their local health practitioner with a recent low-trauma fracture was not managed appropriately. The analysis demonstrated that failure to investigate was highly predictive of failure to treat and that one of the major barriers to effective osteoporosis management is a lack of specific knowledge about who to investigate and treat.

INTRODUCTION

Osteoporotic fractures are associated with significant morbidity and mortality. The current study aimed (i) to determine the number of patients with osteoporotic fractures who were not investigated or treated for osteoporosis by their primary care physician and (ii) to identify factors that contribute to the ongoing gap in osteoporosis care.

METHODS

We conducted an observational retrospective study (2012-2014) using explicit medical record review at three major general practices in metropolitan Sydney. Patients aged 55 years or older who had a documented minimal trauma fracture (MTF) were identified. Data collected included demographics, prior fractures, testing for vitamin D/bone mineral density and initiation of osteoporosis pharmacotherapy. The main outcome measures included the number of patients who did not undergo the following: (i) a bone density scan, (ii) vitamin D measurement and/or (iii) initiation of osteoporosis pharmacotherapy.

RESULTS

Of the 87 patients (69% female; mean age 71.7 years) with prevalent MTF, 55 (63%) were not referred for a bone density scan. Vitamin D levels were not measured in 36 patients (41%) and 55 patients (63%) did not receive specific osteoporosis pharmacotherapy. Failure to investigate was highly predictive of failure to treat (p < 0.001). The presence of major osteoporotic risk factors did not affect the likelihood of investigation or treatment, indicating that a major barrier to effective osteoporosis management was a lack of knowledge.

CONCLUSION

Management of patients with MTF's in primary care is poor. Systems aimed at improving the identification and treatment of patients with osteoporotic fractures in this setting is required in order to close the osteoporosis care gap.

A fracture prevention service reduces further fractures two years after incident minimal trauma fracture

AIM

To evaluate the impact of a fracture prevention clinic service on initiation of treatment, continuing treatment and subsequent minimal trauma fractures (MTF).

METHOD

Participants were people aged 50 and over, with a minimal trauma fracture presenting to the Emergency Department (ED) in a large tertiary referral hospital in New South Wales, Australia, between February 2007 and March 2009. A cohort of patients who attended a Fracture Prevention Clinic (clinic group) were compared with a cohort who did not attend the clinic (non-clinic group). A telephone questionnaire was conducted with participants or their carers between December 2010 and April 2011 at least 12 months post-fracture presentation. Questionnaire items included demographics, fracture types, osteoporosis treatment, recurrent fractures and smoking and dietary habits. Data were compared using chi-squared test for categorical variables and Student's t-test or Mann-Whitney U-test for continuous variables.

RESULTS

Two hundred and fourteen clinic attendees and 220 non-clinic attendees were surveyed between 12 and 40 months (mean 24 months) post-initial fracture. New fracture rates were lower in the clinic group (5.1%) than the non-clinic group (16.4%, P < 0.001). Treatment rates for bone fragility were higher in the clinic group (81.3%) than in the non-clinic group (54.1%, P < 0.001) with 66.8% of the clinic group and 34.1% of the non-clinic group on a bisphosphonate or strontium ranelate at the time of the survey (P < 0.001).

CONCLUSION

Patients managed by a fracture prevention clinic service following a MTF have fewer new fractures and are more likely to be on treatment for bone fragility.

Assessing osteoporosis risk factors in Spanish menopausal women

OBJECTIVES

(1) To assess the prevalence of osteoporosis risk factors in Spanish menopausal women; (2) to detect medical and lifestyle risk factor differences between perimenopausal and postmenopausal women; (3) and to identify the main factors responsible for osteoporosis.

METHODS

Cross-sectional descriptive study encompassing women aged 45-65 across Spain. The study population sample was collected through random sampling and a total of 10,514 women were included. Socio-demographic, medical history, and lifestyle data were assessed.

RESULTS

The prevalence of osteoporosis risk factors was 67.6%. The most common risk factors were physical inactivity (53.6%), use of medication related to osteoporosis risk (45.9%), and low calcium intake (30.1%). There were statistically significant differences between peri- and postmenopausal women in terms of smoking status, alcohol intake, personal history, poor dairy product intake, and medication use that could increase risk. Logistic regression analysis showed that osteoporosis was significantly associated with age, family history, age at onset of menopause, Kupperman Index, prolonged immobilization, weight loss, and other diseases that increase the probability of developing osteoporosis.

CONCLUSIONS

A high prevalence of women taking osteoporosis risk-related medication was observed in our study. There was correlation between the menopausal symptoms' degree of severity and the risk of suffering from osteoporosis.

Antiresorptive therapies for osteoporosis: a clinical overview

Antiresorptive therapies are used to increase bone strength in individuals with osteoporosis and include five principal classes of agents: bisphosphonates, estrogens, selective estrogen receptor modulators (SERMs), calcitonin and monoclonal antibodies such as denosumab. However, no head-to-head studies have compared different antiresorptive agents using fracture as an end point. Bisphosphonates, which have proven antifracture efficacy and a good safety profile, are the most widely used first-line antiresorptive therapy and are recommended for patients with osteoporosis, a prior fragility fracture or osteopenia, as well as individuals with a high risk of fracture. Denosumab, which also has good antifracture efficacy, is another possible first-line therapy, although long-term safety data are lacking. However, no single antiresorptive therapy is currently appropriate for all patients or clearly superior to other therapies. Antiresorptive agents such as estrogens, SERMs (in postmenopausal women) and calcitonin are considered to be second-line agents that are appropriate in special circumstances. Clinicians should determine the most appropriate pharmacological therapy after a careful assessment of the risk:benefit profiles of these drugs in each patient. In addition, patients should receive a detailed explanation of the treatment goals, so that the therapeutic benefit can be maximized through good compliance and persistence.

Regional differences in treatment for osteoporosis. The Global Longitudinal Study of Osteoporosis in Women (GLOW)

PURPOSE

To determine if important geographic differences exist in treatment rates for osteoporosis and whether this variation can be explained by regional variation in risk factors.

METHODS

The Global Longitudinal Study of Osteoporosis in Women is an observational study of women ≥55 years sampled from primary care practices in 10 countries. Self-administered questionnaires were used to collect data on patient characteristics, risk factors for fracture, previous fractures, anti-osteoporosis medication, and health status.

RESULTS

Among 58,009 women, current anti-osteoporosis medication use was lowest in Northern Europe (16%) and highest in U.S.A. and Australia (32%). Between 48% (U.S.A., Southern Europe) and 68% (Northern Europe) of women aged ≥65 years with a history of spine or hip fracture since age 45 were untreated. Among women with osteoporosis, the percentage of treated cases was lowest in Europe (45-52% versus 62-65% elsewhere). Women with osteopenia and no other risk factors were treated with anti-osteoporosis medication most frequently in U.S.A. (31%) and Canada (31%), and least frequently in Southern Europe (12%), Northern Europe (13%), and Australia (16%). After adjusting for risk factors, U.S. women were threefold as likely to be treated with anti-osteoporosis medication as Northern European women (odds ratio 2.8; 95% confidence interval 2.5-3.1) and 1.5 times as likely to be treated as Southern European women (1.5, 1.4-1.6). Up to half of women reporting previous hip or spine fracture did not receive treatment.

CONCLUSIONS

The likelihood of being treated for osteoporosis differed between regions, and cannot be explained by variation in risk factors. Many women at risk of fracture do not receive prophylaxis.

Women with cardiovascular disease have increased risk of osteoporotic fracture

This study investigated whether women with cardiovascular disease (CVD) would have an increased risk of fractures as osteoporosis and CVD share many common risk factors. From February 2006 to January 2007, 17,033 women aged ≥50 years (mean 71.8, range 50-106) were recruited by 1,248 primary care practitioners and interviewed by trained nurses. For each woman, 10-year probability of a future major osteoporotic fracture was estimated using the World Health Organization Fracture Risk Assessment Tool (FRAX). The study showed that the 10-year probability of a major osteoporotic fracture was higher for 6,219 CVD women compared to 10,814 non-CVD women after adjustment for age, BMI, current smoking, and alcohol use (adjusted geometric means 14.3 and 13.8%, respectively; P < 0.001). With regard to high risk of fracture (i.e., 10-year probability ≥ 20%), the adjusted odds ratio for CVD was 1.23 (95% CI 1.13-1.35, P < 0.001). However, compared to non-CVD women, CVD women were more likely to report a previous fracture, to have a secondary osteoporosis, and to use glucocorticoids. Among the 4,678 women who were classified as having a high fracture risk, current use rate of bone-related medications (i.e., any one of bisphosphonates, raloxifene, PTH, vitamin D, calcium, or hormone therapy) was 50.2% in the CVD group and 56.9% in the non-CVD group. Women with CVD were at increased risk of fracture partly due to bone-specific risk factors such as history of previous fracture, use of glucocorticoids, and secondary osteoporosis. This risk is not being treated appropriately by primary health physicians.