Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial

The effect of osteoporosis education on osteoporosis knowledge level and daily life in Parkinson's disease patients: A 12-week, randomized-controlled trial

Objectives

This study aims to evaluate the effect of osteoporosis education on osteoporosis knowledge level (OKL) and behavioral changes in daily life in patients with Parkinson's disease (PD).

Patients and methods

Between May 2019 and December 2019, a total of 54 patients (34 males, 20 females; median age: 68.5 years; range, 50 to 87 years) were included in the study. We randomly assigned in a 1:1 ratio, patients with PD to receive either only the brochure or in addition to this a verbal osteoporosis education. The patients were randomized into the control (n=27) and intervention groups (n=27). Seven of the patients (two in the control group and five in the intervention group) were lost to follow-up. The patients were assessed at baseline and Week 12. The primary outcomes were Physical Activity Scale for the Elderly (PASE) score (0-400) and daily calcium intake (DCI). The secondary outcomes were revised 2011 osteoporosis knowledge test (rOKT) score (0-32), frequency of falls, smoking and alcohol use at Week 12.

Results

The median total PASE score was 81 (range, 0 to 205) for the intervention group, compared to 61 (range, 0 to 242) for control group at Week 12. There was no statistically significant difference between the groups at Week 12, except for the medians of the frequency of falls that was significantly lower in the intervention group (p<0.05). A significant improvement from baseline was observed in the median rOKT scores (control group 16 (range, 6 to 21) to 19 (range, 11 to 25); intervention group 13 (range, 6 to 24) to 18 (range, 9 to 24); p<0.001) and DCI (control group 855 (range, 420 to 1,640) to 890 (range, 550 to 1,660); intervention group, 870 (range, 400 to 1,385) to 1,020 (range, 400 to 1,940) mg/day; p<0.01) in both groups. Also, a significant improvement in the leisure activities (PASE subgroup) was observed in the intervention group (p<0.05).

Conclusion

Osteoporosis education had some positive effects in patients with PD, even when only given the brochure. With additional verbal education, more benefits can be obtained.

The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years

Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline.

PURPOSE

After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines.

METHODS

PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance.

RESULTS

Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures.

CONCLUSIONS

Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.

Biomechanical structure-function relations for human trabecular bone - comparison of calcaneus, femoral neck, greater trochanter, proximal tibia, and vertebra

MicroCT-based finite element models were used to compute power law relations for uniaxial compressive yield stress versus bone volume fraction for 78 cores of human trabecular bone from five anatomic sites. The leading coefficient of the power law for calcaneus differed from those for most of the other sites (p < 0.05). However, after normalizing by site-specific mean values, neither the leading coefficient (p > 0.5) nor exponent (p > 0.5) differed among sites, suggesting that a given percentage deviation from mean bone volume fraction has the same mechanical consequence for all sites investigated. These findings help explain the success of calcaneal x-ray and ultrasound measurements for predicting hip fracture risk.

Pharmacist interventions in osteoporosis management: a systematic review

Internationally, there is an osteoporosis treatment gap, which pharmacists may assist in closing. This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness. Pharmacist interventions are shown to improve osteoporosis management in terms of increasing investigation and treatment commencement and osteoporosis therapy adherence.

INTRODUCTION

This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness.

METHODS

A literature search using PubMed, Embase, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was undertaken from database inception to June 2022. Randomised controlled trials were eligible, if they included adults diagnosed with or at risk of osteoporosis and assessed pharmacist interventions to improve osteoporosis management. Outcomes regarding investigation, treatment, adherence and patient knowledge were evaluated using qualitative analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration tool to assess the risk of bias (Rob 2.0).

RESULTS

Sixteen articles (12 different studies) with a total of 16,307 participants, published between 2005 and 2018 were included. Pharmacist interventions were classified into two categories, those targeting investigation and treatment (n = 10) and those targeting adherence (n = 2). The impact of the intervention on patient knowledge was considered by studies targeting both investigation and treatment (n = 2) and adherence (n = 1). Pharmacist interventions demonstrated benefit for all outcomes; however, the extent to which conclusions can be drawn on their effectiveness is limited by the heterogeneity of interventions employed and methodological issues identified. Patient education and counselling were identified as a cornerstone of pharmacist interventions targeting both investigation and treatment and adherence, along with the importance of pharmacist and physician collaboration.

CONCLUSION

Pharmacist interventions show promise for improving osteoporosis management. The potential for pharmacists to contribute to closing the osteoporosis treatment gap through undertaking population screening has been identified.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.

Interventions Preventing Osteoporosis in Primary Care: A Systematic Review

Objective: The aim of this study was to conduct a systematic review to find interventions in primary health care that would increase osteoporosis prevention behaviors. Methods: Systematic searches of CINAHL, Eric, Medline complete, PsycInfo, Ovid, Web of Science, Cochrane Library (N=1270). A total of 17 published articles met our inclusion criteria. English-language articles published between January 2000-May 2019, in primary care settings, participants with healthy or risk of osteoporosis, investigated osteoporosis preventing behaviors. The data extracted included population characteristics, diagnosis, mean age and setting, intervention and control groups, and outcomes of significance to the review question and specific objectives. In this review, a meta-analysis could not be performed due to the heterogeneity of the data. Results: The majority of studies have been found to use multiple strategies to prevent osteoporosis. Eight studies focused only on the female gender and seven studies focused only on older adults. Compared to the control groups, it was found that the participants’ osteoporosis knowledge increased significantly (p

Implementing and Evaluating the Impact of BoneRx: A Healthy Bone Prescription for Men with Prostate Cancer Initiating Androgen Deprivation Therapy

Background: The initiation of Androgen Deprivation Therapy (ADT) results in rapid and profound hypogonadism, resulting in significant bone and muscle loss, increasing the risk for osteoporosis (OP), falls, and fractures. Despite this, there exist very low rates of guideline adherent care regarding bone health in this population. We developed and implemented a healthy bone prescription tool entitled BoneRx to facilitate the uptake of guideline-concordant bone health care into practice and increase patient awareness and promote the uptake of health bone behaviours (HBBs). Methods: We conducted a cross-sectional pre-BoneRx implementation (n = 143) vs. post-implementation (n = 149) cohort study to evaluate the impact on (i) bone health care, patient engagement in HBB, and patient knowledge and health beliefs regarding OP. Results: There was a significant difference pre- vs. post BoneRx implementation on receipt of baseline BMD (34.7% vs. 59.5%, p < 0.0001) and bone health counselling (32.4% vs. 59.9%, p < 0.0001). More participants in the post-BoneRx implementation cohort reported taking vitamin D supplements 57% vs. 81% (p < 0.001) and calcium supplements 39% vs. 61% (p < 0.001). Physical activity levels also significantly increased (p = 0.021). No differences were detected in OP knowledge or feelings of OP susceptibility, seriousness, or health motivation. Conclusion: BoneRx is a simple, cost-effective, and acceptable strategy that could improve the care of PCa survivors receiving ADT.

Gender Disparities in Osteoporosis Screening and Management Among Older Adults

INTRODUCTION

One in two women and one in four men experience an osteoporosis-related fracture in their lifetime. Related morbidity and mortality rates are higher in men versus women. Current guidelines are inconsistent in the screening recommendations for osteoporosis in men. Examination of gender disparities in the management of osteoporosis-related fractures among Medicare enrollees is currently lacking.

METHODS

In this retrospective cohort study using 5% National Medicare claims data from January 1, 2012 through December 31, 2016, eligible patients who were at least 65 years of age on the date of a new fracture episode were classified into two mutually exclusive cohorts on the basis of whether they received testing and/or treatment for osteoporosis in the 6-month period after the new fracture episode. The cohorts were defined on the basis of the National Committee for Quality Assurance (NCQA) quality measure "osteoporosis management in women who had a fracture." Patients were followed to identify the occurrence of subsequent fracture, all-cause mortality, and a composite outcome-defined as the first occurrence of either subsequent fracture or mortality. Logistic regression models were carried out to identify predictors of testing and/or treatment and time-varying survival analysis to identify the relationship between the presence of testing and/or treatment and patient outcomes.

RESULTS

Of the 35,774 eligible patients, only 10.2% (12.1% women and 5.7% men) received osteoporosis testing and/or treatment within 6 months after a fracture. The interaction between gender and fragility fracture was significant (P < 0.0001). Fragility fracture had greater adjusted odds of testing and/or treatment among men (adjusted odds ratio [AOR] 3.47; 95% CI 2.94-4.10) than women (AOR 1.65; 95% CI 1.53-1.79). Of patients who were eligible for the outcome assessment, 27.5% experienced a subsequent fracture, 23.2% died, and 44.3% experienced a composite outcome during follow-up. Patients who received testing and/or treatment had a significantly lower hazard of all-cause mortality (hazard ratio [HR] 0.57; 95% CI 0.50-0.65; P < 0.0001) and the composite outcome (HR 0.42; 95% CI 0.39-0.45; P < 0.0001), but no difference in the risk of subsequent fracture (HR 1.02; 95% CI 0.94-1.11; P = 0.6083). Men were found to have a significantly lower hazard of subsequent fracture (HR 0.69; 95% CI 0.64-0.73; P < 0.0001), all-cause mortality (HR 0.67; 95% CI 0.61-0.72; P < 0.0001), and the composite outcome (HR 0.69; 95% CI 0.65-0.73; P < 0.0001).

CONCLUSION

Testing and/or treatment for osteoporosis among older adults with a fracture is poor in the Medicare fee-for-service population overall and worse for men compared to women. Receiving appropriate testing and/or treatment was associated with reduced mortality and the risk of composite outcome. Improving osteoporosis testing and/or treatment and reducing health disparities are essential for managing the clinical and economic burden of osteoporosis in the USA.

Awareness of osteoporosis risk assessment tools and screening recommendations among community pharmacists in Malaysia

Background The incidence of osteoporosis in Malaysia is increasing due to a fast-ageing population. Because of its silent nature, various osteoporosis risk assessment tools exist to detect high-risk patients and facilitate referrals for bone mineral density measurements. As an accessible point of contact, community pharmacists would benefit from the utilization of these tools and familiarity with guideline recommendations for osteoporosis screening. Aim This study aimed to investigate the awareness of osteoporosis risk assessment tools, practice behaviour towards osteoporosis, and knowledge of guideline recommendations among community pharmacists in the Klang Valley, Malaysia. Setting Community pharmacies. Methods This study was a cross-sectional study which sampled 284 community pharmacists practicing in the Klang Valley, using a stratified sampling approach. The study was conducted using a self-administered questionnaire which was divided into three sections: demographic data, knowledge of osteoporosis risk assessment tools and guideline recommendations, and practice behaviour towards osteoporosis. Practice behaviour was assessed with 15 items using a 5-point Likert scale. Main outcome measure. Proportion of respondents aware of osteoporosis risk assessment tools and respondent knowledge on guideline recommendations for osteoporosis screening. Results A total of 284 community pharmacists participated in the study. 84.1% of the respondents were aware of at least one risk assessment tool. However, only a small proportion of pharmacists (14.9%) regularly used these tools in their practice. Respondents perceived these tools to be relevant and beneficial, but perception towards their accessibility, ease-of-use, and administration time was mixed, suggesting unfamiliarity. Respondents preferred to conduct clinical assessments based on risk factors, with respondents identifying a mean of 10.1 ± 3.4 out of 15 risk factors. However, several clinically relevant risk factors were frequently unidentified. Knowledge of guideline recommendations among respondents was low. Conclusion There is some awareness of osteoporosis risk assessment tools but use in practice remains low among community pharmacists in Malaysia. There is potential to increase the use of these tools and knowledge of recommendations for osteoporosis screening and referral among community pharmacists.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background

The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

Methods

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.

Results

At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Conclusions

The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Education intervention for older adults with osteoporosis: a systematic review

BACKGROUND

Various education interventions were developed for preventing or managing OP, but the effects of those interventions on older adults were inconclusive.

PURPOSE

This study evaluated the effectiveness of educational interventions in preventing osteoporosis in older adults. A literature search was performed in MEDLINE (PubMed), Cochrane Library, and CBM (China BioMed Database) from the initial date of each database to Oct 2016.

DATA EXTRACTION

Two investigators independently extracted essential data from qualified studies concerning the settings, population, interventions, follow-ups, and outcomes of interest, namely effects of bone mineral density tests, changes in behavior, knowledge increase, self-efficacy, medication adherence (calcium and vitamin D), and quality of life, respectively.

DATA SYNTHESIS

A total of 17 studies met the inclusion criteria and therefore were included in the current study. The overall quality of the included studies was moderate. We were unable to carry out a meta-analysis due to the heterogeneity of these studies. We fond that compared with control groups, patients' knowledge of osteoporosis increased significantly (p < .05) through all five interventions, which included PowerPoint presentations and discussion, class-based educational programs, osteoporosis self-management courses, revised health belief model and classes, computerized support programs and brush-up courses.

LIMITATION

Studies included in the present study were all conducted in Western countries and only descriptive methods were applied in synthesis due to heterogeneity in interventions and outcomes.

CONCLUSION

Education interventions were effective in preventing osteoporosis in older adults. Future research should focus on approaching this issue quantitatively (i.e., through meta-analysis).

Feasibility of an interprofessional collaborative osteoporosis screening programme in Malaysia

Background Population screening for osteoporosis using bone mineral density scan is not feasible in Malaysia as this test is costly. Hence, there is a need to develop a more efficient method to screen for osteoporosis.Objectives To determine the feasibility of an interprofessional collaborative osteoporosis screening programme (IPC-OSP). Methods Postmenopausal women aged ≥ 50 years, who had not been diagnosed with osteoporosis were recruited from a primary care clinic from June to August 2014. Patients were assessed for their osteoporosis risk and were counselled on prevention methods. Patients at risk were referred to the doctor with a recommendation for a bone mineral density (BMD) scan. Results Fifty out of 55 patients were recruited (response rate = 90.9%). A total 26/50 (52.0%) went for a bone mineral density scan, none were osteoporotic, 17/50 (34%) were osteopenic, 2/50 (4.0%), were started on osteoporosis medications and 14/50 (28%) modified their lifestyle to improve bone health or started on calcium supplements. Osteoporosis knowledge significantly increased from baseline to month two (46.3 ± 21.4 vs. 79.1 ± 14.3, p < 0.001). Patients had a satisfaction score of 89.8 ± 12.4. Follow-up rates were 83.9% and 100% at months 1 (BMD appointment) and 2 (phone follow up), respectively. The intervention was successfully coordinated. Data entry was determined to be viable based on the researchers' experience. Conclusion The interprofessional collaborative osteoporosis screening programme was found to be feasible in Malaysia.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Establishment of Fracture Liaison Service in Korea: Where Is It Stand and Where Is It Going?

The elderly population growth rate is extremely high in Korean society, and life expectancy is close to 85 years old for women and 80 for men as of people born in 2015. The future hip fracture prediction model of Korea shows that the elderly hip fracture rate will increase by 1.4 times by 2025, which will impose a serious socioeconomic burden on Korean society and become a key issue of public health management. The fracture liaison service (FLS) is defined adequate treatment and services for patients over 50 years old with fragility fractures, enabling systematic identification and decreasing the risk of subsequent osteoporotic fractures. In Korean society, the introduction of FLS, which is verified not only in the socioeconomic aspects but also in the treatment of patients, is thought to be essential. However, the challenges that need to be addressed in order to implement FLS include the lack of awareness regarding the necessity of this system, the lack of healthcare systems, and inadequate policies. In the future, further studies on the FLS and its clinical and socioeconomic effects for the Korean medical system will be necessary.

Clinical outcomes of community pharmacy services: A systematic review and meta-analysis

Community pharmacy services (CPS) have been shown to be positive in many disease management and patient care programs, but clinical outcomes were followed by process indicators and methodological flaws in previous researches made it difficult to prove the effectiveness of clinical outcomes of CPS. Therefore, this study attempted to review the clinical outcomes of CPS. Interventions included are provision of medication review, patient education, adherence assessment, health/lifestyle advice, physical assessment, monitoring, prescribing, or adjusting and administering therapy from community pharmacists. By searching for key words like community pharmacists, pharmaceutical services, clinical outcomes in MEDLINE and EMBASE and manually searching (up to June 2017), 1910 studies investigating the clinical outcomes of CPS were obtained. After screening the titles, abstracts and full texts for relevancy, 52 researches with controlled groups were included and assessed for methodological quality. Finally, 25 studies were selected for the meta-analysis based on their common endpoints: systolic blood pressure, diastolic blood pressure and glycosylated haemoglobin. The Cochrane tool was used to assess the risk of bias. Chi-square and I-square tests were performed to assess heterogeneity, and the weighted mean differences were estimated using random effect models. Of the 52 articles, 47 studies demonstrated that CPS had positive clinical outcomes, 3 studies showed mixed outcomes and 2 studies revealed no effects. In the meta-analysis, intervention groups displayed greater reductions in systolic BP (95% CI: -8.198-2.356), diastolic BP (95% CI: -3.648-0.645) and HbA1c (95% CI: -0.905-0.224) than usual care groups. CPS have positive clinical outcomes, particularly significant reductions in systolic BP, diastolic BP and HbA1c. It was difficult to find out which intervention(s) of CPS directly led to certain changes and influence of CPS might be underestimated for only three common surrogate endpoints. More researches should be conducted with sufficient data.

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.

Analytical quality and effectiveness of point-of-care testing in community pharmacies: A systematic literature review

BACKGROUND

Point-of-care tests are characterised through the ability of conducting them near the patient's side without the necessity of a laboratory. They can be applied in different healthcare settings to improve patients' access to testing.

OBJECTIVE

To evaluate the effectiveness and analytical quality of point-of-care tests performed in the community pharmacy.

METHODS

Six electronic databases were systematically searched using a predefined search strategy. Interventional studies that reported on the effectiveness of the point-of-care tests and accuracy studies that investigated their analytical quality were included. The literature search, study selection, and data extraction were performed independently by two researchers.

RESULTS

In total, eleven studies were identified focusing on blood glucose, cholesterol, creatinine, uric acid, liver enzymes, international normalized ratio for anticoagulation therapy, bone mineral density for osteoporosis, forced expiratory volume for chronic obstructive pulmonary disease, and infection with human immunodeficiency virus. The included studies showed that point-of-care tests that were conducted and analysed in community pharmacies had satisfactory analytical quality and that the interventions applying these tests were effective overall.

CONCLUSIONS

Community pharmacies are well suited to deliver a wide range of point-of-care tests. In the future this will allow easier access to various screening and diagnostic tests for patients.

Australian Community Pharmacists' Experience of Implementing a Chronic Kidney Disease Risk Assessment Service

Introduction

Community pharmacists are well positioned to deliver chronic kidney disease (CKD) screening services. However, little is known about the challenges faced by pharmacists during service implementation. This study aimed to explore community pharmacists’ experiences and perceived barriers of implementing a CKD risk assessment service.

Methods

Data collection was performed by using semistructured, open-ended interview questions. Pharmacists who had implemented a CKD screening service in Tasmania, Australia, were eligible to participate. A purposeful sampling strategy was used to select pharmacists, with variation in demographics and pharmacy location. A conventional content analysis approach was used to conduct the qualitative study. Transcripts were thematically analyzed by using the NVivo 11 software program. Initially, a list of free nodes was generated and data were coded exhaustively into relevant nodes. These nodes were then regrouped to form highly conceptualized themes.

Results

Five broad themes emerged from the analysis: contextual fit within community pharmacy; perceived scope of pharmacy practice; customer perception toward disease prevention; CKD – an underestimated disease; and remuneration for a beneficial service. Pharmacists found the CKD service efficient, user-friendly, and of substantial benefit to their customers. However, several pharmacists observed that their customers lacked interest in disease prevention, and had limited understanding of CKD. More importantly, pharmacists perceived the scope of pharmacy practice to depend substantially on interprofessional collaboration between pharmacists and general practitioners, and customer acknowledgment of pharmacists’ role in disease prevention.

Conclusion

Community pharmacists perceived the CKD service to be worth incorporating into pharmacy practice. To increase uptake, future CKD services should aim to improve customer awareness about CKD before providing risk assessment. Further research investigating strategies to enhance general practitioner involvement in pharmacist-initiated disease prevention services is also needed.

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.

Impact of Pharmacist-Physician Collaboration on Osteoporosis Treatment Rates

BACKGROUND

The vast majority of women at high risk for osteoporotic fractures are not treated, despite known significant clinical and economic consequences of this prevalent condition. To date, this is the first study of this size and duration to examine the role of pharmacists in management of osteoporosis in a family medicine clinic.

OBJECTIVE

To compare the initiation or continuation of prescription antifracture therapy in high-risk patients with collaborative pharmacist-physician to physician-only management; secondarily, to evaluate recommendation rates for antifracture therapy and calcium and vitamin D.

METHODS

This retrospective cohort analysis included women older than 65 years with a dual-energy X-ray absorptiometry (DXA) scan ordered by a family medicine physician. High risk was defined as T-scores ≤-2.5 at the lumbar spine, femoral neck, or 33% radius, or a FRAX 10-year fracture risk score ≥20% for major osteoporosis-related or ≥3% for hip fractures.

RESULTS

There were 466 (311 high-risk) pharmacist-physician and 549 (237 high-risk) physician-managed DXAs included. For high-risk DXAs, collaborative management resulted in increased rates of receiving antifracture therapy prescriptions over physician-only management (66% vs 34%, P < 0.001), advisement for antifracture therapy (87% vs 32%, P < 0.001), and calcium and vitamin D (97% vs 45%, P < 0.001). Collaborative management also improved calcium and vitamin D advisement among all DXAs (96% vs 46%, P < 0.01). There was no difference in adverse events documented in the pharmacist-physician compared with physician-only management (7.2% vs 3.7%, P = 0.32). Conclusion and Relevance: Pharmacist-physician collaboration is associated with higher treatment rates of osteoporosis. This study supports the pharmacist-physician partnership as one method of improving osteoporosis management.

Exploring the current and future role of the pharmacists in osteoporosis screening and management in Malaysia

Background Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area. Objective To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management. Setting A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia. Method Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists. Results All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role. Conclusion Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.

Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis

Osteoporosis is affecting over 200 million people worldwide. Despite available guidelines, care for these patients remains sub-optimal. We developed an osteoporosis tool to address the multiple dimensions of chronic disease management. Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment, so we are revising this tool to include multiple chronic conditions including an update of evidence about osteoporosis. Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis. We searched bibliometric databases for randomized controlled trials (RCTs) in any language evaluating osteoporosis disease management interventions in adults at risk for osteoporosis. Reviewer pairs independently screened citations and full-text articles, extracted data, and assessed risk of bias. Analysis included random effects meta-analysis. Primary outcomes were osteoporosis investigations and treatment, and fragility fractures. Fifty-five RCTs and one companion report were included in the analysis representing 165,703 patients. Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications, and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations. No significant impact was found for any type of intervention to reduce fracture. Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment. Patient education appears to be an important component in osteoporosis disease management.

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.

Patient education in osteoporosis prevention: a systematic review focusing on methodological quality of randomised controlled trials

This review summarizes evidence regarding the effects of patient education in osteoporosis prevention and treatment. The included studies reveal mixed results on a variety of endpoints. Methodological improvem ent of future RCTs (e.g. with regard to randomization and duration of follow-up) might yield more conclusive evidence on the effects of patient education in osteoporosis INTRODUCTION: This review aims to evaluate the effects of patient education on osteoporosis prevention and treatment results.

METHODS

Multiple databases including PubMed and Embase were searched until February 2016. Randomised controlled trials (RCTs) were eligible if they included adults diagnosed with or at risk of osteoporosis and assessed patient education interventions (group- or individual-based). Outcomes regarding osteoporosis management including initiation of and adherence to pharmacological therapy, physical activity, calcium and vitamin D intake, changes in smoking behaviour, fractures, quality of life (QoL) and osteoporosis knowledge were evaluated. The Cochrane collaboration's tool for assessing the risk of bias was used to assess the internal validity of included trials.

RESULTS

Fifteen articles (13 different studies) published between 2001 and 2013 were included (group-based education = 7, individual-based education = 5, both = 1). The general risk of bias was considered as moderate to high. The effects on 'bone mineral density (BMD) testing and/or pharmacological therapy' (composite endpoint), 'calcium intake' and 'vitamin D intake' as well as 'osteoporosis knowledge' were statistically significant in favour of the intervention in ≥50% of the studies analysing these outcomes. Differences between the intervention and the control group regarding 'pharmacological therapy', 'medication adherence', 'physical activity', 'fractures' and 'QoL' were found to be statistically significant in <50% of the trials.

CONCLUSIONS

This review indicates that it is still unclear whether patient education is beneficial and whether it has a significant and clinically relevant impact on osteoporosis management results. Educational programmes for osteoporosis require further investigation within the context of well-conducted RCTs.

Self-Report Dietary Assessment Tools Used in Canadian Research: A Scoping Review

Choosing the most appropriate dietary assessment tool for a study can be a challenge. Through a scoping review, we characterized self-report tools used to assess diet in Canada to identify patterns in tool use and to inform strategies to strengthen nutrition research. The research databases Medline, PubMed, PsycINFO, and CINAHL were used to identify Canadian studies published from 2009 to 2014 that included a self-report assessment of dietary intake. The search elicited 2358 records that were screened to identify those that reported on self-report dietary intake among nonclinical, non-Aboriginal adult populations. A pool of 189 articles (reflecting 92 studies) was examined in-depth to assess the dietary assessment tools used. Food-frequency questionnaires (FFQs) and screeners were used in 64% of studies, whereas food records and 24-h recalls were used in 18% and 14% of studies, respectively. Three studies (3%) used a single question to assess diet, and for 3 studies the tool used was not clear. A variety of distinct FFQs and screeners, including those developed and/or adapted for use in Canada and those developed elsewhere, were used. Some tools were reported to have been evaluated previously in terms of validity or reliability, but details of psychometric testing were often lacking. Energy and fat were the most commonly studied, reported by 42% and 39% of studies, respectively. For ∼20% of studies, dietary data were used to assess dietary quality or patterns, whereas close to half assessed ≤5 dietary components. A variety of dietary assessment tools are used in Canadian research. Strategies to improve the application of current evidence on best practices in dietary assessment have the potential to support a stronger and more cohesive literature on diet and health. Such strategies could benefit from national and global collaboration.

Prevalence of Osteoporosis and Effectiveness of Screening Test Using Ultrasound Bone Densitometry and Education in a Community-Dwelling Population

This prospective intervention study was undertaken to estimate the prevalence and treatment rate of osteoporosis following osteoporosis screening tests in the same cohort. From November 1, 2014 to August 31, 2015, participants received screening tests for osteoporosis using ultrasound bone densitometry and education concerning osteoporosis and related conditions. The participants were interviewed using a questionnaire on the diagnosis and initiation of osteoporosis treatment during the follow-up period. Of 960 potential participants, 595 people (68.8%; 150 men and 445 women) were given bone densitometry measurements and completed the questionnaire. The mean age of the participants was 74.0 years. Of the 595 participants, 393 people (66.1%; 67 men and 326 woman) were diagnosed with osteoporosis (T score < -2.5). The prevalence of osteoporosis showed an increasing trend, from 48.1% in 2004 to 66.1% in 2015. Of the 393 participants diagnosed with osteoporosis, 65 participants received additional bone densitometry measurements while hospitalized and osteoporosis management was re-initiated in 44 patients. The osteoporosis management rate in the study cohort increased from 21.6% to 32.8%, with osteoporosis diagnosed in 66.2% of participants at the latest follow-up. This prospective intervention study demonstrated that a screening test and an educational brochure increased the treatment rate from 21.6% to 32.8%.

A Systematic Review of the Effect of Individualized Risk Communication Strategies on Screening Uptake and Its Psychological Predictors: The Role of Psychology Theory

People might be more likely to attend for health screening if they are told their individual risk of an illness. The way this risk of ill-health is communicated might have an effect on screening uptake or its psychological proxies. It is possible that the format, presentation, and details of the information as well as the complexity of an intervention and use of psychological theory to inform the intervention may impact the effectiveness of individual risk communication. This systematic review collates, analyses and synthesizes the evidence for effectiveness of these aspects of individual risk communication. The synthesis indicated that written, individualized risk scores or categories are effective at supporting screening uptake and its psychological proxies. Complex, or theory-based interventions, surprisingly, are no more effective than simpler or atheoretical interventions.

An analysis of inter-professional collaboration in osteoporosis screening at a primary care level using the D'Amour model

OBJECTIVES

This study describes the perspective of patients, nurses, pharmacists, doctors and policy makers to identify the level of collaboration and the areas for improvement to achieve inter-professional collaboration between doctors, nurses, pharmacists and policy makers in a primary care clinic.

METHODS

Patients (n = 20), Nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) from a primary care were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis informed by constant comparison.

RESULTS

Patients, doctors, nurses, pharmacists and policy makers were eager for pharmacists to be more proactive in creating health awareness and conducting osteoporosis screening at the primary care clinic via inter-professional collaboration. These findings were further examined using the D'Amour's structural model of collaboration which encompasses four main themes: shared goals and visions, internalization, formalization and governance. This model supports our data which highlights a lack of understanding of the pharmacists' role among the doctors, nurses, policy makers and pharmacists themselves. There is also a lack of governance and formalization, that fosters consensus, leadership, protocol and information exchange. Nonetheless, the stakeholders trust that pharmacists have sufficient knowledge to contribute to the screening of osteoporosis. Our primary care clinic can be described as developing towards an inter-professional collaboration in managing osteoporosis but is still in its early stages.

CONCLUSIONS

Inter-professional collaboration in osteoporosis management at the primary care level is beginning to be practised. Efforts extending to awareness and acceptance towards the pharmacists' role will be crucial for a successful change.

A qualitative study of community pharmacists' opinions on the provision of osteoporosis disease state management services in Malaysia

BACKGROUND

Osteoporosis has significant impact on healthcare costs and quality of life. Amongst the models for collaborative disease state management services published internationally, there is sparse evidence regarding the role of community pharmacists in the provision of osteoporosis care. Hence, the aim of our study was to explore community pharmacists' opinions (including the barriers and facilitators) and scope of osteoporosis disease state management services by community pharmacists in Malaysia, informing a vision for developing these services.

METHODS

Semi-structured individual interviews and focus groups discussions were conducted with community pharmacists from October 2013 to July 2014. Three trained researchers interviewed the participants. Interviews were recorded and transcribed verbatim. Data were analyzed thematically using an interpretative description approach.

RESULTS

Nineteen community pharmacists with 1-23 years of experience were recruited (in depth interviews: n = 9; focus group discussions: n = 10). These participants reflected on their experience with osteoporosis-related enquiries, which included medication counseling, bone density screening and referral of at-risk patients. Key barriers were the lack of numerous factors: public awareness of osteoporosis, accurate osteoporosis screening tools for community pharmacists, pharmacists' knowledge on osteoporosis disease and medications, time to counsel patients about bone health, collaboration between pharmacists and doctors, and support from the government and professional body. The pharmacists wanted more continuing education on osteoporosis, osteoporosis awareness campaigns, a simple, unbiased osteoporosis education material, and inter-professional collaboration practices with doctors, and pharmacists' reimbursement for osteoporosis care.

CONCLUSIONS

The involvement of community pharmacists in the provision of osteoporosis disease state management was minimal. Only ad-hoc counseling on osteoporosis prevention was performed by community pharmacists. Development and trial of collaborative osteoporosis disease state management services in community pharmacy could be facilitated by training, support and remuneration.

Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial

Background

Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge.

Methods

The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates.

Results

At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point.

Conclusions

A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care.

Trial registration

Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.

Osteoporosis-Related Health Behaviors in Men With Prostate Cancer and Survivors: Exploring Osteoporosis Knowledge, Health Beliefs, and Self-Efficacy

This descriptive study aimed to (a) determine the extent of osteoporosis knowledge, perceived health beliefs, and self-efficacy with bone healthy behaviors in men with prostate cancer and survivors and (b) identify how dietary bone healthy behaviors are associated with these psychobehavioral and psychosocial factors. Three different questionnaires were used to measure osteoporosis knowledge, health beliefs, and self-efficacy in a group of men with prostate cancer and survivors. Bone health was assessed via dual-energy X-ray absorptiometry and calcium intake using a diet history. The prevalence of osteoporosis and low bone mass was high at over 70%. Participants had inadequate osteoporosis knowledge with a mean score of 43.3% ( SD = 18%) on the Facts on Osteoporosis Quiz. Participants scored low on the subscale measuring barriers to exercise (median = 11; interquartile range [IQR] = 6.5), indicating minimal barriers to exercise participation, and the subscale measuring the benefits of exercise scored the highest (median = 24; IQR = 3.5) compared with the other subscales. Men with prostate cancer and survivors were highly confident in their exercise and calcium self-efficacy (83.0%, IQR = 24.0% and 85.7%, IQR = 27.0%, respectively). Participants did not meet their calcium requirements or consume enough dairy products for optimum bone health. Men with prostate cancer and survivors have poor osteoporosis knowledge, but are confident in their self-efficacy of undertaking bone healthy behaviors. This confidence did not translate to specific dietary behaviors as they did not meet their calcium or dairy intake requirements. Implications for cancer survivors is that there is a need for bone health education programs among prostate cancer survivors. These programs should go beyond education and empowerment to provide practical guidance to maximize uptake of bone healthy behaviors.

Instructing students to measure their own bone density and prepare a simulated health class during pharmacy school improves their awareness and understanding of osteoporosis prevention

Background

Osteoporosis is estimated to afflict over 200 million people worldwide and healthcare professionals are needed to successfully intervene. The aim of this study was to assess cognitive changes in students pertaining to the primary prevention of osteoporosis after measuring their bone density and having them participate in a simulated health class during pharmacy school.

Methods

Third year pharmacy students participated in the training program, which consisted of measuring their bone density using quantitative ultrasound and preparing educational materials and conducting a simulated health class. The students’ knowledge concerning the prevention and education on osteoporosis was surveyed using questionnaires before and after the training.

Results

The bone area ratio (BAR) in 24 % of the students was evaluated as category 4 (slightly low) or 5 (low or caution). Regression analysis indicated a significant relationship between the BAR and amount of exercise reported in both males (p = 0.005) and females (p = 0.004). The student-made educational materials were prepared in line with the requirements of the Japanese 2011 guidelines. The student response rates for the importance of food, exercise, and the bone density measurement in youth were significantly increased after the training (p < 0.001 in all). More than 95 % of students reported that the program was useful, improved their understanding, and important, with 94 % satisfied with the experience.

Conclusions

This experience-based educational program combining measuring the bone density and the preparation and presentation of a simulated health class appeared to improve the awareness and understanding of osteoporosis prevention in pharmacy students.

An Internet-based Controlled Trial Aimed to Improve Osteoporosis Prevention among Chronic Glucocorticoid Users

OBJECTIVE

To address the low prevention and treatment rates for those at risk of glucocorticoid-induced osteoporosis (GIOP), we evaluated the influence of a direct-to-patient, Internet-based educational video intervention using "storytelling" on rates of antiosteoporosis medication use among chronic glucocorticoid users who were members of an online pharmacy refill service.

METHODS

We identified members who refilled ≥ 5 mg/day of prednisone (or equivalent) for 90 contiguous days and had no GIOP therapy for ≥ 12 months. Using patient stories, we developed an online video addressing risk factors and treatment options, and delivered it to members refilling a glucocorticoid prescription. The intervention consisted of two 45-day "Video ON" periods, during which the video automatically appeared at the time of refill, and two 45-day "Video OFF" periods, during which there was no video. Members could also "self-initiate" watching the video by going to the video link. We used an interrupted time series design to evaluate the effectiveness of this intervention on GIOP prescription therapies over 6 months.

RESULTS

Among 3017 members (64.8%) exposed to the intervention, 59% had measurable video viewing time, of which 3% "self-initiated" the video. The GIOP prescription rate in the "Video ON" group was 2.9% versus 2.7% for the "Video OFF" group. There was a nonsignificant trend toward greater GIOP prescription in members who self-initiated the video versus automated viewing (5.7% vs 2.9%, p = 0.1).

CONCLUSION

Among adults at high risk of GIOP, prescription rates were not significantly affected by an online educational video presented at the time of glucocorticoid refill. ClinicalTrials.gov Identifier: NCT01378689.

The Development and Validation of the Osteoporosis Prevention and Awareness Tool (OPAAT) in Malaysia

OBJECTIVES

To develop and validate Osteoporosis Prevention and Awareness Tool (OPAAT) in Malaysia.

METHODS

The OPAAT was modified from the Malaysian Osteoporosis Knowledge Tool and developed from an exploratory study on patients. Face and content validity was established by an expert panel. The OPAAT consists of 30 items, categorized into three domains. A higher score indicates higher knowledge level. English speaking non-osteoporotic postmenopausal women ≥ 50 years of age and pharmacists were included in the study.

RESULTS

A total of 203 patients and 31 pharmacists were recruited. Factor analysis extracted three domains. Flesch reading ease was 59.2. The mean ± SD accuracy rate was 0.60 ± 0.22 (range: 0.26-0.94). The Cronbach's α for each domain ranged from 0.286-0.748. All items were highly correlated (Spearman's rho: 0.761-0.990, p < 0.05), with no significant change in the overall test-retest scores, indicating that OPAAT has achieved stable reliability. Pharmacists had higher knowledge score than patients (80.9 ± 8.7 vs 63.6 ± 17.4, p < 0.001), indicating that the OPAAT was able to discriminate between the knowledge levels of pharmacists and patients.

CONCLUSION

The OPAAT was found to be a valid and reliable instrument for assessing patient's knowledge about osteoporosis and its prevention in Malaysia. The OPAAT can be used to identify individuals in need of osteoporosis educational intervention.

A knowledge translation tool improved osteoporosis disease management in primary care: an interrupted time series analysis

BACKGROUND

Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems, yet gaps in management still exist. In response, we developed a multi-component osteoporosis knowledge translation (Op-KT) tool involving a patient-initiated risk assessment questionnaire (RAQ), which generates individualized best practice recommendations for physicians and customized education for patients at the point of care. The objective of this study was to evaluate the effectiveness of the Op-KT tool for appropriate disease management by physicians.

METHODS

The Op-KT tool was evaluated using an interrupted time series design. This involved multiple assessments of the outcomes 12 months before (baseline) and 12 months after tool implementation (52 data points in total). Inclusion criteria were family physicians and their patients at risk for osteoporosis (women aged ≥ 50 years, men aged ≥ 65 years). Primary outcomes were the initiation of appropriate osteoporosis screening and treatment. Analyses included segmented linear regression modeling and analysis of variance.

RESULTS

The Op-KT tool was implemented in three family practices in Ontario, Canada representing 5 family physicians with 2840 age eligible patients (mean age 67 years; 76% women). Time series regression models showed an overall increase from baseline in the initiation of screening (3.4%; P < 0.001), any osteoporosis medications (0.5%; P = 0.006), and calcium or vitamin D (1.2%; P = 0.001). Improvements were also observed at site level for all the three sites considered, but these results varied across the sites. Of 351 patients who completed the RAQ unprompted (mean age 64 years, 77% women), the mean time for completing the RAQ was 3.43 minutes, and 56% had any disease management addressed by their physician. Study limitations included the inherent susceptibility of our design compared with a randomized trial.

CONCLUSIONS

The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practices, and highlights its potential to facilitate patient self-management. Next steps include wider implementation and evaluation of the tool in primary care.

Effectiveness of intervention led by a community pharmacist for improving recognition of sleep apnea in primary care--a cohort study

Despite its high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. The aim of this study was to determine whether the involvement of a community pharmacist (CP) in the care pathway of a patient at risk of OSAS, through the implementation of a community pharmacist (CP) intervention, was effective, i.e. increased the use of diagnostic tests in this population. We compared a cohort of patients included in a research protocol (exposed to a CP intervention) with patients having the same characteristics taken from a general population database who did not receive the intervention (unexposed group). The aim of the CP intervention was to educate patients about the risk of untreated OSAS, encouraging them to consult their general practitioner, and urging the doctor to continue investigations. We included 782 patients at risk of OSAS, i.e. taking one or more anti-hypertensive drugs, being overweight (body mass index >25) and snoring almost every night (88 in the exposed group and 694 in the unexposed group). After a 6-month follow-up, the number of patients who underwent an OSAS diagnostic test was significantly higher in the exposed group compared to the unexposed group (22.7 versus 11.4%, P = 0.003). Being exposed to the pharmacist intervention was associated with a higher chance of undergoing a diagnostic test for OSAS, adjusted odds ratio: 2.24 (1.25-4.01). In conclusion, these findings provide arguments for the implementation of a CP OSAS screening intervention in CP routine practice.

Proactive pharmaceutical care interventions decrease patients' nonadherence to osteoporosis medication

Using a protocolled intervention program, pharmacists can decrease nonadherence to osteoporosis medication, by continuous monitoring and tailored counseling sessions, starting at treatment initiation. In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group.

PURPOSE

While community pharmacies have been shown to offer a promising platform for osteoporosis management in patients with osteoporosis, more research is needed to determine pharmacists' effects on improving adherence. The aim of this study was to determine the effects of a community pharmacists' intervention program on the 1-year discontinuation and nonadherence rates of patients initiating osteoporosis medication.

METHODS

This intervention study included 937 patients, recruited from 13 Dutch community pharmacies, initiating osteoporosis medication. The intervention group (N = 495), received the Medication Monitoring and Optimization (MeMO) intervention, comprising of continuous monitoring of patients' adherence to their osteoporosis medication and tailored counseling sessions with nonadherent patients. Results were compared to an internal (n = 442) reference group, receiving usual pharmacy care. Primary study outcomes were therapy discontinuation and nonadherence; results were adjusted for potential confounders using Cox proportional hazard analysis. Secondary outcome was patients' satisfaction.

RESULTS

In the usual care group, 32.8% of patients initiating osteoporosis medication discontinued or were nonadherent, compared to 19.0% of patients in the intervention group (P < 0.001). Ninety-three percent of the respondents were satisfied with the pharmacies' services provided. Notably, 31% mentioned that the pharmacy was the only place where they received information on various aspects of administration and acting of their medication.

CONCLUSION

Pharmacists can decrease nonadherence and discontinuation with osteoporosis medication by providing tailored counseling sessions and continuous monitoring of drug use. Pharmaceutical care programs, such as MeMO, contribute to more optimal use of osteoporosis medication.

The development and validation of the Satisfaction Questionnaire for Osteoporosis Prevention in Malaysia

PURPOSE

To develop and validate the English version of the Satisfaction Questionnaire for Osteoporosis Prevention (SQOP) in Malaysia.

METHODS

The SQOP was modified from the Osteoporosis Patient Satisfaction Questionnaire and developed based on literature review and patient interviews. Face and content validity were established via an expert panel. The SQOP consists of two sections: clinical services and types of counseling. There were 23 items in total, each with a five-point Likert-type response. Satisfaction score was calculated by converting the total score to a percentage. A higher score indicates higher satisfaction. English speaking, non-osteoporotic, postmenopausal women aged ≥50 years were included in the study. Participants were randomized to either the control or intervention group. Intervention participants were provided counseling, whereas control participants received none. Participants answered the SQOP at baseline and 2 weeks later.

RESULTS

A total of 140 participants were recruited (control group: n=70; intervention group: n=70). No significant differences were found in any demographic aspects. Exploratory factor analysis extracted seven domains. Cronbach's α for the domains ranged from 0.531-0.812. All 23 items were highly correlated using Spearman's correlation coefficient 0.469-0.996 (P<0.05), with no significant change in the control group's overall test-retest scores, indicating that the SQOP achieved stable reliability. The intervention group had a higher score than the control group (87.91±5.99 versus 61.87±8.76; P<0.05), indicating that they were more satisfied than control participants. Flesch reading ease was 62.9.

CONCLUSION

The SQOP was found to be a valid and reliable instrument for assessing patients' satisfaction towards an osteoporosis screening and prevention service in Malaysia.

Increase in prophylaxis of glucocorticoid-induced osteoporosis by pharmacist feedback: a randomised controlled trial

The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis would stimulate the prescribing of osteoporosis prophylaxis. The intervention did not significantly increase the prescribing of bisphosphonates in the total study population, but a significant increase was seen in men and in the elderly. However, the proportion of bisphosphonate-treated patients remained low.

INTRODUCTION

The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis (GIOP) would stimulate the implementation of the Dutch GIOP guideline.

METHODS

This randomised controlled trial included 695 patients who were dispensed ≥675 mg prednisone equivalents without a concomitant bisphosphonate prescription within 6 months before baseline. Pharmacists were asked to contact the physicians of GIOP-eligible patients in the intervention group to suggest osteoporosis prophylaxis. The primary endpoint was a bisphosphonate prescription. Secondary endpoints were a prescription of calcium supplements, vitamin D or any prophylactic osteoporosis drug (bisphosphonate, calcium supplements, vitamin D).

RESULTS

The group assigned to the intervention was slightly younger than the control group (68.7 ± 15.4 vs. 65.9 ± 16.9 years, p = 0.02) and used hydrocortisone more often (7.0% vs. 3.1%, p = 0.02). Within 6 months, the intervention did not significantly increase the prescribing of bisphosphonates (11.4% after intervention vs. 8.0% for controls; hazard ratio [HR] 1.47, 95% confidence interval [CI] 0.91-2.39). However, subgroup analyses showed a significant increase for the primary endpoint in men (12.8% vs. 5.1%, HR 2.53, 95% CI 1.11-5.74) and patients ≥70 years (13.4% vs. 4.9%, HR 2.88, 95% CI 1.33-6.23). The prescribing of calcium and vitamin D was not significantly altered.

CONCLUSION

This study showed that active identification of patients eligible for GIOP by pharmacists did not significantly increase the prescribing of bisphosphonates in the total study population, but there was an increase in men and the elderly. However, the proportion of GIOP-treated patients remained low.

Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group

This study aims to systematically review, critically appraise and identify from the published literature, the most effective interventions to improve medication adherence in osteoporosis. A literature search using Medline, EMBASE, Cochrane library, and Cumulative Index to Nursing and Allied Health Literature was undertaken to identify prospective studies published between January 1, 1999 and June 30, 2012. We included studies on adult users of osteoporosis medications that tested a patient adherence intervention (e.g., patient education, intensified patient care, different dosing regimens) and reported quantitative results of adherence. The Delphi list was modified to assess the quality of studies. Of 113 articles identified, 20 studies fulfilled the inclusion criteria. The most frequent intervention was education (n = 11) followed by monitoring/supervision (n = 4), drug regimens (n = 2), drug regimens and patient support (n = 1), pharmacist intervention (n = 1), and electronic prescription (n = 1). Although patient education improved medication adherence in four studies, two large-scale randomized studies reported no benefits. Simplification of dosing regimens (with and without patient support program) was found to have a significant clinical impact on medication adherence and persistence. Monitoring/supervision showed no impact on medication persistence while electronic prescription and pharmacist intervention increased medication adherence or persistence. In conclusion, this review found that simplification of dosing regimens, decision aids, electronic prescription, or patient education may help to improve adherence or persistence to osteoporosis medications. We identified wide variation of quality of studies in the osteoporosis area. The efficacy of patient education was variable across studies, while monitoring/supervision does not seem an effective way to enhance medication adherence or persistence.

We can do more than just sell the test: pharmacist perspectives about over-the-counter rapid HIV tests

Pharmacist attitudes about the over-the-counter (OTC) sale of HIV rapid tests in pharmacies were explored through interviews conducted among 17 licensed community pharmacists in a Midwestern, moderate HIV incidence state between May and September 2012. Participants recognized that OTC rapid HIV tests would increase the number of people aware of their HIV status. Concerns included linkage to care and results consultation for those who test HIV-positive. Point of sale was identified as an opportunity for consultation about the test and to establish a relationship for future discussion about results and linkage to care. Pharmacists could provide initial test consultation or information, and consultation about the test results in order to provide post diagnosis support and facilitate linkage to care.

Cost-Effectiveness of a Community Pharmacist-Led Sleep Apnea Screening Program - A Markov Model

Background

Despite the high prevalence and major public health ramifications, obstructive sleep apnea syndrome (OSAS) remains underdiagnosed. In many developed countries, because community pharmacists (CP) are easily accessible, they have been developing additional clinical services that integrate the services of and collaborate with other healthcare providers (general practitioners (GPs), nurses, etc.). Alternative strategies for primary care screening programs for OSAS involving the CP are discussed.

Objective

To estimate the quality of life, costs, and cost-effectiveness of three screening strategies among patients who are at risk of having moderate to severe OSAS in primary care.

Design

Markov decision model.

Data Sources

Published data.

Target Population

Hypothetical cohort of 50-year-old male patients with symptoms highly evocative of OSAS.

Time Horizon

The 5 years after initial evaluation for OSAS.

Perspective

Societal.

Interventions

Screening strategy with CP (CP-GP collaboration), screening strategy without CP (GP alone) and no screening.

Outcomes measures

Quality of life, survival and costs for each screening strategy.

Results of base-case analysis

Under almost all modeled conditions, the involvement of CPs in OSAS screening was cost effective. The maximal incremental cost for “screening strategy with CP” was about 455€ per QALY gained.

Results of sensitivity analysis

Our results were robust but primarily sensitive to the treatment costs by continuous positive airway pressure, and the costs of untreated OSAS. The probabilistic sensitivity analysis showed that the “screening strategy with CP” was dominant in 80% of cases. It was more effective and less costly in 47% of cases, and within the cost-effective range (maximum incremental cost effectiveness ratio at €6186.67/QALY) in 33% of cases.

Conclusions

CP involvement in OSAS screening is a cost-effective strategy. This proposal is consistent with the trend in Europe and the United States to extend the practices and responsibilities of the pharmacist in primary care.

The role of community pharmacists in the prevention and management of osteoporosis and the risk of falls: results of a cross-sectional study and qualitative interviews

In a mailed survey and qualitative interviews, it was observed that community pharmacists and public health authorities believe that pharmacists should play a significant role in the prevention and management of osteoporosis and the risk of falls. However, pharmacists acknowledge a wide gap between their ideal and actual levels of involvement.

INTRODUCTION

The aim of this study was to explore perceptions of community pharmacists and public health authorities regarding the role of pharmacists in providing services in relation to osteoporosis and risk of falls and the barriers to providing them.

METHODS

Using a modified five-step version of Dillman's tailored design method, a questionnaire was mailed to a random sample of 1,250 community pharmacists practicing in Montreal (Quebec, Canada) and surrounding areas. A similar questionnaire was sent to public health officers in these regions. Additionally, telephone interviews were conducted with regional and ministry level public health officers.

RESULTS

Of the 1,250 pharmacists contacted, 28 were ineligible. In all, 571 of 1,222 (46.7 %) eligible community pharmacists and all the public health officers returned the questionnaire. Six public health officers (five regional and one at ministry level) were interviewed. Most pharmacists believed they should be involved in screening for osteoporosis (46.6 %) and risk of falls (50.3 %); however, fewer reported actually being involved in such services (17.4 % and 19.2 %, respectively). In their view, the main barriers to providing these services in current practice were lack of time (78.8 %), lack of clinical tools (65.4 %), and lack of coordination with other healthcare professionals (54.5 %). Public health authorities also thought community pharmacists should play a significant role in providing osteoporosis and fall risk services. However, few community pharmacist-mediated activities are in place in the participating regions.

CONCLUSIONS

Although community pharmacists and public health authorities believe pharmacists should play a significant role with regard to osteoporosis and the risk of falls, they acknowledge a wide gap between the ideal and actual levels of pharmacist involvement.

Screening for major diseases in community pharmacies: a systematic review

OBJECTIVES

The aim of this systematic review was to assess the published evidence about the feasibility and acceptability of community pharmacy-based screening for major diseases.

METHOD

Studies published between January 1990 and August 2012 involving community pharmacy-based screening interventions, published in the English language, were identified from electronic databases. Reference lists of included studies were also searched.

KEY FINDINGS

Fifty studies (one randomised controlled trial, two cluster randomised studies, five non-randomised comparative studies and 42 uncontrolled studies) were included. The quality of most of these was assessed as poor. Screening was mostly opportunistic and screening tools included questionnaires or risk assessment forms, medical equipment to make physiological measurements, or a combination of both. Few studies assessed the accuracy of pharmacy-based screening tools. More than half of the screening interventions included an element of patient education. The proportion of screened individuals, identified with disease risk factors or the disease itself, ranged from 4% to 89%. Only 10 studies reported any economic information. Where assessed, patient satisfaction with pharmacy-based screening was high, but individuals who screened positive often did not follow pharmacist advice to seek further medical help.

CONCLUSION

Available evidence suggests that screening for some diseases in community pharmacies is feasible. More studies are needed to compare effectiveness and cost-effectiveness of pharmacy-based screening with screening by other providers. Strategies to improve screening participants' adherence to pharmacist advice also need to be explored. This systematic review will help to inform future studies wishing to develop community pharmacy-based screening interventions.