Failure to perceive increased risk of fracture in women 55 years and older: the Global Longitudinal Study of Osteoporosis in Women (GLOW)

A comprehensive set of ultrashort echo time magnetic resonance imaging biomarkers to assess cortical bone health: A feasibility study at clinical field strength

INTRODUCTION

Conventional bone imaging methods primarily use X-ray techniques to assess bone mineral density (BMD), focusing exclusively on the mineral phase. This approach lacks information about the organic phase and bone water content, resulting in an incomplete evaluation of bone health. Recent research highlights the potential of ultrashort echo time magnetic resonance imaging (UTE MRI) to measure cortical porosity and estimate BMD based on signal intensity. UTE MRI also provides insights into bone water distribution and matrix organization, enabling a comprehensive bone assessment with a single imaging technique. Our study aimed to establish quantifiable UTE MRI-based biomarkers at clinical field strength to estimate BMD and microarchitecture while quantifying bound water content and matrix organization.

METHODS

Femoral bones from 11 cadaveric specimens (n = 4 males 67-92 yrs of age, n = 7 females 70-95 yrs of age) underwent dual-echo UTE MRI (3.0 T, 0.45 mm resolution) with different echo times and high resolution peripheral quantitative computed tomography (HR-pQCT) imaging (60.7 μm voxel size). Following registration, a 4.5 mm HR-pQCT region of interest was divided into four quadrants and used across the multi-modal images. Statistical analysis involved Pearson correlation between UTE MRI porosity index and a signal-intensity technique used to estimate BMD with corresponding HR-pQCT measures. UTE MRI was used to calculate T1 relaxation time and a novel bound water index (BWI), compared across subregions using repeated measures ANOVA.

RESULTS

The UTE MRI-derived porosity index and signal-intensity-based estimated BMD correlated with the HR-pQCT variables (porosity: r = 0.73, p = 0.006; BMD: r = 0.79, p = 0.002). However, these correlations varied in strength when we examined each of the four quadrants (subregions, r = 0.11-0.71). T1 relaxometry and the BWI exhibited variations across the four subregions, though these differences were not statistically significant. Notably, we observed a strong negative correlation between T1 relaxation time and the BWI (r = -0.87, p = 0.0006).

CONCLUSION

UTE MRI shows promise for being an innocuous method for estimating cortical porosity and BMD parameters while also giving insight into bone hydration and matrix organization. This method offers the potential to equip clinicians with a more comprehensive array of imaging biomarkers to assess bone health without the need for invasive or ionizing procedures.

Bisphosphonate alternative regimens for the prevention of osteoporotic fragility fractures: BLAST-OFF, a mixed-methods study

Background

Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice.

Objectives

1. Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. 2. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. 3. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities.

Methods

The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: • Stage 1A - we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. • Stage 1B - we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. • Stage 2 - we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates.

Results

Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting.

Conclusions

Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs.

Future work

Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting.

Limitations

Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates.

Trial registration

This trial is registered as ISRCTN10491361.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.

Patient Perception on Osteoporosis in Korean Female Patients with Osteoporosis

BACKGROUND

Patient perception is a key element in improving compliance with medications for osteoporosis. This study evaluated the awareness, perception, sources of information, and knowledge of osteoporosis among Korean women with osteoporosis.

METHODS

A questionnaire survey was conducted from July 22, 2021 to 13 August 2021. Patients who were followed up in endocrinology (Endo), orthopedic surgery (OS), and gynecology (GY) were recruited (N=40, 40, and 20 in each group). Patients were allocated according to their age, as follows: 15, 15, and 10 patients in their 60s, 70s, and 80s for Endo and OS, and 10 and 10 patients in their 60s and 70s for GY. The questionnaire was composed of the following topics: patient journey to the hospital, drug-related issues, communication with medical doctors, patient knowledge, and sources of information about osteoporosis.

RESULTS

The results of medical check-ups were the most common reason for patient visits to the hospital for an initial diagnosis of osteoporosis (61%). A knowledge gap regarding mortality, refracture, and drug-induced osteoporosis was observed. Doctors were the most preferred and trustful source of information, while health-related TV shows were the second most common source of information. Patients with OS reported lower perceived severity and higher drug discontinuation, along with a higher proportion of fractures, as the initial reasons for hospital visits for osteoporosis.

CONCLUSIONS

Variations in perceptions according to the issue and group were identified. These should be considered during patient consultations to improve compliance with osteoporosis treatment.

Management of Postmenopausal Osteoporosis by Moroccan General Practitioners: A Cross-Sectional Survey

BACKGROUND

Despite the existence of effective treatments and prescribed therapeutic protocols, there is a lack of management of osteoporosis, resulting in increased secondary morbidity and mortality. The general practitioner (GP) is the first-line practitioner for the detection and management of osteoporosis.

OBJECTIVE

This study was conducted to explore the practices, knowledge, and difficulties in postmenopausal osteoporosis management reported by GPs.

METHODS

An anonymous questionnaire (19 questions) was created via Google Forms and distributed to 300 GPs via social networks (WhatsApp, Facebook, and Gmail). The survey results were automatically calculated on "Google Forms" and checked using SPSS.20 software.

RESULTS

A total of 129 responses were received, representing a response rate of 43%. The majority of respondents were women (67.2%). The definition of osteoporosis was variable, with 51.6% defining it as a T-score of ≤-2.5 SD, 25.8% defining it as diffuse bone demineralization, and 12.1% defining it as a fracture after falling with low energy. Prolonged corticosteroid therapy was the most commonly indicated reason for measuring bone mineral density (BMD) (81.39%). The calcium phosphate balance was the most requested (90.1%). Vitamin D and calcium supplementation were reported by 74.41% and 54.26% of GPs, respectively. Fracture of the upper end of the femur was the main therapeutic indication (65.11%). Most GPs surveyed (73.3%) were unfamiliar with the fracture risk assessment tool (FRAX). Most of the GPs gave advice on fall prevention to their patients (83.72%), and 62.5% of GPs monitored their patients' height. Anti-osteoporosis treatment was maintained for 3 to 5 years by 44.96% of GPs.

CONCLUSION

Our survey found that the practices and knowledge of GPs on osteoporosis vary widely and often deviate from the recommended standards. This highlights the need for more excellent education of GPs, due to their vital role in the management of osteoporosis.

Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years

BACKGROUND

Accurate estimation of the imminent fragility fracture risk currently represents a challenging task. The novel Fragility Score (FS) parameter, obtained during a Radiofrequency Echographic Multi Spectrometry (REMS) scan of lumbar or femoral regions, has been developed for the non-ionizing estimation of skeletal fragility.

AIMS

The aim of this study was to assess the performance of FS in the early identification of patients at risk for incident fragility fractures with respect to bone mineral density (BMD) measurements.

METHODS

Data from 1989 Caucasians of both genders were analysed and the incidence of fractures was assessed during a follow-up period up to 5 years. The diagnostic performance of FS to discriminate between patients with and without incident fragility fracture in comparison to that of the BMD T-scores measured by both Dual X-ray Absorptiometry (DXA) and REMS was assessed through ROC analysis.

RESULTS

Concerning the prediction of generic osteoporotic fractures, FS provided AUC = 0.811 for women and AUC = 0.780 for men, which resulted in AUC = 0.715 and AUC = 0.758, respectively, when adjusted for age and body mass index (BMI). For the prediction of hip fractures, the corresponding values were AUC = 0.780 for women and AUC = 0.809 for men, which became AUC = 0.735 and AUC = 0.758, respectively, after age- and BMI-adjustment. Overall, FS showed the highest prediction ability for any considered fracture type in both genders, resulting always being significantly higher than either T-scores, whose AUC values were in the range 0.472-0.709.

CONCLUSION

FS displayed a superior performance in fracture prediction, representing a valuable diagnostic tool to accurately detect a short-term fracture risk.

Osteoporosis in 2022: Care gaps to screening and personalised medicine

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.

Accounts of health risk assessment survey administration in the Catch a Break Program: the social construction of osteoporosis risk identification and need for intervention

Catch a Break staff conducting the organizational work of delivering secondary fracture prevention screening conversations drew on cultural and organizational resources to determine eligibility of individuals. They encountered and navigated their way through interactional troubles as they requested participation, assessed trauma risk, and provided lifestyle information.

PURPOSE

We investigated delivery of a population-based type C fracture liaison service for non-hip fractures. The purpose of this study was to examine accounts of how osteoporosis health risk screening interactions were delivered.

METHODS

A pre-determined sample of 5 organizational representatives (program staff) were interviewed by telephone. We analyzed the qualitative data through the lens of interpretive inquiry, informed by discourse analysis, to examine staff's "talk" about conducting the program risk screening conversations.

RESULTS

A dominant finding emerging from CAB staff's accounts of program delivery was the conversational work required to include only those individuals deemed appropriate for the program while managing the survey interaction. Staff talked about specific examples of interactional troubles they experienced as barriers to the smooth and successful risk screening conversation. They drew on cultural and organizational resources as interpretive frameworks to make decisions about individuals and groups at risk and in need of further investigation. They drew on larger ideas about ageism and genderism, judging as inappropriate for participation the oldest old adults, men involved in high risk occupations, and adults aged 50 to 70. Staff also employed interactional resources useful in managing problems in the conversation during the request to participate, trauma risk assessment, and lifestyle/health information provision sequences of the risk screening call.

CONCLUSION

We uncovered areas in the screening interaction that were talked about by staff as problematic to achieving the program objective of identifying and enrolling individuals in the secondary fracture prevention program. By highlighting areas for improvement in program delivery, this study may help to reduce the interactional troubles staff negotiate as they deliver this type of program.

Women Living With Osteoporosis: A Meta-Synthesis

BACKGROUND AND OBJECTIVES

The experiences and needs of individuals with osteoporosis, especially among women, are poorly understood. This meta-synthesis aimed to examine the experiences and needs of women living with osteoporosis.

RESEARCH DESIGN AND METHODS

Six databases were searched for qualitative studies from each database's inception to July 18, 2019. Qualitative data were meta-summarized, then meta-synthesized.

RESULTS

A total of 2,781 studies were obtained, and 2,768 studies were screened after the removal of 13 duplicates. Two thousand seven hundred and sixty studies failed to meet the eligibility criteria, resulting in the inclusion of eight studies in this meta-synthesis. Three themes emerged: (a) physical and psychological consequences of living with osteoporosis, (b) coping strategies to "live better" with osteoporosis, and (c) sources of support and support needs.

DISCUSSION AND IMPLICATIONS

Women living with osteoporosis experienced negative physical and psychological consequences that led to changes in their lives, particularly in their relationships. They adopted various coping strategies such as acceptance and engaging in doing things that they loved. They expressed support needs such as educational and self-help groups that may help them to cope better. As the included studies were only from the West, more studies from geographically diverse backgrounds such as the Middle East and Asia are required to explore the experiences and needs of women living with osteoporosis. Theory-based health services that incorporate active coping strategies such as self-seeking behaviors should be designed to create awareness about osteoporosis to assist such women in maintaining their independence and overall well-being to age gracefully.

Use of path modeling to inform a clinical decision support application to encourage osteoporosis medication use

BACKGROUND

Osteoporosis medication use is suboptimal. Simple interventions personalized to a patients' stage of readiness are needed to encourage osteoporosis medication use.

OBJECTIVES

To estimate interrelationships of sociodemographic factors, perceived fracture risk, health literacy, receipt of medication information, medication trust and readiness to use osteoporosis medication; and apply observed relationships to inform design specifications for a clinical decision support application that can be used for personalized patient counseling.

METHODS

Data from a national sample of older women (n = 1759) with self-reported history of fractures and no current use of osteoporosis medication treatment were used to estimate an acceptable path model that describes associations among key sociodemographic characteristics, health literacy, perceived fracture risk, receipt of osteoporosis medication information within the past year, trust in osteoporosis medications, and readiness to use osteoporosis medication. Path model results were used to inform an application for personalized patient counseling that can be easily integrated into clinical decision support systems.

RESULTS

Increased age (β = 0.13), trust for medications (β = 0.12), higher perceived fracture risk (β = 0.21), and having received medication information within the past year (β = 0.21) were all positively associated with readiness to use osteoporosis medication (p < 0.0001). Whereas, health literacy (β = -0.09) was inversely associated with readiness to use osteoporosis medication (p < 0.0001). Using these results, a brief 6-item question set was constructed for simple integration into clinical decision support applications. Patient responses were used to inform a provider dashboard that integrates a patient's stage of readiness for osteoporosis medication use, predictors of readiness, and personalized counseling points appropriate to their stage of readiness.

CONCLUSION

Content of counseling strategies must be aligned with a patient's stage of readiness to use treatment. Path modeling can be effectively used to identify factors for inclusion in an evidenced-based clinical decision support application designed to assist providers with personalized patient counseling and osteoporosis medication use decisions.

Self-perceived Fracture Risk in the Global Longitudinal Study of Osteoporosis in Women: Its Correlates and Relationship with Bone Microarchitecture

The purpose of this study is to examine correlates of self-perceived fracture risk (SPR) and relationships between SPR and subsequent bone density and microarchitecture in the UK arm of the Global Longitudinal Study of Osteoporosis in Women. 3912 women completed baseline questionnaires detailing medical history and SPR; 492 underwent HRpQCT scans of the radius and tibia and DXA scans of total body, hip, femoral neck and lumbar spine a median of 7.5 years later. Correlates of SPR were examined and a cluster analysis of potential predictors of SPR performed. SPR in relation to HRpQCT and aBMD parameters was examined using linear regression with and without adjustment for anthropometric, demographic and lifestyle covariates. Mean (SD) baseline age was 69.0 (9.0) years; 56.6% reported a similar SPR; 28.6% lower SPR; 14.9% higher SPR compared to women of similar age. In mutually-adjusted analysis, higher SPR was associated (p < 0.05) with: lower physical activity and educational attainment; use of anti-osteoporosis medications (AOM) and calcium supplements; greater number of falls in the previous year; history of fracture since aged 45; family history of hip fracture; and increased comorbidity. Higher SPR, history of fracture, and use of AOM, calcium and vitamin D clustered together. Even after adjustments that included AOM use, higher SPR was associated with: lower radial trabecular volumetric density and number, and higher trabecular separation; lower tibial cortical area and trabecular volumetric density; and lower aBMD at the femoral neck. Despite greater AOM use, women with higher baseline SPR had poorer subsequent bone health.

Ambiguity hindering self-management and prevention of osteoporosis in post-menopausal women

As osteoporosis relies largely on self-managed prevention and adherence to long-term treatment regimens, it is imperative that those at risk understand the disease that they are attempting to prevent. Ambiguity regarding osteoporosis and reluctance to take anti-osteoporosis medication (AOM) as well as calcium was noted in Australian post-menopausal women. This may lead to underestimating women's own risk of osteoporosis and fracture.

INTRODUCTION

Fragility fractures caused by osteoporosis have been known to inflict significant personal and financial burden on individuals and society. As treatment of osteoporosis relies largely on self-managed prevention and adherence to long-term AOM regimens, it is imperative that women have a sound understanding of the disease that they are attempting to prevent. Much can also be gained from qualitatively exploring the level of osteoporosis knowledge particularly in post-menopausal women who are at greater risk of osteoporosis and fractures. This study thus aims to determine what post-menopausal Australian women know about osteoporosis and osteoporosis prevention.

METHOD

Six focus group sessions, using purposive sampling, were conducted with 23 female participants (mean age 68 years (range 62-83)). Women responded to a series of open-ended questions regarding their knowledge about osteoporosis. The audiotaped focus groups were transcribed verbatim and analysed using a thematic analysis framework.

RESULTS

Three key themes were identified: ambiguity about the nature of osteoporosis, ambiguity about osteoporosis prevention and reluctance to take AOM and calcium.

CONCLUSION

Ambiguity associated with risk and prevention may provide women with a false sense of security that they are adequately acting to prevent the disease. Underestimation of their risk of osteoporosis and fracture as well as reluctance associated with AOM may be barriers to osteoporotic fracture prevention.

General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal

PURPOSE OF REVIEW

The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied.

RECENT FINDINGS

A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.

Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies

Background

Patients with low bone density or osteoporosis need information for effective prevention or disease management, respectively. However, patients may not be getting enough information from their primary care providers or other sources. Inadequate disease information leaves patients ill-informed and creates misconceptions and unnecessary concerns about the disease.

Objective

We systematically reviewed and synthesized the available literature to determine patient knowledge, beliefs, and concerns about osteoporosis and identify potential gaps in knowledge.

Methods

A systematic search was conducted for full-text qualitative studies addressing understanding, literacy, and/or perceptions about osteoporosis and its management, using Medline, EMBASE, Web of Science, Cochrane Library, CINAHL, ERIC, PsychINFO, Psyc Behav Sci Collec, and PubMed, from inception through September 2016. Studies were selected by two reviewers, assessed for quality, and themes extracted using the Joanna Briggs Institute data extraction tool. Thematic analysis was used to identify themes and subthemes.

Results

Twenty-five studies with a total of 757 participants (including 105 men) were selected for analysis out of 1031 unique citations. Selected studies were from Australia, Canada, Denmark, Norway, the United Kingdom, and the United States. Four main themes emerged: inadequate knowledge, beliefs and misconceptions, concerns about osteoporosis, and lack of information from health care providers. Participants had inadequate knowledge about osteoporosis and were particularly uninformed about risk factors, causes, treatment, and prevention. Areas of concern for participants included diagnosis, medication side effects, and inadequate information from primary care providers.

Conclusion

Although there was general awareness of osteoporosis, many misconceptions and concerns were evident. Education on bone health needs to reinforce areas of knowledge and address deficits, misconceptions, and concerns.

Systematic screening using FRAX® leads to increased use of, and adherence to, anti-osteoporosis medications: an analysis of the UK SCOOP trial

In the large community-based SCOOP trial, systematic fracture risk screening using FRAX^® led to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.

INTRODUCTION

In the SCreening of Older wOmen for Prevention of fracture (SCOOP) trial, we investigated the effect of the screening intervention on subsequent long-term self-reported adherence to anti-osteoporosis medications (AOM).

METHODS

SCOOP was a primary care-based UK multicentre trial of screening for fracture risk. A total of 12,483 women (70-85 years) were randomised to either usual NHS care, or assessment using the FRAX^® tool ± dual-energy X-ray absorptiometry (DXA), with medication recommended for those found to be at high risk of hip fracture. Self-reported AOM use was obtained by postal questionnaires at 6, 12, 24, 36, 48 and 60 months. Analysis was limited to those who initiated AOM during follow-up. Logistic regression was used to explore baseline determinants of adherence (good ≥ 80%; poor < 80%).

RESULTS

The mean (SD) age of participants was 75.6 (4.2) years, with 6233 randomised to screening and 6250 to the control group. Of those participants identified at high fracture risk in the screening group, 38.2% of those on treatment at 6 months were still treated at 60 months, whereas the corresponding figure for the control group was 21.6%. Older age was associated with poorer adherence (OR per year increase in age 0.96 [95% CI 0.93, 0.99], p = 0.01), whereas history of parental hip fracture was associated with greater rate adherence (OR 1.67 [95% CI 1.23, 2.26], p < 0.01).

CONCLUSIONS

Systematic fracture risk screening using FRAX^® leads to greater use of AOM and greater adherence, in women at high fracture risk, compared with usual care.

Understanding Patients' Perspectives and Educational Needs by Type of Osteoporosis in Men and Women and People with Glucocorticosteroid-Induced Osteoporosis: A Qualitative Study to Improve Disease Management

The aim of the study was to investigate similarities and differences in health beliefs, experiences and educational needs by type of osteoporosis (OP), particularly in people with glucocorticoid-induced OP (GIOP) and men. A qualitative study was conducted via focus groups involving post-menopausal women with or without osteoporotic fractures, osteoporotic men and people with GIOP. Fifty-three participants were included in eight groups. A wide range of health beliefs was found for all types of OP. Osteoporosis was considered a natural consequence of ageing except in men or conversely a serious disease associated with risk of new fractures and disability. GIOP patients had heterogeneous knowledge of OP and reported fewer prevention behaviours, and their quality of life was affected by the causal illness. Men had difficulties coping with the loss of their functional abilities and felt that OP was a "women's" disease. Beliefs about treatments ranged from confidence to fear of adverse effects or doubt about efficacy in all types of OP. Participants were interested in physical activity, fall prevention and diet, and preferred group sessions. GIOP patients and men had an interest in face-to-face education. Men were also interested in brief information including via the Internet. Patients' beliefs about OP differed by type of OP. Specific populations such as men or people with GIOP need particular care owing to experiences and needs. Offering group sessions in educational interventions is of interest to allow for sharing experiences and also face-to-face education for men and GIOP patients or the Internet for men.

Association between serum levels of bone turnover markers and bone mineral density in men and women with type 2 diabetes mellitus

Background

In patients with type 2 diabetes mellitus (T2DM), higher risks of impaired bone metabolism are widely reported. To evaluate bone metabolism, bone mineral density (BMD) and bone turnover levels should be included. In this article, we analyzed the relationship between them in T2DM.

Methods

We conducted a hospital‐based cross‐sectional study enrolling 1499 patients hospitalized for T2DM between October 2009 and January 2013. Multivariate linear regression models were used to identify the relationship between bone turnover markers (BTMs) and BMD levels. A two‐sided P‐value < .05 was considered statistically significant.

Results

After adjusting for confounding factors, osteocalcin (OC) showed a negative relationship with total lumbar, femur neck, and total hip BMD in men and women. N‐terminal propeptides of type I collagen (P1NP) and alkaline phosphatase (ALP) showed a negative association with BMD at three sites in men and total lumbar BMD in women, whereas in the femur neck and total hip in women, the relationship was only found for P1NP with total hip. For β‐C‐terminal telopeptides of type I collagen (β‐CTX), a negative relationship was also found in all three sites for BMD in men and total lumbar BMD in women, whereas β‐CTX was not associated in the femoral neck and total hip in women.

Conclusion

In patients with T2DM, serum levels of OC, P1NP, β‐CTX, and ALP were negatively correlated with BMD levels in men in three sites and with total lumbar BMD in women. The relationship varied in femur neck and total hip BMD in women.

Prescribing and adherence to bone protection medications following hip fracture in the United Kingdom: results from the World Hip Trauma Evaluation (WHiTE) cohort study

AIMS

Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group.

PATIENTS AND METHODS

The World Hip Trauma Evaluation (WHiTE) is a multicentre, prospective cohort of hip fracture patients in NHS hospitals in England and Wales. Patients aged 60 years and older who received operative treatment for a hip fracture were eligible for inclusion in WHiTE. The prescription of bone protection medications was recorded from participants' discharge summaries, and participant-reported use of bone protection medications was recorded at 120 days following surgery.

RESULTS

Of 5456 recruited patients with baseline data, 2853 patients (52%) were prescribed bone protection medication at discharge, of which oral bisphosphonates were the most common, 4109 patients (75%) were prescribed vitamin D or calcium, and 606 patients (11%) were not prescribed anything. Of those prescribed a bone protection medication, only 932 patients (33%) reported still taking their medication 120 days later.

CONCLUSION

These data provide a reference for current prescription and adherence rates. Adherence with oral medication remains poor in patients with hip fracture. Cite this article: Bone Joint J 2019;101-B:1402-1407.

Fracture liaison programs

In view of the high imminent risk of having subsequent fractures after a fracture, early evaluation and treatment decisions to prevent subsequent fractures are advocated. After a hip fracture, the fracture liaison service (FLS) and orthogeriatric care are considered the most appropriate organisational approaches for secondary fracture prevention following a recent fracture. Their introduction and implementation have been shown to increase evaluation and treatment of patients at high risk for subsequent fracture. Of real-world cohort studies, most, but not all studies, indicate a lower incidence of fracture and longer survival after treatment with nitrogen-containing bisphosphonates.

Medication Decision-making in Osteoporosis: Can We Explain Why Patients Do Not Take Their Osteoporosis Medications?

Patients at high risk of fracture often do not take medication for osteoporosis. Recent literature may give us some insights into why patients at high risk of fracture do not take medications for osteoporosis.

Knowledge of risk factors and prevention of osteoporosis: the Israeli women's health at midlife study

Wide disparities in knowledge of risk factors and prevention of osteoporosis were demonstrated among midlife Israeli minority women (Arabs and immigrants from the former USSR) compared to Jewish long-time residents. Women who believed osteoporosis to be a serious disease and those who felt susceptible to it reported better knowledge.

PURPOSE

The main goals of this study were to assess knowledge of risk factors and preventive measures for osteoporosis in middle-aged women and to evaluate the relationship of knowledge to personal risk factors and personal perceptions about osteoporosis.

METHODS

Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJRs), immigrants from the former Soviet Union, and Arab women. The survey instrument included five knowledge statements related to the risk after menopause, the risk of smoking, family history of fractures, decreased risk by physical activity, and by use of medications.

RESULTS

The findings indicated wide disparities in knowledge about risk factors and preventive behavior of osteoporosis between the two minority groups (immigrants from the former Soviet Union and Arab women) and the majority group of midlife Israeli women. Knowledge of osteoporosis was related to perceived severity of the disease and partly to perceived susceptibility to osteoporosis. Past diagnosis of osteoporosis, current or past smoking status, and BMI were unrelated to knowledge in multivariate analyses.

CONCLUSIONS

There is a need to improve knowledge of osteoporosis especially among less educated and minority women. Subjective perception of risk was more strongly related to knowledge than actual risk factors and should be targeted in public campaigns. The efforts should be aimed at strengthening women's perception of their own susceptibility to osteoporosis and of the severity of this disease.

Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial

Osteoporosis treatment rates are declining, even among those with past fractures. Novel, low-cost approaches are needed to improve osteoporosis care. We conducted a parallel group, controlled, randomized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use. A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women (GLOW) sites were randomized 1:1 to receive a multimodal, tailored, direct-to-patient, video intervention versus usual care. The primary study outcome was self-report of osteoporosis medication use at 6 months. Other outcomes included calcium and vitamin D supplementation, bone mineral density (BMD) testing, readiness for behavioral change, and barriers to treatment. In intent-to-treat analyses, there were no significant differences between groups (intervention versus control) in osteoporosis medication use (11.7% versus 11.4%, p = 0.8), calcium supplementation (31.8% versus 32.6%, p = 0.7), vitamin D intake (41.3% versus 41.9%, p = 0.8), or BMD testing (61.8% versus 57.1%, p = 0.2). In the intervention group, fewer women were in the precontemplative stage of behavior change, more women reported seeing their primary care provider, had concerns regarding osteonecrosis of the jaw, and difficulty in taking/remembering to take osteoporosis medications. We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment, those who provided contact information, and those with no past BMD testing. In per protocol analyses, women with appreciable exposure to the online intervention (n = 257) were more likely to start nonbisphosphonates (odds ratio [OR] = 2.70; 95% confidence interval [CI] 1.26-5.79) compared with the usual care group. Although our intervention did not increase the use of osteoporosis therapy at 6 months, it increased nonbisphosphonate medication use and BMD testing in select subgroups, shifted participants' readiness for behavior change, and altered perceptions of barriers to osteoporosis treatment. Achieving changes in osteoporosis care using patient activation approaches alone is challenging. © 2018 American Society for Bone and Mineral Research.

Experiences of being diagnosed with osteoporosis: a meta-synthesis

This systematic review provides synthesised knowledge and guidance to health professionals on the experiences and perspectives of being diagnosed with osteoporosis from the patient's point of view. Using individuals' experiences and meanings can promote tailored and targeted information and guidance on osteoporosis, bone care and treatment at different stages of the osteoporosis trajectory.

INTRODUCTION

To be diagnosed with osteoporosis with or without fragility fractures affects individuals differently. The aim of this review was firstly to aggregate existing qualitative evidence regarding an individual's experience of being diagnosed with osteoporosis at different stages, and secondly, to use a systematic approach to develop a conceptual understanding of central issues relevant for health professionals in order to provide support and guidance to patients/individuals.

METHODS

This study used a systematic review methodology and methods for qualitative synthesis as recommended by Cochrane and integrated the findings of qualitative research from eight databases (Medline, PubMed, CINAHL, Embase, SweMed+, PsycINFO, ERIC, Web of Science) to July 2016. Selection and assessment were performed by three authors while four authors were involved in the analysis. Findings were cross-checked with the original article to ensure consistency with the individual's accounts.

RESULTS

Our findings have revealed that individuals diagnosed with osteoporosis do not perceive osteoporosis as a biomedical trajectory but as a self-perceived continuum of severity and health. To be diagnosed with osteoporosis affects individuals differently depending on, for example, personal experience, pre-conceived notions of or knowledge about the disease, fragility fractures or pain. Hence, individuals will create a meaning of the diagnosis based on self-perceived fracture risk, self-perceived severity of osteoporosis and at the same time, self-perceived health.

CONCLUSIONS

This meta-synthesis provides knowledge for health professionals on the experiences and perspectives of being diagnosed with osteoporosis from the patient's point of view. The experience, meaning and significance of osteoporosis must be taken into consideration and can be used to promote tailored and targeted information and guidance on osteoporosis, bone care and treatment at different stages of the osteoporosis trajectory.

Bone Phenotype Assessed by HRpQCT and Associations with Fracture Risk in the GLOW Study

The epidemiology and pathogenesis of fractures in postmenopausal women has previously been investigated in the Global Longitudinal study of Osteoporosis in Women (GLOW). To date, however, relationships between bone imaging outcomes and fracture have not been studied in this cohort. We examined relationships between high-resolution peripheral quantitative computed tomography (HRpQCT) parameters and fracture in the UK arm of GLOW, performing a cluster analysis to assess if our findings were similar to observations reported from older participants of the Hertfordshire Cohort Study (HCS), and extended the analysis to include tibial measurements. We recorded fracture events and performed HRpQCT of the distal radius and tibia and dual-energy X-ray absorptiometry (DXA) of the hip in 321 women, mean age 70.6 (SD 5.4) years, identifying four clusters at each site. We saw differing relationships at the radius and tibia. Two radial clusters (3 and 4) had a significantly lower hip areal bone mineral density (p < 0.001) compared to Cluster 1; only individuals in Cluster 4 had a significantly higher risk of fracture (p = 0.005). At the tibia, clusters 1, 3 and 4 had lower hip areal bone mineral density (p < 0.001) compared to Cluster 2; individuals in Cluster 3 had a significantly higher risk of fracture (p = 0.009). In GLOW our findings at the radius were very similar to those previously reported in the HCS, suggesting that combining variables derived from HRpQCT may give useful information regarding fracture risk in populations where this modality is available. Further data relating to tibial HRpQCT-phenotype and fractures are provided in this paper, and would benefit from validation in other studies. Differences observed may reflect age differences in the two cohorts.

Self-perception of fracture risk: what can it tell us?

In this study, we report that self-perception of fracture risk captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is associated with improved medication uptake. It suggests that adequate appreciation of fracture risk may be beneficial and lead to greater healthcare engagement and treatment.

INTRODUCTION

This study aimed to assess how well self-perception of fracture risk, and fracture risk as estimated by the fracture prediction tool FRAX, related to fracture incidence and uptake and persistence of anti-osteoporosis medication among women participating in the Global Longitudinal study of Osteoporosis in Women (GLOW).

METHODS

GLOW is an international cohort study involving 723 physician practices across 10 countries in Europe, North America and Australia. Aged ≥ 55 years, 60,393 women completed baseline questionnaires detailing medical history, including co-morbidities, fractures and self-perceived fracture risk (SPR). Annual follow-up included self-reported incident fractures and anti-osteoporosis medication (AOM) use. We calculated FRAX risk without bone mineral density measurement.

RESULTS

Of the 39,241 women with at least 1 year of follow-up data, 2132 (5.4%) sustained an incident major osteoporotic fracture over 5 years of follow-up. Within each SPR category, risk of fracture increased as the FRAX categorisation of risk increased. In GLOW, only 11% of women with a lower baseline SPR were taking AOM at baseline, compared with 46% of women with a higher SPR. AOM use tended to increase in the years after a reported fracture. However, women with a lower SPR who were fractured still reported lower AOM rates than women with or without a fracture but had a higher SPR.

CONCLUSIONS

These results suggest that SPR captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is also associated with improved medication uptake.

Comparing self-perceived and estimated fracture risk by FRAX® of women with osteoporosis

In this study, we compared subjective fracture risks of Hungarian women with osteoporosis to FRAX®-based estimates. Patients with a previous fracture, parental hip fracture, low femoral T-score, higher age, and higher BMI were more likely to underestimate their risks. Patients also failed to associate risk factors with an increased risk of fractures.

PURPOSE

The main objectives were to explore associations between self-perceived 10-year fracture risks of women with osteoporosis (OP) and their risks calculated by the FRAX® algorithm and to identify determinants of the underestimation of risk.

METHODS

We carried out a cross-sectional study in 11 OP centers in Hungary and collected data on the risk factors considered by the FRAX® calculator. Patients estimated their subjective 10-year probability of any major osteoporotic and hip fracture numerically, in percentages and also on a visual analog scale (VAS). We compared subjective and FRAX® estimates and applied logistic regression to analyze the determinants of the underestimation of risk. Associations between risk factors and subjective risk were explored using linear probability models.

RESULTS

Nine hundred seventy-two OP patients were included in the analysis. Major OP and hip fracture risk by FRAX® were on average 20.1 and 10.5%, while subjective estimates were significantly higher, 30.0 and 24.7%, respectively. Correlations between FRAX® and subjective measures were very weak (r = 0.12-0.16). Underestimation of major OP fracture risk was associated with having had a single previous fracture (OR = 2.0), parental hip fracture (OR = 3.4), femoral T-score ≤-2.5 (OR = 4.2), higher age, body mass index, and better general health state. We did not find significant associations between subjective risk estimates and most of the risk factors except for previous fractures.

CONCLUSIONS

Hungarian OP patients fail to recognize most of the risk factors of fractures. Thus, education of patients about these risk factors would be beneficial especially for the elderly with a low femoral T-score and parental hip fracture history.

Utilization of bone mineral density testing among breast cancer survivors in British Columbia, Canada

Breast cancer survivors are at high osteoporosis risk. Bone mineral density testing plays a key role in osteoporosis management. We analyzed a historical utilization of bone mineral density testing in breast cancer survivors. The utilization remained low in the 1995-2008 period. Lower socio-economic status and rural residency were associated with lower utilization.

INTRODUCTION

To evaluate the utilization of bone mineral density (BMD) testing for female breast cancer survivors aged 65+ surviving ≥ 3 years in British Columbia, Canada.

METHODS

A retrospecitve population-based data linkage study. Trends in proportion of survivors with ≥ 1 BMD test for each calendar year from 1995 to 2008 were evaluated with a serial cross-sectional analysis. Associations between factors (socio-demographic and clinical) and BMD testing rates over the period 2006-2008 for 7625 survivors were evaluated with a cross-sectional analysis and estimated as adjusted prevalence ratios (PR_adj) using log-binomial models.

RESULTS

Proportions of survivors with ≥ 1 BMD test increased from 1.0% in 1995 to 10.1% in 2008. The BMD testing rate in 2006-2008 was 26.5%. Socio-economic status (SES) and urban/rural residence were associated with BMD testing rates in a dose-dependent relationship (p for trend< 0.01). Survivors with lower SES (PR_adj = 0.66-0.78) or rural residence (PR_adj = 0.70) were 20-30% less likely to have BMD tests, compared with survivors with the highest SES or urban residence. BMD testing rates were also negatively associated with older age (75+) (PR_adj = 0.47; 95% CI = 0.42, 0.52), nursing home residency (0.05; 0.01, 0.39), recent osteoporotic fractures (0.21; 0.14, 0.32), and no previous BMD tests (0.26; 0.23, 0.29).

CONCLUSION

Utilization of BMD testing was low for breast cancer survivors in BC, Canada. Lower SES and rural residence were associated with lower BMD testing rates.

IMPLICATION FOR CANCER SURVIVORS

Female breast cancer survivors, especially those with lower SES or rural residence, should be encouraged to receive BMD tests as recommended by Canadian guidelines.

Prevalence and risk factors associated with glucocorticoid-induced osteoporosis in Chinese patients with rheumatoid arthritis

Usage of glucocorticoid (GC) is a strong risk factor of osteoporosis (OP) and osteoporotic fracture (OPF) in Chinese patients with rheumatoid arthritis (RA). Controlling GC daily dosage and shortening GC course are helpful in preventing glucocorticoid-induced osteoporosis (GIOP) and OPF for Chinese patients with RA.

INTRODUCTION

This study aims to investigate the prevalence and risk factors of GIOP, and also identify influences of GC daily dosage and GC treatment course for GIOP in Chinese patients with RA.

METHODS

Seven hundred and ninety patients with RA and 158 normal subjects were enrolled in the study. Clinical and laboratory features and medications of GC were recorded in detail. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry in all subjects.

RESULTS

BMD at all measured sites in RA was significantly lower than that in control group. Prevalence of OP was obviously higher in RA with GC group (41.6%), compared with RA without GC group (29.4%). Prevalence of OPF in group of RA with GC (21.0%) was higher than that in group of RA without GC (13.3%). Usage of GC, female, and age were risk factors for the occurrence of OP and OPF in RA, while body mass index (BMI) was the protective factor of OP. Prevalence of GIOP and OPF had statistical significance among groups of different treatment courses with GC, whereas no statistical difference was found among groups with different daily dosages of GC.

CONCLUSIONS

GIOP exists generally in Chinese patients with RA, which relates to treatment course not daily dosage of GC. Usage of GC is also the risk factor for the happening of OPF in Chinese patients with RA.

Imminent fracture risk

The clinical significance of osteoporosis is in the occurrence of fractures and re-fractures. The main risk factor of sustaining a fracture is a previous one, but a recent fracture is a better fracture risk factor than fracture history. The role of the recency of fracture has been shown for both vertebral and non-vertebral fracture risk. This imminent risk is explained by both bone-related factors (underlying osteoporosis) and fall-related factors (including those related to postfracture care). Such a short-term increased risk has been shown also in patients initiating corticosteroids and in frail osteoporotic subjects with central nervous system (CNS) diseases or drugs targeting CNS, and thus a high risk of falls. Patients with an imminent (i.e. 2 years) risk of fracture or refracture should be identified in priority in order to receive an immediate treatment and a program of fall prevention.

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures

This narrative review considers the key challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health. These challenges broadly fall into four distinct themes: (1) case finding and management of individuals at high risk of fracture, (2) public awareness of osteoporosis and fragility fractures, (3) reimbursement and health system policy and (4) epidemiology of fracture in the developing world. Findings from cohort studies, randomised controlled trials, systematic reviews and meta-analyses, in addition to current clinical guidelines, position papers and national and international audits, are summarised, with the intention of providing a prioritised approach to delivery of optimal bone health for all. Systematic approaches to case-finding individuals who are at high risk of sustaining fragility fractures are described. These include strategies and models of care intended to improve case finding for individuals who have sustained fragility fractures, those undergoing treatment with medicines which have an adverse effect on bone health and people who have diseases, whereby bone loss and, consequently, fragility fractures are a common comorbidity. Approaches to deliver primary fracture prevention in a clinically effective and cost-effective manner are also explored. Public awareness of osteoporosis is low worldwide. If older people are to be more pro-active in the management of their bone health, that needs to change. Effective disease awareness campaigns have been implemented in some countries but need to be undertaken in many more. A major need exists to improve awareness of the risk that osteoporosis poses to individuals who have initiated treatment, with the intention of improving adherence in the long term. A multisector effort is also required to support patients and their clinicians to have meaningful discussions concerning the risk-benefit ratio of osteoporosis treatment. With regard to prioritisation of fragility fracture prevention in national policy, there is much to be done. In the developing world, robust epidemiological estimates of fracture incidence are required to inform policy development. As the aging of the baby boomer generation is upon us, this review provides a comprehensive analysis of how bone health can be improved worldwide for all.

Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced.

INTRODUCTION

Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year.

METHODS

We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison.

RESULTS

We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time.

CONCLUSIONS

The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Low self-awareness of osteoporosis and fracture risk among postmenopausal women

Postmenopausal women with a high risk of fractures may not perceive their risk. This study showed no concordance between the perceived and calculated risk of fracture. Almost 80 % of the women identified as a high risk of fracture by the FRAX algorithm tool perceived themselves to have little risk.

PURPOSE

This study aimed to assess the concordance between self-perception of osteoporosis and fracture risk and the 10-year risk of fractures calculated by the FRAX algorithm.

METHODS

A cross-sectional study was conducted in Santa Maria, RS, Brazil, between March 1 and August 31, 2013. Postmenopausal women over 55 years of age who have had at least one appointment at primary care in the 2 years prior to the enrolment were recruited. We excluded women with cognitive impairment. A standardized questionnaire regarding the perception of personal risk of osteoporosis and fractures was used. We also evaluated previous fractures, family history of fracture, smoking, alcohol consumption, use of glucocorticoids, and secondary causes of osteoporosis. Weight and height of the participants were measured. The risk of fractures of each participant was calculated using the FRAX algorithm (Fracture Risk Assessment Tool).

RESULTS

Of the 1301 invited women, 1057 completed the survey. The average (mean [SD]) age and BMI were 67.2 (7.6) years and 29.3 (5.5) kg/m(2), respectively. Only 16.9 and 19.9 % participants believed themselves to be at a high risk of osteoporosis and fractures, respectively. There was no agreement between the perceived risk of fractures and the calculated FRAX risk of fractures. Moreover, almost 79.3 % of the women identified with a high risk of fractures by the FRAX algorithm perceived themselves as having little risk.

CONCLUSION

These results show that postmenopausal women underestimate their risk of osteoporotic fractures when compared with their 10-year fracture risk according to FRAX algorithm.

Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure

CONTEXT

Patient education materials can provide important information related to osteoporosis prevention and treatment. However, available osteoporosis education materials fail to follow best-practice guidelines for patient education.

OBJECTIVE

To develop an educational brochure on bone health for adults aged 50 years and older using mixed-method, semistructured interviews.

DESIGN

This project consisted of 3 phases. In Phase 1, we developed written content that included information about osteoporosis. Additionally, we designed 2 graphic-rich brochures, Brochure A (photographs) and Brochure B (illustrations). In Phase 2, interviewers presented the text-only document and both brochure designs to 53 participants from an academic Medical Center in the Midwest and an outpatient clinic in the Southeastern region of the US. Interviewers used open- and closed-ended questions to elicit opinions regarding the brochures. In Phase 3, using feedback from Phase 2, we revised the brochure and presented it to 11 participants at a third site in the Southeastern US.

MAIN OUTCOME MEASURES

Participants' comprehension of brochure text and acceptability of brochure design.

RESULTS

We enrolled 64 participants. Most were women, white, and college-educated, with an average age of 66.1 years. Participants were able to restate the basic content of the brochure and preferred Brochure A's use of photographs.

CONCLUSIONS

Using feedback from older adults, we developed and refined a brochure for communicating bone health information to older adults at risk of osteoporosis and fragility fractures. The methods outlined in this article may serve to guide others in developing health educational brochures for chronic medical conditions.

Barriers to Effective Postmenopausal Osteoporosis Treatment: A Qualitative Study of Patients' and Practitioners' Views

BACKGROUND

Only a minority of patients at high risk for osteoporotic fracture receive treatment.

OBJECTIVE

Study patients' and physicians' views regarding postmenopausal osteoporosis (PMO) to identify impediments to good care.

METHODS

A qualitative study involving 18 physicians and 37 women (age 57-87) with PMO.

RESULTS

All women interviewed considered PMO to be somewhat normal wear-and-tear associated with old age. The women identified a large number of "causes" for osteoporosis but finally viewed it as chance. They all described its progression as slow. Three representations of PMO severity were identified: some women tended to interpreted it as benign (21), others tended to dramatize it (11), and the rest were uncertain (5). These representations did not appear linked to age or fracture. Even the women who associated fracture and PMO were uncertain of the link between them. Fractures were considered to be random events, independent of osteoporosis. Women received general life-style recommendations from their physicians positively, but did not connect them specifically to osteoporosis. Indeed, these recommendations, along with the fear of side effects, the absence of tangible results of treatments, the view of PMO as a natural process, and the representations of PMO severity are factors that may deter treatments and impact compliance. As for the physicians, they identified eight risk factors, recognizing menopause as central to PMO and recognized the link between risk of fracture and PMO. However, some considered the impact of fractures to be limited in time, and viewed PMO as a "benign" disease. Seeing the progression of PMO as slow and inevitable reduced their urgency to diagnose and treat it as compared to other diseases. Some physicians acknowledged limited mastery of the existing therapeutic arsenal and unsuccessful handling of patient compliance.

CONCLUSION

Women's and physicians' perspectives on PMO converged to trivialize postmenopausal osteoporosis and thus disqualify it as a legitimate disease. A better understanding of women's and physicians' views, practices, and concerns related to PMO can improve osteoporosis management.

Increased risk of humerus and lower leg fractures in postmenopausal women with self-reported premenopausal hirsutism and/or oligomenorrhea

OBJECTIVE

The aim of this study was to investigate the prevalence of fracture in women aged >55 years with self-reported premenopausal hirsutism and/or oligomenorrhea.

STUDY DESIGN

A cross-sectional study including 1057 post-menopausal women aged >55 years who were treated in a primary care facility in Santa Maria, South Brazil, from March 2013 through August 2013. Data were collected using a standardized questionnaire for characteristics including fracture history, medication use, and reproductive history (oligomenorrhea, hirsutism, miscarriage, the diagnosis or treatment of hypothyroidism, hyperprolactinemia, or infertility).

RESULTS

A non-significant trend towards an increased prevalence of all fragility fractures was observed in women with premenopausal hirsutism and/or oligomenorrhea when compared to those without (20.4% vs. 15.7%). After correction for age, falls, and comorbidities, fracture prevalence was significantly higher in the lower leg (OR 3.1 [CI 1.1-8.6]; P=0.029), and humerus (OR 2.6 [CI 1.2-5.4]; P=0.015) in the women with hirsutism and/or oligomenorrhea.

CONCLUSION

This is a hypothesis-generating study which evaluated the association between hirsutism and/or oligomenorrhea and fractures in postmenopausal women. Our results suggest that premenopausal hirsutism and/or oligomenorrhea may be associated with an increased risk of fracture postmenopause, particularly in the humerus and lower leg.

The Relationship of Perceived Risk and Biases in Perceived Risk to Fracture Prevention Behavior in Older Women

BACKGROUND

A bias in perceived risk for health outcomes, including fracture, exists.

PURPOSE

We compared perceived risk and biases in perceived risk for fracture to fracture preventive behavior.

METHODS

Women over age 55 (n = 2874) completed a survey five times over 5 years, and data was pulled from the medical record. Perceived risk was measured by asking women to rate their risk of fracture compared to similar women. Actual risk was measured using FRAX score. Bias was measured using an interaction between perceived and actual risk.

RESULTS

Higher perceived risk was related to lower quality of life and self-reported health, more medication and calcium use, increased bone density scan use, and less walking. Bias was only associated with less medication use. Neither perceived risk nor bias predicted medication adherence.

CONCLUSIONS

Perceived risk, but not bias, may predict different fracture prevention behaviors. Clinicians may need to base interventions on risk perceptions.

Association between gastrointestinal events and osteoporosis treatment initiation in women diagnosed with osteoporosis in France: a retrospective analysis

Background

A substantial portion of women diagnosed with osteoporosis (OP) do not initiate pharmacotherapy to reduce fracture risk. In clinical practice, gastrointestinal (GI) events have been linked with OP therapy discontinuation. However, there is limited research examining GI events as barrier to treatment initiation following an OP diagnosis. The objective of this study was to examine the association between gastrointestinal (GI) events and osteoporosis (OP) treatment initiation among post-menopausal women diagnosed with osteoporosis in France.

Methods

A retrospective claims analysis of the Mediplus France database during 1997 to 2010 identified women aged ≥ 55 with an OP diagnosis and without prior OP treatment (first diagnosis date was defined as the index date). GI events were identified during the 1 year pre-index and up to 1 year post-index. OP treatment initiation post-index was identified based on the presence of claims for any bisphosphonate (BIS) or non-BIS OP medication within 1 year post-index. Multivariate models (logistic regression, Cox proportional hazards regression and discrete choice) adjusted for pre-index patient characteristics were used to assess the association of pre- and post-index GI events with the likelihood of initiating OP treatment, and the type of treatment initiated (BIS vs. non-BIS).

Results

A total of 10,292 women (mean age 70.3 years) were identified; only 25 % initiated OP treatment. Post-index GI events occurred in 11.5 % of patients, and were associated with a 75.7 % lower likelihood of initiating OP treatment. Among treated patients, a discrete choice model estimated that patients with post-index GI events were 34.6 % less likely to receive BIS vs non-BIS as compared to patients without post-index GI events.

Conclusion

Among women aged ≥ 55 years with an OP diagnosis, post-index GI events were associated with a lower likelihood of OP treatment initiation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1041-8) contains supplementary material, which is available to authorized users.

Patient acceptance of osteoporosis treatment: Application of the stages of change model

OBJECTIVES

To examine whether a commonly used model of behaviour change, stages of change, is helpful in understanding osteoporosis treatment initiation in a cohort of fragility fracture patients.

STUDY DESIGN

This longitudinal cohort study used data from a provincial osteoporosis screening program targeting fragility fracture patients age 50 and over. Logistic regression was used to identify baseline factors associated with patients moving from the first, pre-contemplation stage at baseline to the more advanced stages of action/maintenance at follow-up, when treatment is initiated and maintained.

MAIN OUTCOME MEASURE

Patient's stage-of-change readiness to accept osteoporosis treatment.

RESULTS

At baseline, 91% of patients were in the pre-contemplation stage. Of these, 74.1% remained at the same stage at follow-up, 2.7% moved to contemplation and preparation while 23.2% moved to action/maintenance. The adjusted analysis showed that those who moved from pre-contemplation to action/maintenance were more likely to have a previous fracture OR 1.5 (1.1-2.0), history of oral steroid use OR 2.1 (1.3-3.5), higher perceived benefits to osteoporosis drug treatment OR 1.2 (1.0-1.3), perception of bones as "thin" OR 2.8 (2.0-4.0) and were less likely to perceive that they were taking too many medications OR 0.6 (0.5-0.9).

CONCLUSIONS

With the majority of patients in the pre-contemplation and the action/maintenance stages, our results suggest an existence of a two-stage model. The baseline factors that we identified can be used to predict which patients are less likely to initiate treatment, which in turn, can be used to inform post-fracture interventions and facilitate behaviour change.

An exploration of barriers and facilitators to older adults' participation in higher impact physical activity and bone health: a qualitative study

SUMMARY

This qualitative study explored the acceptability of high-impact physical activity for increasing bone strength in later life. Thematic analysis established the barriers and facilitators to this physical activity. They prioritised joint over skeletal health, of which they had little concept. Interventions need to clearly communicate the rationale and benefits.

INTRODUCTION

The aim of this study was to explore the acceptability of doing high-impact physical activity in later life.

METHODS

This qualitative study was embedded within a large-scale observational study and was designed to address specific objectives and feed into a subsequent intervention. Five focus groups with physically active men and women (over 50 years) were used to develop an interview topic guide to explore the acceptability of high-impact physical activity in older men and women (over 65 years) in South West England. A total of 28 semi-structured interviews with 31 participants were then conducted and transcripts analysed thematically.

RESULTS

Three main barriers emerged: conceptualising bone, damage to joints and falling/safety concerns. Two main facilitators were also identified: the need to understand clear tangible benefits and incorporation of activity into everyday habits. Older adults were interested how high-impact physical activity would help to maintain their mobility, independence or social relationships. Some participants wanted tangible feedback from accelerometers, health care professionals and/or bone scans in order to develop a more intimate knowledge of their bone health.

CONCLUSIONS

Interventions incorporating high-impact physical activity for older adults need to communicate how this activity can impact more broadly on health and lives; that physical activity will be safe, beneficial and not damaging to their joints will need to be clearly conveyed. Ways in which high-impact physical activity can be habitualised into everyday activities, be fun and interactive may help facilitate longer term adoption.

Patients do not have a consistent understanding of high risk for future fracture: a qualitative study of patients from a post-fracture secondary prevention program

We examined fracture patients' understanding of "high" fracture risk after they were screened through a post-fracture secondary prevention program and educated about their risk verbally, numerically, and graphically. Our findings suggest that messages about fracture risk are confusing to patients and need to be modified to better suit patients' needs.

INTRODUCTION

The aim of this study was to examine fracture patients' understanding of high risk for future fracture.

METHODS

We conducted an in-depth qualitative study in patients who were high risk for future fracture. Patients were screened through the Osteoporosis Exemplary Care Program where they were educated about fracture risk: verbally told they were "high risk" for future fracture, given a numerical prompt that they had a >20 % chance of future fracture over the next 10 years, and given a visual graph highlighting the "high risk" segment. This information about fracture risk was also relayed to patients' primary care physicians (PCPs) and specialists. Participants were interviewed at baseline (within six months of fracture) and follow-up (after visit with a PCP and/or specialist) and asked to recall their understanding of risk and whether it applied to them.

RESULTS

We recruited 27 patients (20 females, 7 males) aged 51-87 years old. Fractures were sustained at the wrist (n = 7), hip (n = 7), vertebrae (n = 2), and multiple or other locations (n = 11). While most participants recalled they had been labeled as "high risk" (verbal cue), most were unable to correctly recall the other elements of risk (numerical, graphical). Further, approximately half of the patients who recalled they were high risk did not believe that high risk applied, or had meaning, to them. Participants also had difficulty explaining what they were at risk for.

CONCLUSIONS

Our results suggest that health care providers' messages about fracture risk are confusing to patients and that these messages need to be modified to better suit patients' needs.

The NYU Osteoporosis Model of Care Experience

INTRODUCTION

Participants who sustain a fragility fracture are at increased risk for subsequent fractures. Despite the consequences of recurrent fractures, bone mineral density (BMD) testing and treatment rates for osteoporosis after a fracture remain low. The New York University (NYU) Langone Osteoporosis Model of Care was developed to identify women at increased risk for recurrent fractures and to reduce the rates of subsequent fracture through patient and physician education.

METHODS

Women aged 50 years and older who had a fracture and received their care at NYU affiliated hospitals were contacted via mail after discharge. Participants were provided educational materials explaining decreased bone strength and its possible relationship to their fracture and were asked to complete a questionnaire. One year postfracture, participants were sent follow-up questionnaires requesting their most recent fracture treatment and BMD information. Educational material was also provided to the treating orthopedic surgeons.

RESULTS

Overall, 524 patients were contacted and 210 (40%) enrolled. By the end of 24 months, 92 participants completed their 1-year questionnaire (44% of the enrollees). Forty-two (46%) participants had undergone new BMD testing and 37 (40%) were receiving antiresorptive medications, including 6 (6%) who had not been prescribed these medications before enrolling in the program.

CONCLUSIONS

The Osteoporosis Model of Care is a simple and cost-effective educational program, which improved comprehensive fracture care in an actual clinical setting. Patient enrollment remains a challenge in implementing the program. Our program highlights difficulties in providing community-dwelling participants with appropriate postfracture care. With increasing concern among the public regarding the use of bone strengthening medications and continued low postfracture treatment rates, educating patients with high fracture risk is critical to reducing the rate of subsequent fracture. Our Model of Care Program demonstrates both the success and limitations of a postfracture educational approach using discharge diagnosis data to identify patients with fracture.

Association between gastrointestinal events and compliance with osteoporosis therapy

PURPOSE

The aim of this study was to estimate the rate of gastrointestinal (GI) events, and association between GI events and compliance with osteoporosis therapy among osteoporotic women.

METHODS

A retrospective cohort study using a large administrative claims database in the United States from 2001 through 2010 was conducted. We studied women ≥ 55 years old who were continuously enrolled in a health plan for at least 2 years, a baseline year before and a follow-up year after the date of the first prescription of oral bisphosphonate as the first oral osteoporosis treatment. Compliance with osteoporosis therapy was measured using the medication possession ratio (MPR), with compliance defined as MPR ≥ 0.8. Multivariate logistic regression was used to assess the association between occurrence of GI events and compliance with osteoporosis therapy after controlling for demographic and clinical characteristics.

RESULTS

A sample consisting of 75,593 women taking at least one oral bisphosphonate with mean (SD) age of 64 (8) years was identified. A total of 21,142 (28%) patients experienced at least one GI event during the follow-up period. Only 31,306 (41%) patients were compliant with osteoporosis therapy. Patients who experienced GI events after initiation of oral bisphosphonates were 29% less likely to adhere to osteoporosis therapy as compared to patients who did not experience GI events (odds ratio [95% CI], 0.71 [0.69-0.74]; P < .001).

CONCLUSIONS

Less than half of the patients were compliant with osteoporosis therapy within one year after initiating oral bisphosphonates, and the likelihood of compliance was significantly lower by 29% among women with GI events.

Self-perceived facture risk: factors underlying women's perception of risk for osteoporotic fractures: the Risk-Stratified Osteoporosis Strategy Evaluation study (ROSE)

SUMMARY

This Danish cross-sectional study (n=20,905) showed that women aged 65-81 years generally underestimated fracture risk compared to absolute risk estimated by the FRAX® algorithm. Significant association was found between risk factors (e.g., previous fracture, parental hip fracture, and self-rated heath) and self-perceived fracture risk. Although women recognized the importance of some fracture risk factors, a number of significant risk factors appeared to be less well known.

INTRODUCTION

The aim of this study is to investigate women's self-perceived fracture risk and potential factors associated with this and to compare self-perceived risk with absolute fracture risk estimated by FRAX® in women aged 65-80 years.

METHODS

Data from 20,905 questionnaires from the ROSE study were analyzed. The questionnaire included 25 items on osteoporosis, risk factors for fractures, and self-perceived risk of fractures and enabled calculation of absolute fracture risk by FRAX®. Data were analyzed using bivariate tests and regression models.

RESULTS

Women generally underestimated their fracture risk compared to absolute risk estimated by FRAX®. Women with risk factors for facture estimated their fracture risk significantly higher than their peers. No correlation between self-perceived risk and absolute risk was found. The ordered logistic regression model showed a significant association between high self-perceived fracture risk and previous fragility fracture, parental hip fracture, falls, self-rated heath, conditions related to secondary osteoporosis, and inability to do housework.

CONCLUSIONS

These women aged 65-81 years underestimated their risk of fracture. However, they did seem to have an understanding of the importance of some risk factors such as previous fractures, parental hip fracture and falls. Risk communication is a key element in fracture prevention and should have greater focus on less well-known risk factors. Furthermore, it is important to acknowledge that risk perception is not based solely on potential risk factors but is also affected by experiences from everyday life to personal history.

Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States

OBJECTIVES

To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations.

PATIENTS AND METHODS

The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011.

RESULTS

From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion).

CONCLUSION

These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden.

Improving bone mineral density reporting to patients with an illustration of personal fracture risk

Background

To determine patients’ preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations.

Methods

Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration.

Results

Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most “clear,” “clean,” and “easy to read”. The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category.

Conclusions

Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference.

Trial Registration

ClinicalTrials.gov Identifier: NCT01507662

Challenges in implementing and maintaining osteoporosis therapy

In the United States, an estimated 19% of older men and 30% of older women are at elevated risk of osteoporotic fracture and considered to be eligible for treatment. The burden of osteoporosis is similar in Europe and is projected to rise worldwide, with aging populations and increasing fracture rates accompanying urbanization. Notwithstanding its high prevalence, osteoporosis is often underdiagnosed and undertreated. Moreover, even when the diagnosis is made and the decision is taken to treat, there are remaining challenges in implementing therapy for osteoporosis. Several patient populations are particularly challenging for clinicians to treat and require further study with regard to osteoporosis therapy. These include the very elderly, who face challenges relating to adherence; men, in whom osteoporosis remains under-recognized; patients with glucocorticoid-induced osteoporosis or renal impairment, who are at increased risk of fracture; patients with preexisting gastrointestinal problems who cannot tolerate existing orally administered osteoporosis therapies; and high-risk patients who show inadequate response to therapy. Moreover, poor adherence and poor persistence with osteoporosis medications are common and result in an increased risk of fracture, higher medical costs, and increased hospitalizations. Once the decision to institute therapy is made, patient education about osteoporosis and fracture risk should be provided. This is particularly important for men, who may not be aware that osteoporosis can be a concern. Secondary prevention programs, including fracture liaison services and bone therapy groups, can help to improve adherence to therapy. Further study is needed to guide the treatment of men, the very elderly, patients with glucocorticoid-induced osteoporosis and renal impairment, high-risk patients not well-controlled despite therapy, and patients with preexisting gastrointestinal conditions. Moreover, therapies are needed that are viewed as effective and safe by both physicians and patients, and as convenient to take by patients.

Insights from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

GLOW is an observational, longitudinal, practice-based cohort study of osteoporosis in 60,393 women aged ≥55 years in 10 countries on three continents. In this Review, we present insights from the first 3 years of the study. Despite cost analyses being frequently based on spine and hip fractures, we found that nonvertebral, nonhip fractures were around five times more common and doubled the use of health-care resources compared with hip and spine fractures combined. Fractures not at the four so-called major sites in FRAX(®) (upper arm, forearm, hip and clinical vertebral fractures) account for >40% of all fractures. The risk of fracture is increased by various comorbidities, such as Parkinson disease, multiple sclerosis and lung and heart disease. Obesity, although thought to be protective against all fractures, substantially increased the risk of fractures in the ankle or lower leg. Simple assessment by age plus fracture history has good predictive value for all fractures, but risk profiles differ for first and subsequent fractures. Fractures diminish quality of life as much or more than diabetes mellitus, arthritis and lung disease, yet women substantially underestimate their own fracture risk. Treatment rates in patients at high risk of fracture are below those recommended but might be too frequent in women at low risk. Comorbidities and the limits of current therapeutic regimens jeopardize the efficacy of drugs; new regimens should be explored for severe cases.

How long should we treat?

Osteoporosis is a chronic disease, for which effective drugs are available. These drugs have reduced the risk of osteoporosis-related fractures in robust trials of 3-5 years duration. There is no evidence of anti-fracture efficacy for treatments of longer duration. The consequences of stopping treatments are very different for the different molecules. Bisphosphonates can be safely discontinued after 3-5 years of treatment if there was optimal adherence and if patients are no longer osteoporotic. This discontinuation cannot be applied in patients with recent fractures or for other treatments. Safety of prolonged treatment is a huge concern which must be managed appropriately. The decision of a prolonged treatment is driven by the underlying risk of fracture. This risk must be assessed regularly in order to share with the patient the benefit-risk ratio of prolonged treatment.