Public priorities for osteoporosis and fracture research: results from a focus group study

A person-centred primary care pharmacist-led osteoporosis review for optimising medicines (PHORM): a protocol for the development and co-design of a model consultation intervention

INTRODUCTION

Adherence to medicines in osteoporosis is poor, with estimated 1 year persistence rates between 16% and 60%. Poor adherence is complex, relating to combinations of fear of side effects, beliefs about medication being unnecessary, doubts about effectiveness and the burden of medication management. This is compounded by an absence of monitoring, as many patients are effectively discharged from ongoing care following the initial prescription. Clinical pharmacists in general practice are a relatively new workforce in the UK NHS; this is an unexplored professional group that could provide person-centred, adherence-focused interventions in an osteoporosis context.A model consultation intervention to be delivered by clinical pharmacists in general practice for patients already prescribed fracture prevention medications will be developed using existing evidence and theory and empirical qualitative work outlined in this protocol.

METHODS AND ANALYSIS

We will investigate the current practice and barriers and facilitators to a clinical pharmacist-led osteoporosis intervention, including exploring training needs, through focus groups with people living with osteoporosis, pharmacists, general practitioners, osteoporosis specialists and service designers/commissioners. Framework analysis will identify and prioritise salient themes, followed by mapping codes to the theoretical domains framework and normalisation process theory to understand integration and implementation issues.We will further develop the content and model of care for the new consultation intervention through co-design workshops with stakeholder and patient and public involvement and engagement group members. The intervention in practice will be refined in a sequential process with workshops and in-practice testing with people prescribed fracture prevention medication, pharmacists and the multidisciplinary team.

ETHICS AND DISSEMINATION

Ethical approval was obtained from NHS North West-Greater Manchester South Research Ethics Committee (Ref 23/NW/0199). Dissemination and knowledge mobilisation will be facilitated through a range of national bodies/stakeholders. Impact and implementation plans will accelerate this research towards a future clinical trial to determine cost and clinical effectiveness.

Nocebo-associated treatment discontinuation with subcutaneous anti-osteoporotic drugs. A systematic review and meta-analysis of placebo-arm dropouts in randomized-controlled trials

OBJECTIVE

Nocebo is a concept of therapeutics referring to unpleasant symptoms attributed by a patient to a drug, due to negative anticipation. Patients receiving oral anti-osteoporotic drugs in randomized controlled trials (RCT) can experience adverse events leading to dropout, implying that nocebo contributes to treatment discontinuation for these drugs. In this study we aim to investigate the nocebo effect of subcutaneous anti-osteoporotic drugs with a higher compliance rate than orally administered drugs.

STUDY DESIGN

We searched MEDLINE, EMBASE, SCOPUS, and Cochrane databases for double-blind trials investigating subcutaneous anti-osteoporotic drugs for osteoporosis (namely, denosumab, teriparatide, abaloparatide and romosozumab) published up to May 2023.

MAIN OUTCOME MEASURE

Dropouts due to reported adverse events in the placebo arms ("nocebo dropouts").

RESULTS

Data from 17 trials were extracted. Among 10,529 placebo-treated patients the pooled nocebo-dropout percentage was 3 % for denosumab (average: 0.03; 95 % CI: 0.01-0.05), 1 % for romosozumab (average: 0.01; 95 % CI: 0.00-0.03) and 6 % for teriparatide and abaloparatide (average: 0.06; 95 % CI: 0.05-0.07). Nocebo-dropouts were significantly higher in men than women (6 % vs. 3 %, respectively, p = 0.012), in older (mean age >68 years) than in younger patients (5 % vs. 1 %, respectively, p = 0.017) and in those with more severe osteoporosis (based on the percentage of participants with prior fragility-related fractures in the study cohort) compared with patients with no prior fracture history (4 % vs. 1 %, respectively, p = 0.046).

CONCLUSION

Nocebo responses may contribute to treatment discontinuation with subcutaneous anti-osteoporotic drugs in clinical practice. Higher nocebo-related dropout rates in the higher-risk RCT population (older patients, males, those with prior fractures) show that nocebo mechanisms have the potential to hinder therapeutic efforts to specific populations who would benefit most. Prospero registration number CRD42020212843.

Recruitment of patients, carers and members of the public to advisory boards, groups and panels in public and patient involved health research: a scoping review

OBJECTIVES

The objectives of this scoping review are to: (1) identify the distribution of and context of the recruitment strategies used, (2) explore the facilitators, benefits, barriers and ethical issues of the identified recruitment strategies, (3) distinguish the varying terminology for involvement (ie, panels, boards, individual) and (4) determine if the individual recruitment strategies used were to address issues of representation or bias.

DESIGN

A scoping review.

SETTING

This scoping review follows the framework by Peters et al. Seven electronic databases were explored including Scopus, Medline, PubMed, Web of Science, CINAHL, Cochrane Library and PsycINFO (conducted July 2021). The search strategy was codeveloped among the research team, PPI research experts and a faculty librarian. Two independent reviewers screened articles by title and abstract and then at full text based on predetermined criteria.

PRIMARY AND SECONDARY OUTCOME MEASURES

Explore recruitment strategies used, facilitators, benefits, barriers and ethical issues of the identified recruitment strategies. Identify terminology for involvement. Explore recruitment strategies used to address issues of representation or bias.

RESULTS

The final sample was from 51 sources. A large portion of the extracted empirical literature had a clinical focus (37%, n=13) but was not a randomised control trial. The most common recruitment strategies used were human networks (78%, n=40), such as word of mouth, foundation affiliation, existing networks, clinics or personal contacts. Within the reviewed literature, there was a lack of discussion pertaining to facilitators, benefits, barriers and ethical considerations of recruitment strategies was apparent. Finally, 41% (n=21) of studies employed or proposed recruitment strategies or considerations to address issues of representation or bias.

CONCLUSION

We conclude with four key recommendations that researchers can use to better understand appropriate routes to meaningfully involve patients, carers and members of the public to cocreate the evidence informing their care.

Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise

PURPOSE

Worldwide, many people who would benefit from osteoporosis drugs are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate treatment regimens for prevention of osteoporotic fractures.

METHODS

A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered from a large programme of related research studies about bisphosphonate regimens and from recent published international clinical guidelines. Clinical and public stakeholders refined the list of uncertainties into research questions. The third step prioritised the questions using a modified nominal group technique.

RESULTS

In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. The top 10 includes questions relating to which people should be offered intravenous bisphosphonates first line (1); optimal duration of treatment (2); the role of bone turnover markers in treatment breaks (3); support patient need for medicine optimisation (4); support primary care practitioner need regarding bisphosphonates (5); comparing zoledronate given in community vs hospital settings (6); ensuring quality standards are met (7); the long-term model of care (8); best bisphosphonate for people aged under 50 (9); and supporting patient decision-making about bisphosphonates (10).

CONCLUSION

This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. These findings have implications for research into implementation to address the care gap and education of healthcare professionals. Using James Lind Alliance methodology, this study reports prioritised topics of importance to stakeholders in the research of bisphosphonate treatment in osteoporosis. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care.

Dolichos Lablab Linné Inhibits Bone Density Loss and Promotes Bone Union in Senile Osteoporosis through Osteogenesis

As populations continue to age, osteoporosis has emerged as an increasingly critical concern. Most advancements in osteoporosis treatment are predominantly directed toward addressing abnormal osteoclast activity associated with menopause, with limited progress in developing therapies that enhance osteoblast activity, particularly in the context of aging and fractures, and serious side effects associated with existing treatments have highlighted the necessity for natural-product-based treatments targeting senile osteoporosis and fractures. Dolichos lablab Linné (DL) is a natural product traditionally used for gastrointestinal disorders, and its potential role in addressing bone diseases has not been extensively studied. In this research, we investigated the anti-osteoporosis and bone-union-stimulating effects of DL using the SAMP6 model, a naturally aged mouse model. Additionally, we employed MC3T3-E1 cells to validate DL's osteoblast-promoting effect and to assess the involvement of core mechanisms such as the BMP-2/Smad and Wnt/β-catenin pathways. The experimental results revealed that DL promoted the formation of osteoblasts and calcified nodules by upregulating both the BMP-2/Smad and Wnt/β-catenin mechanisms. Based on its observed effects, DL demonstrated the potential to enhance bone mineral density in aged osteoporotic mice and promote bone union in fractured mice. These findings indicate the promising therapeutic potential of DL for the treatment of osteoporosis and bone-related conditions, thus warranting further investigation and potential clinical applications.

BONEcheck: A digital tool for personalized bone health assessment

Objectives

Osteoporotic fracture is a significant public health burden associated with increased mortality risk and substantial healthcare costs. Accurate and early identification of high-risk individuals and mitigation of their risks is a core part of the treatment and prevention of fractures. Here we introduce a digital tool called 'BONEcheck' for personalized assessment of bone health.

Methods

The development of BONEcheck primarily utilized data from the prospective population-based Dubbo Osteoporosis Epidemiology Study and the Danish Nationwide Registry. BONEcheck has 3 modules: input data, risk estimates, and risk context. Input variables include age, gender, prior fracture, fall incidence, bone mineral density (BMD), comorbidities, and genetic variants associated with BMD.

Results

Based on the input variables, BONEcheck estimates the probability of any fragility fracture and hip fracture within 5 years, subsequent fracture risk, skeletal age, and time to reach osteoporosis. The probability of fracture is shown in both numeric and human icon array formats. The risk is also contextualized within the framework of treatment and management options on Australian guidelines, with consideration given to the potential fracture risk reduction and survival benefits. Skeletal age was estimated as the sum of chronological age and years of life lost due to a fracture or exposure to risk factors that elevate mortality risk.

Conclusions

BONEcheck is an innovative tool that empowers doctors and patients to engage in well-informed discussions and make decisions based on the patient's risk profile. Public access to BONEcheck is available via https://bonecheck.org and in Apple Store (iOS) and Google Play (Android).

Osteoporosis care through an Integrated, People-Centred Health Services framework lens: a hybrid qualitative analysis of international patient experiences

OBJECTIVES

Globally, patients with osteoporosis have unmet needs in terms of care accessibility, patient-centredness and care comprehensiveness. The WHO developed the Integrated, People-Centred Health Services (IPCHS) framework to reorient and integrate healthcare systems using 5 interdependent strategies and 20 substrategies. Patients' perspectives with regard to these strategies are poorly understood. We sought to relate patient-experienced gaps in osteoporosis care to the IPCHS strategies and identify key strategies to guide osteoporosis care reforms.

DESIGN, SETTING AND PARTICIPANTS

Qualitative online study of the experiences of international patients with osteoporosis.

PROCEDURE

Two researchers conducted semi-structured interviews in English, Dutch, Spanish and French that were recorded and transcribed verbatim. Patients were categorised according to their countries' healthcare systems (universal, public/private and private) and fracture status. A hybrid (sequential theory-driven and data-driven) analysis was performed, with the IPCHS framework used for the theory-driven analysis.

RESULTS

Thirty-five patients (33 women) from 14 countries participated. Twenty-two patients had universal healthcare and 18 had experienced fragility fractures. Prioritised substrategies overlapped among healthcare systems, with reported shortcomings related primarily to 'empowering and engaging individuals and families' and 'coordinating care' (at varying levels). Patients with all healthcare types prioritised 'reorienting care', with different substrategies prioritised. Patients with private healthcare called for 'improving funding and reforming payment systems'. Substrategy prioritisation did not differ between those receiving primary and secondary fracture prevention.

CONCLUSION

Patients' experiences with osteoporosis care are universal. Given the current care gaps and associated patient burdens, policymakers should make osteoporosis a(n) (inter)national health priority. Integrated osteoporosis care reforms should focus on patient-reported experiences with and be guided by priorities in IPCHS strategies, taking into account the healthcare system context.

Incorporating FRAX into a nurse-delivered integrated care review: a multi-method qualitative study

BACKGROUND

People with inflammatory rheumatological conditions (IRCs) are at increased risk of common comorbidities including osteoporosis.

AIM

To explore the barriers to and facilitators of implementing nurse-delivered fracture risk assessments in primary care, in the context of multimorbidity reviews for people with IRCs.

DESIGN & SETTING

A multi-method qualitative study in primary care.

METHOD

As part of a process evaluation in a pilot trial, semi-structured interviews were conducted with 20 patients, two nurses, and three GPs. Twenty-four patient-nurse INCLUDE review consultations were audiorecorded and transcribed. A framework analysis was conducted using the Theoretical Domains Framework (TDF).

RESULTS

Nurses reported positive views about the value of the Fracture Risk Assessment Tool (FRAX) and they felt confident to deliver the assessments following training. Barriers to implementation, as identified by TDF, particularly related to the domains of knowledge, skills, professional roles, and environmental context. GPs reported difficulty keeping up to date with osteoporosis guidelines and voiced differing opinions about whether fracture risk assessment was the role of primary or secondary care. Lack of integration of FRAX into IT systems was a barrier to use. GPs and nurses had differing views about the nurse role in communicating risk and acting on FRAX findings; for example, explanations of the FRAX result and action needed were limited. Patients reported limited understanding of FRAX outcomes.

CONCLUSION

The findings suggest that, with appropriate training including risk communication, practice nurses are likely to be confident to play a key role in conducting fracture risk assessments, but further work is needed to address the barriers identified.

Effective Communication and the Osteoporosis Care Gap

Many pharmacological treatments are now available to prevent the occurrence of fragility fractures in patients with osteoporosis. Despite this, concerns persist that many individuals who might benefit from osteoporosis treatment do not receive it-the "osteoporosis treatment gap." The underlying reasons for this gap are diverse and include those who are not identified as being eligible for treatment as well as those who intentionally choose not to take medications because of uncertainty, unanswered questions, or an inability to understand or do what is being asked of them. In this perspective article we highlight the importance of providing information on the causes and consequences of osteoporosis during encounters when treatment is being discussed as well as what osteoporosis treatment can achieve and what it cannot. We also review the importance of communicating the benefits and risks of treatment in absolute terms so that patients can understand what taking treatment will mean for them and discuss the utility of decision aids to assist in these conversations. We suggest it is not the treatment gap that is the problem but the care gap. This language acknowledges the importance of healthcare providers identifying those likely to benefit from treatment and increasing the quality of clinical conversations to promote patient engagement and involvement while respecting that treatment is not suitable or wanted by all. © 2022 American Society for Bone and Mineral Research (ASBMR).

Supporting patients to get the best from their osteoporosis treatment: a rapid realist review of what works, for whom, and in what circumstance

Systematic reviews that examine effectiveness of interventions to improve medicines optimisation do not explain how or why they work. This realist review identified that interventions which effectively optimise medicines use in osteoporosis include opportunities to address patients' perceptions of illness and treatment and/or support primary care clinician decision making.

INTRODUCTION

In people with osteoporosis, adherence to medicines is poorer than other diseases and patients report follow-up is lacking, and multiple unmet information needs. We conducted a rapid realist review to understand what contextual conditions and mechanisms enable interventions to support osteoporosis medication optimisation.

METHODS

A primary search identified observational or interventional studies which aimed to improve medicines adherence or optimisation; a supplementary second search identified research of any design to gain additional insights on emerging findings. Extracted data was interrogated for patterns of context-mechanism-outcome configurations, further discussed in team meetings, informed by background literature and the Practicalities and Perception Approach as an underpinning conceptual framework.

RESULTS

We identified 5 contextual timepoints for the person with osteoporosis (identifying a problem; starting medicine; continuing medicine) and the practitioner and healthcare system (making a diagnosis and giving a treatment recommendation; reviewing medicine). Interventions which support patient-informed decision making appear to influence long-term commitment to treatment. Supporting patients' practical ability to adhere (e.g. by lowering treatment burden and issuing reminders) only appears to be helpful, when combined with other approaches to address patient beliefs and concerns. However, few studies explicitly addressed patients' perceptions of illness and treatment. Supporting primary care clinician decision making and integration of primary and secondary care services also appears to be important, in improving rates of treatment initiation and adherence.

CONCLUSIONS

We identified a need for further research to identify a sustainable, integrated, patient-centred, and cost- and clinically effective model of long-term care for people with osteoporosis.

Research priorities to reduce the impact of musculoskeletal disorders: a priority setting exercise with the child health and nutrition research initiative method

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities.

Involving stakeholders in research priority setting: a scoping review

BACKGROUND

This scoping review provides a thorough analysis of how stakeholders have so far been involved in research priority setting. The review describes, synthesizes, and evaluates research priority setting projects not only for the field of health-as previous reviews have done-but does so on a much broader scale for any research area.

METHODS

A comprehensive electronic literature search was conducted in the databases PubMed, Scopus, and Web of Science. Reflecting the importance of grey literature, Google Scholar and relevant websites were also screened for eligible publications. A computational approach was then used for the study selection. The final screening for inclusion was done manually.

RESULTS

The scoping review encompasses 731 research priority setting projects published until the end of 2020. Overall, the projects were conducted within the realm of 50 subject areas ranging from agriculture and environment over health to social work and technology. Key learnings include that nearly all priority setting projects aimed to identify research priorities for the field of health (93%), particularly for nursing and care, cancer, pediatrics, and mental, behavioral and neurodevelopmental disorders. Only 6% of the projects were not health-related and 1% identified research priorities at the interface between health and a non-health area. Over time, 30 different stakeholder groups took part in research priority setting. The stakeholders most frequently asked to identify research priorities were doctors, patients, academics/researchers, nurses, allied healthcare professionals, family members, friends, and carers. Nearly two thirds of all projects have been conducted in Europe and North America. Overall, only 9% of the projects emphasized the importance of stakeholders in their goals and rationales and actively involved them. In around a quarter of the projects, stakeholders deliberated on their research priorities throughout the entire process.

CONCLUSION

By mapping out the complex landscape of stakeholder involvement in research priority setting, this review guides future efforts to involve stakeholders effectively, inclusively, and transparently, which in turn may increase the overall value of research for society. As a practical addition to this review, the first worldwide research priority setting database was created: https://ois.lbg.ac.at/en/project-database . The database contains all the projects analyzed for this review and is constantly updated with the latest published research priority setting projects.

Clinical Management of Women with Newly Diagnosed Osteoporosis: Data from Everyday Practice in Bulgaria

INTRODUCTION

The real duration of osteoporosis treatment in clinical practice is still not well described. The primary objective is to estimate the proportion of patients who stayed on treatment during a 4-year follow-up, and the secondary objective is to estimate the proportion of patients who switched treatment and the reasons for switch or discontinuation.

METHODS

This was a national retrospective chart review, based on routine clinical data. Data were collected electronically from medical records in 33 representative primary care physicians' sites. Inclusion criteria were women with postmenopausal osteoporosis that have received initial treatment prescription following diagnosis by DXA between January 1, 2012 and December 31, 2014, and at least a 12-month database history after the index date. Exclusion criteria were women receiving treatment for osteoporosis and follow-up at secondary care physicians' sites only. All statistical analyses were performed with the R statistical package.

RESULTS

A total of 1206 female patients with newly diagnosed osteoporosis and treatment initiation were followed for 4 years. The majority (88.3%) had no history of previous fractures. Bone mineral density data were available in 70.1%. Endocrinology was the most common specialty among prescribing specialists (40.0%), followed by rheumatology (30.3%). Bisphosphonates (BPs) were the most common initial treatment (72.7%), followed by denosumab (20.1%). Ibandronate (70.2%) and alendronate (24.2%) constituted the majority of all prescribed BPs; 731 patients remained on treatment during the second year (60.6%), 524 during the third year (43.4%) and 403 (33.4%)-at study end (fourth year). In all groups, except that on denosumab, the most common reason for switching to another treatment was presumed lack of effect. The main reasons for treatment discontinuation were financial on the patient's part.

CONCLUSIONS

The duration of osteoporosis treatment in real-world clinical practice is far from optimal: < 3-4 years irrespective of fracture risk. Factors other than medical considerations are at play, mainly limitations set by the Health Insurance Fund. The health authorities should be aware of this.

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation.

PURPOSE

The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study.

METHODS

A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content.

RESULTS

Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps.

CONCLUSIONS

This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.