Barriers and Expectations for Patients in Post-Osteoporotic Fracture Care in France: The EFFEL Study

A Hip New Standard: Improving Osteoporosis Care with Inpatient Administration of IV Zoledronate

BACKGROUND

Osteoporosis continues to be underdiagnosed and inadequately treated in older hip-fracture patients. Our aim was to improve the rate of osteoporosis treatment with IV bisphosphonate therapy in eligible patients admitted for hip-fracture surgery.

METHODS

The present study was designed as a quality improvement initiative using Plan-Do-Study-Act (PDSA) cycles at an academic medical center in Portland, Oregon, over 2.5 years. A protocol was developed (1) to administer IV zoledronate on postoperative day 2 to inpatients aged ≥50 years who underwent surgery for a low-energy hip fracture and (2) to formally diagnose osteoporosis during admission. The protocol was introduced across 3 care settings in a stepped-wedge manner. Outcome measures were the percentage of inpatient zoledronate administered to eligible patients and formal documented diagnosis of osteoporosis. Balance measures included fever after administration and hospital length of stay (LOS). Measures were assessed through quarterly chart review and tracked via control charts.

RESULTS

The rate of zoledronate administration significantly increased from 34.5% (29 of 84) to 74.6% (53 of 71) following the second PDSA cycle (p < 0.001). Documented osteoporosis diagnosis also significantly improved from 51.0% (53 of 104) to 85.7% (96 of 112) following the second PDSA cycle (p < 0.001). No significant differences were shown for hospital LOS, and 1 of 82 patients had medical work-up for post-infusion acute phase reaction after administration.

CONCLUSIONS

This initiative was effective at improving osteoporosis diagnosis and treatment among older hip-fracture patients at our institution. Protocol development for administrating inpatient zoledronate after hip fracture is a reliable way to predictably offer bone health care and secondary-fracture prevention to hip-fracture patients and can be adapted and implemented at other institutions.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Patient perceptions of osteoporosis management: a qualitative pilot study by a patient advisory group

The management of osteoporosis even after a fracture is declining. Our pilot study in patients with osteoporosis confirms a large ignorance of the disease and major fears and uncertainties about the treatments. Complete and sustained medical information seems essential to counteract the contradictory information, which are exclusively negative.

PURPOSE

The management of osteoporosis (OP) even after a fracture has declined over recent years despite the actions of the medical societies concerned with this disease. The objective of this pilot study was to investigate patients' perceptions of OP, their treatment pathways, and how information is obtained.

METHODS

The Association Française de Lutte Anti-Rhumatismale (AFLAR) constituted an advisory group of 7 French patients (mean age 63.7 years [54-74 years]), with various stages of OP and duration of disease. A qualitative, anonymized study was conducted with an open-ended semi-structured questionnaire, with a contribution of the International Osteoporosis Foundation (IOF) and the "Groupe de Recherche et Informations sur les Ostéoporoses" (GRIO).

RESULTS

The onset of OP was often sudden, with the fracture occurring in a context of deep misunderstanding of OP by both the public and physicians. The patients have confidence in the physician, mostly a rheumatologist, who informs about OP and initiates the treatment. The main cause of non-adherence being major fears and uncertainties about efficacy and safety of treatments. Medical information is considered as insufficient, or poorly understood. Negative information has the highest impact, even if the sources seem unreliable, such as media. There is no trust in pharmaceutical companies and the ethics of physicians are in question.

CONCLUSION

This IOF/GRIO/AFLAR Patient Advisory Group pilot study illustrates the numerous barriers to effective OP management. Complete and sustained medical information, especially at the time of diagnosis and initiation of treatment, seems essential to counteract the contradictory information, which are exclusively negative.

Clinical characteristics and risk factors of osteoporosis among older Asian men with type-2 diabetes mellitus, hypertension, or hyperlipidaemia

This study investigated osteoporosis risk factors among older Asian men with type-2 diabetes mellitus, hypertension, or hyperlipidaemia in primary care. Advanced age, dementia, depression, and polypharmacy were associated with higher risks for osteoporosis. Screening strategies targeting these factors are crucial for improving bone health as part of comprehensive preventive care.

PURPOSE

Asian patients with type-2 diabetes mellitus (T2DM), hypertension, or hyperlipidaemia (DHL) are predominantly managed in primary care. They are also at risk of osteoporosis, but men are often under-screened and under-treated for this preventable bone disorder. This study aimed to identify the clinical characteristics and risk factors of osteoporosis among older men with DHL in primary care for early intervention.

METHODS

This retrospective study included men aged 65 years and older managed in public primary care clinics for their DHL between 1st July 2017 and 30th June 2018. Demographic, clinical, laboratory, and imaging data were extracted from their electronic medical records based on their International Classification of Diseases-10 (ICD-10) diagnosis codes. Descriptive statistical analyses, with statistical significance set at p < 0.05, were conducted, followed by generalized estimating equation (GEE) modelling.

RESULTS

Medical records of 17,644 men (83.1% Chinese, 16.9% minority ethnic groups, median age 71 years) were analysed. 2.3% of them had diagnosis of osteoporosis, 0.15% had fragility fracture, and 26.0% of those diagnosed with osteoporosis were treated with bisphosphonates. Their mean HbA1c was 6.9%; mean systolic and diastolic blood pressure were 133 and 69 mmHg. The GEE model showed that age (OR = 1.07, 95%CI = 1.05-1.09, p < 0.001), dementia (OR = 2.24, 95%CI = 1.33-3.77, p = 0.002), depression (OR = 2.38, 95%CI = 1.03-5.50, p = 0.043), and polypharmacy (OR = 6.85, 95%CI = 3.07-15.26, p < 0.001) were significantly associated with higher risks for osteoporosis.

CONCLUSION

Age, dementia, depression, and polypharmacy are associated with osteoporosis risks in men with DHL. Strategies to incorporate osteoporosis screening among older men with these risk factors are needed to improve their bone health.

Real-World Effectiveness of Osteoporosis Medications in France: A Nationwide Cohort Study

Although drugs for osteoporosis have been demonstrated to be effective in reducing fracture risk in placebo-controlled clinical trials, data on effectiveness in real-world practice is limited. Data from the French national health insurance claims database (SNDS) were used to follow five cohorts of women aged ≥55 years after initiating treatment for ≥6 months with either denosumab, zoledronic acid, oral bisphosphonates, raloxifene, or teriparatide in 2014-2016. Fracture incidence was compared within each cohort between the 3 months following initiation (baseline fracture risk) and the 12month, 18month, and 24 month postinitiation periods. Data are presented as incidence rate ratios (IRRs) with their 95% confidence intervals (CIs)s. Overall, 67,046 women were included in the denosumab cohort, 52,914 in the oral bisphosphonate cohort, 41,700 in the zoledronic acid cohort, 11,600 in the raloxifene cohort, and 7510 in the teriparatide cohort. The baseline vertebral fracture rate ranged from 1.74 per 1000 person years (‰PY) in the raloxifene cohort to 34.75‰PY in the teriparatide cohort, and the baseline hip fracture rate from 0.70‰PY in the raloxifene cohort to 10.52‰PY in the zoledronic acid cohort. Compared with the baseline fracture rate, vertebral fractures involving hospitalization were significantly reduced in the 3-24-month postinitiation period with denosumab (IRR 0.6; 95% CI, 0.5-0.7), zoledronic acid (IRR 0.4; 95% CI, 0.3-0.4), teriparatide (IRR 0.3; 95% CI, 0.2-0.5), and oral bisphosphonates (IRR 0.6; 95% CI, 0.4-0.8). Hip fracture incidence was reduced with denosumab (IRR 0.8; 95% CI, 0.6-0.9), but higher for oral bisphosphonates (IRR 1.7; 95% CI, 1.2-2.3); no significant change in hip fracture rate was observed for zoledronic acid, teriparatide, or raloxifene. A reduction in nonvertebral, non-hip fracture incidence was observed only in the denosumab cohort (IRR 0.8; 95% CI, 0.7-0.9). These findings indicate that treatment with osteoporosis drugs is effective in the real-world setting. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The Economic Burden of Severe Osteoporotic Fractures in the French Healthcare Database: The FRACTOS Study

Osteoporosis carries a high medical, economic, and societal burden principally because of the risk of severe fractures. The objective of this cost-of-illness study was to describe health resource utilization and associated costs in all patients aged ≥50 years hospitalized for a severe osteoporotic fracture over a 6-year period (2009 to 2014) in France. Data were extracted from the French national healthcare database (SNDS) on all health care resource utilization between the index date (date of hospitalization for first fracture during the enrollment period) and study end (December 31, 2016) or until the patient died. Costing was restricted to direct costs and determined from the payer perspective. Variables related to costs were identified through multivariate logistic regression analysis. A total of 356,895 patients were included (median follow-up 39.1 months). In the year after the index fracture, 36,622 patients (10.5%) were rehospitalized for a fracture-related reason. Only 18,474 (5.3%) underwent bone densitometry and 58,220 (16.7%) received a specific treatment. The total annual per capita osteoporosis-related cost in the year after the index severe osteoporotic fracture was €18,040 (from €8598 for multiple ribs to €21,085 for hip fracture) of which €17,905 was incurred by fracture-related costs. The cost incurred by management of osteoporosis was €135. Over years 2 to 5, the mean annual per capita costs of fracture treatment (€806, mostly attributable to the treatment of refractures) continued to dominate those of osteoporosis management (€99). Total annual cost of care was €1260 million (year 2014). Variables associated with higher cost were older age, male sex, site of fracture, a history of prior osteoporotic fracture, and the number of refracture events. The 5-year cost of severe osteoporotic fractures to the French health care system is high and mostly attributable to the treatment of refractures. Improved fracture prevention measures in patients with osteoporosis is crucial to reduce the economic burden of the disease. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).