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Wang M, Seibel MJ. Secondary fracture prevention in primary care: a narrative review. Osteoporos Int 2024:10.1007/s00198-024-07036-1. [PMID: 38652313 DOI: 10.1007/s00198-024-07036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/28/2024] [Indexed: 04/25/2024]
Abstract
The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.
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Affiliation(s)
- Mawson Wang
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia.
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia.
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia
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Galasso AC, Herzog LN, Sekar M, Hartsock LA, Reid KR. Intradepartmental orthopaedic fragility fracture liaison improves osteoporosis follow-up and treatment. Injury 2023; 54:110985. [PMID: 37599192 DOI: 10.1016/j.injury.2023.110985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/05/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE Over 2 million people in the United States sustain fractures related to osteoporosis annually, but only 20% of these patients receive treatment for their osteoporosis. The purpose of this study was to evaluate the effects of a fragility fracture liaison within the orthopedic department on treatment and follow up for osteoporosis. DESIGN Retrospective cohort study SETTING: University Level I Trauma center PARTICIPANTS: 112 patients treated under the aegis of an interdepartmental fracture liaison and 208 patients treated following the introduction of an orthopedic fragility fracture liaison at a single institution. INTERVENTION Transition from referral to interdepartmental fracture liaison to intradepartmental orthopedic fragility fracture liaison for fragility fractures. MAIN OUTCOME MEASURES Outcomes evaluated included demographics, fracture type, DEXA scan results, follow up and treatment plan, and subsequent fracture. RESULTS The mean age at time of fracture was 75 years, and the mean BMI was 27. The most common fracture types were femoral neck fractures (29%), pertrochanteric fractures (30%) and femur fractures (8%). There was a statistically significant increase in adherence to follow up and treatment after the introduction of an orthopaedic fragility fracture liaison. CONCLUSIONS The introduction of an intradepartmental fragility fracture liaison significantly increases osteoporosis follow-up and introduces the ability to combine both osteoporosis treatment and postoperative orthopaedic care. The results of this study highlight the utility of incorporating a fragility fracture liaison within the orthopaedic department given the economic burden of fragility fractures and the morbidity associated with these fractures. LEVEL OF EVIDENCE III cohort study.
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Affiliation(s)
| | | | - Molly Sekar
- University of Arizona, College of Medicine Phoenix, United States
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Wingood M, Criss MG, Irwin KE, Freshman C, Phillips EL, Dhaliwal P, Chui KK. Screening for Osteoporosis Risk Among Community-Dwelling Older Adults: A Scoping Review. J Geriatr Phys Ther 2023; 46:E137-E147. [PMID: 36827688 DOI: 10.1519/jpt.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND AND PURPOSE Due to potential health-related consequences of osteoporosis (OP), health care providers who do not order imaging, such as physical therapists, should be aware of OP screening tools that identify individuals who need medical and rehabilitation care. However, current knowledge and guidance on screening tools is limited. Therefore, we explored OP screening tools that are appropriate and feasible for physical therapy practice, and evaluated tools' effectiveness by examining their clinimetric properties. METHODS A systematic search of the following databases was performed: PubMed, PEDro, PsycINFO, CINAHL, and Web of Science. Articles were included if the study population was 50 years and older, had a diagnosis of OP, if the screening tool was within the scope of physical therapy practice, and was compared to either a known diagnosis of OP or bone densitometry scan results. Included articles underwent multiple reviews for inclusion and exclusion, with each review round having a different randomly selected pair of reviewers. Data were extracted from included articles for participant demographics, outcome measures, cut-off values, and clinimetric properties. Results were categorized with positive and negative likelihood ratios (+LR/-LR) based on the magnitude of change in the probability of having or not having OP. RESULTS +LRs ranged from 0.15 to 20.21, with the Fracture Risk Assessment Tool (FRAX) and Study of Osteoporotic Fractures (SOF) having a large shift in posttest probability. -LRs ranged from 0.03 to 1.00, with the FRAX, Male Osteoporosis Risk Estimation Scores, Osteoporosis Self-Assessment Tool (OST), and Simple Calculated Osteoporosis Risk Estimation having a large shift in posttest probability. CONCLUSION Tools with moderate-large shift for both +LR and -LR recommended for use are: (1) OST; (2) FRAX; and (3) SOF. The variability in cut-off scores and clinimetric properties based on gender, age, and race/ethnicities made it impossible to provide one specific recommendation for an OP screening tool. Future research should focus on OP risk prediction among males and racial and ethnic groups.
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Affiliation(s)
- Mariana Wingood
- Department of Rehabilitation and Movement Sciences, University of Vermont, Burlington
| | - Michelle G Criss
- School of Health Sciences, Chatham University, Pittsburgh, Pennsylvania
| | - Kent E Irwin
- Department of Physical Therapy, Midwestern University, Downers Grove, Illinois
| | - Christina Freshman
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania
| | | | - Puneet Dhaliwal
- Department of Physical Therapy, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Kevin K Chui
- Department of Physical Therapy, Radford University, Roanoke, Virginia
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Tarantino U, Greggi C, Visconti VV, Cariati I, Bonanni R, Gasperini B, Iundusi R, Gasbarra E, Tranquilli Leali P, Brandi ML. Fracture liaison service model: project design and accreditation. Osteoporos Int 2023; 34:339-348. [PMID: 36422656 PMCID: PMC9852196 DOI: 10.1007/s00198-022-06600-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED Frailty fractures place a significant socioeconomic burden on the health care system. The Italian Society of Orthopaedics and Traumatology (SIOT) is proceeding to fracture liaison service (FLS) model accreditation in several Italian Fracture Units (FUs), which provides a multidisciplinary approach for the management of the fragility fracture patient. INTRODUCTION Osteoporosis and the resulting fragility fractures, particularly femoral fractures, place significant socioeconomic burdens on the health care system globally. In addition, there is a general lack of awareness of osteoporosis, resulting in underestimation of the associated risks and suboptimal treatment of the disease. The fracture liaison service (FLS) represents an exemplary model of post-fracture care that involves a multidisciplinary approach to the frail patient through the collaboration of multiple specialists. The purpose of this article is to highlight the path undertaken by the Italian Society of Orthopaedics and Traumatology (SIOT) for the purpose of certification of numerous FLS centers throughout Italy. METHODS SIOT is proceeding with international FLS accreditation in several Italian Fracture Units (FUs), following the creation of a model that provides specific operational and procedural steps for the management of fragility fractures throughout the country. FUs that decide to join the project and implement this model within their facility are then audited by an ACCREDIA-accredited medical certification body. RESULTS The drafted FLS model, thanks to the active involvement of a panel of experts appointed by SIOT, outlines a reference operational model that describes a fluid and articulated process that identifies the procedure of identification, description of diagnostic framing, and subsequent initiation of appropriate secondary prevention programs for fractures of individuals who have presented with a recent fragility fracture of the femur. CONCLUSION Accreditation of this prevention model will enable many facilities to take advantage of this dedicated diagnostic-therapeutic pathway for the purpose of fracture prevention and reduction of associated health and social costs.
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Affiliation(s)
- U Tarantino
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy.
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy.
| | - C Greggi
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - V V Visconti
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - I Cariati
- Department of Biomedicine and Prevention, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - R Bonanni
- Department of Biomedicine and Prevention, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - B Gasperini
- Department of Biomedicine and Prevention, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - R Iundusi
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
| | - E Gasbarra
- Department of Clinical Sciences and Translational Medicine, "Tor Vergata" University of Rome, Via Montpellier 1, 00133, Rome, Italy
- Department of Orthopaedics and Traumatology, "Policlinico Tor Vergata" Foundation, Viale Oxford 81, 00133, Rome, Italy
| | | | - M L Brandi
- FIRMO Foundation, Via San Gallo 123, 50100, Florence, Italy
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Non-Adherence to Anti-Osteoporosis Medication: Factors Influencing and Strategies to Overcome It. A Narrative Review. J Clin Med 2022; 12:jcm12010014. [PMID: 36614816 PMCID: PMC9821321 DOI: 10.3390/jcm12010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
To evaluate the reasons for inadequate adherence to osteoporosis therapy and to describe the strategies for improving adherence to and persistence with regular medications, we conducted a review of the literature. The primary outcome of the study was the determination of the factors adverse to the onset and maintenance of anti-osteoporosis therapies. Secondly, we focused on studies whose efforts led to finding different strategies to improve adherence and persistence. We identified a total of 26 articles. The most recurrent and significant factors identified were aging, polypharmacy, and smoking habits. Different strategies to guide patients in their osteoporosis care have been identified, such as monitoring and follow-up via telephone calls, email, and promotional meetings, and proactive care interventions such as medication monitoring, post-fracture care programs, and decision aids. Changes in the drugs regimen and dispensation are strategies tried to lead to better adherence and persistence, but also improved satisfaction of patients undergoing anti-osteoporosis treatment. Patient involvement is an important factor to increase medication persistence while using a flexible drugs regimen.
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Vaughn N, Akelman M, Marenghi N, Lake AF, Graves BR. Patients undergoing surgical treatment for low-energy distal radius fractures are more likely to receive a referral and participate in a fracture liaison service program. Arch Osteoporos 2022; 17:96. [PMID: 35854058 DOI: 10.1007/s11657-022-01122-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/18/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Patients often do not receive osteoporosis screening after a low-energy distal radius fracture (DRF). The effect of osteoporosis on the healing of DRFs remains a debate, and it is unclear if surgical treatment of this injury affects the referral and participation rates in a fracture liaison service (FLS) program. The purpose of this study is to report on a large cohort of low-energy DRFs and identify demographic, clinical, and treatment factors that affect referral and participation rates in an FLS program. METHODS A retrospective review identified patients over 50 years old who sustained a low-energy DRF between 2013 and 2018. Patients with high-energy or unknown injury mechanisms were excluded. The primary outcome was the effect of DRF surgical treatment on referral and participation rates in an FLS program. Secondary outcomes included patient demographic and clinical characteristic effects on referral and participation rates in an FLS program. RESULTS In total, 950 patients met inclusion criteria. Two hundred thirty patients (24.2%) were referred and 149 (15.7%) participated in the FLS program. Patients who underwent surgery were more likely to be referred to the FLS (OR 1.893, CI 1.403-2.555, p < 0.001) and participate in the FLS program (OR 2.47, CI 1.723-3.542, p < 0.001) compared to patients who received non-operative treatment of their DRF. CONCLUSIONS Patients who undergo surgical treatment of a low-energy DRF are more likely to be referred and participate in a FLS program. Further study is needed to identify why surgical treatment may affect referral and participation rates.
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Affiliation(s)
- Natalie Vaughn
- Department of Orthopaedic Surgery, Department of Orthopaedic Surgery Wake Forest University School of Medicine Atrium / Wake Forest Baptist Health Winston-Salem, Winston-Salem, NC, USA
| | - Matthew Akelman
- Department of Orthopaedic Surgery, Department of Orthopaedic Surgery Wake Forest University School of Medicine Atrium / Wake Forest Baptist Health Winston-Salem, Winston-Salem, NC, USA
| | - Natalie Marenghi
- Department of Orthopaedic Surgery, Department of Orthopaedic Surgery Wake Forest University School of Medicine Atrium / Wake Forest Baptist Health Winston-Salem, Winston-Salem, NC, USA.
| | - Anne F Lake
- Department of Orthopaedic Surgery, Department of Orthopaedic Surgery Wake Forest University School of Medicine Atrium / Wake Forest Baptist Health Winston-Salem, Winston-Salem, NC, USA
| | - Benjamin R Graves
- Department of Orthopaedic Surgery, Department of Orthopaedic Surgery Wake Forest University School of Medicine Atrium / Wake Forest Baptist Health Winston-Salem, Winston-Salem, NC, USA
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Miller KL, Steffen MJ, McCoy KD, Cannon G, Seaman AT, Anderson ZL, Patel S, Green J, Wardyn S, Solimeo SL. Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation. Arch Osteoporos 2021; 16:27. [PMID: 33566174 PMCID: PMC7875846 DOI: 10.1007/s11657-021-00882-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
An informatics-driven population bone health clinic was implemented to identify, screen, and treat rural US Veterans at risk for osteoporosis. We report the results of our implementation process evaluation which demonstrated BHT to be a feasible telehealth model for delivering preventative osteoporosis services in this setting. PURPOSE An established and growing quality gap in osteoporosis evaluation and treatment of at-risk patients has yet to be met with corresponding clinical care models addressing osteoporosis primary prevention. The rural bone health tea m (BHT) was implemented to identify, screen, and treat rural Veterans lacking evidence of bone health care and we conducted a process evaluation to understand BHT implementation feasibility. METHODS For this evaluation, we defined the primary outcome as the number of Veterans evaluated with DXA and a secondary outcome as the number of Veterans who initiated prescription therapy to reduce fracture risk. Outcomes were measured over a 15-month period and analyzed descriptively. Qualitative data to understand successful implementation were collected concurrently by conducting interviews with clinical personnel interacting with BHT and BHT staff and observations of BHT implementation processes at three site visits using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. RESULTS Of 4500 at-risk, rural Veterans offered osteoporosis screening, 1081 (24%) completed screening, and of these, 37% had normal bone density, 48% osteopenia, and 15% osteoporosis. Among Veterans with pharmacotherapy indications, 90% initiated therapy. Qualitative analyses identified barriers of rural geography, rural population characteristics, and the infrastructural resource requirement. Data infrastructure, evidence base for care delivery, stakeholder buy-in, formal and informal facilitator engagement, and focus on teamwork were identified as facilitators of implementation success. CONCLUSION The BHT is a feasible population telehealth model for delivering preventative osteoporosis care to rural Veterans.
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Affiliation(s)
- Karla L. Miller
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
- Division of Rheumatology, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Melissa J. Steffen
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
| | - Kimberly D. McCoy
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
| | - Grant Cannon
- Department of Internal Medicine, Rheumatology Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Aaron T. Seaman
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Division of Genera l Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242 Iowa City, IA USA
| | - Zachary L. Anderson
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Anesthesiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Shardool Patel
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Department of Anesthesiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Janiel Green
- VA Office of Rural Health, Veterans Rural Health Resource Center-Salt Lake City (VRHRC-SLC), Salt Lake City, UT USA
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Shylo Wardyn
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
| | - Samantha L. Solimeo
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Salt Lake City, UT USA
- Comprehensive Access & Delivery Research and Evaluation (CADRE), Primary Care Analytics Team Iowa City (PCAT-IC), Department of Veterans Affairs, CADRE, Iowa City VA HCS, Research 152, 601 Highway 6 West, Iowa City, IA 52246 USA
- Division of Genera l Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 52242 Iowa City, IA USA
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Martin J, Viprey M, Castagne B, Merle B, Giroudon C, Chapurlat R, Schott AM. Interventions to improve osteoporosis care: a systematic review and meta-analysis. Osteoporos Int 2020; 31:429-446. [PMID: 31993718 DOI: 10.1007/s00198-020-05308-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/17/2020] [Indexed: 12/13/2022]
Abstract
Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription.
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Affiliation(s)
- J Martin
- Univ Lyon, Université Claude Bernard Lyon 1, HESPER EA 7425, F-69008, Lyon, France
- Hospices Civils de Lyon, Pôle de Santé Publique, 69003, Lyon, France
| | - M Viprey
- Univ Lyon, Université Claude Bernard Lyon 1, HESPER EA 7425, F-69008, Lyon, France
- Hospices Civils de Lyon, Pôle de Santé Publique, 69003, Lyon, France
| | - B Castagne
- Univ Lyon, Université Claude Bernard Lyon 1, HESPER EA 7425, F-69008, Lyon, France
- Department of Rheumatology, CHU Gabriel Montpied, 63000, Clermont-Ferrand, France
| | - B Merle
- INSERM UMR1033, Lyon, France
| | - C Giroudon
- Centre de documentation, Hospices Civils de Lyon, Lyon, France
| | - R Chapurlat
- INSERM UMR1033, Lyon, France
- Service de Rhumatologie et de Pathologie Osseuse, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - A-M Schott
- Univ Lyon, Université Claude Bernard Lyon 1, HESPER EA 7425, F-69008, Lyon, France.
- Hospices Civils de Lyon, Pôle de Santé Publique, 69003, Lyon, France.
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Nayak S, Greenspan SL. How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis. J Bone Miner Res 2018; 33:1585-1594. [PMID: 29637658 PMCID: PMC6129396 DOI: 10.1002/jbmr.3437] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/20/2018] [Accepted: 04/01/2018] [Indexed: 12/13/2022]
Abstract
Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.
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Qiu J, Huang G, Na N, Chen L. MicroRNA-214-5p/TGF-β/Smad2 signaling alters adipogenic differentiation of bone marrow stem cells in postmenopausal osteoporosis. Mol Med Rep 2018. [PMID: 29532880 PMCID: PMC5928609 DOI: 10.3892/mmr.2018.8713] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Postmenopausal osteoporosis (OPM) is a common type of osteoporosis in females. It is a systemic, chronic bone disease that presents as microstructure degradation of osseous tissue, decreased bone mineral density and increased osteopsathyrosis caused by hypoovarianism and reduced estrogen levels in the body following menopause. In the present study, the role of microRNA (miR)-214-5p in the regulation of the expression of bone marrow stem cells (BMSCs) was investigated, and its molecular mechanism of osteogenic induction in vitro was assessed. When dexamethasone-induced adipogenic differentiation was performed, miR-214-5p expression was increased compared with the control group, as determined by RT-qPCR. Furthermore, oil red O staining, RT-qPCR and western blot analysis demonstrated that overexpression of miR-214-5p promoted adipogenic differentiation, inhibited alkaline phosphatase (ALP), runt-related transcription factor 2 (Runx2), osteocalcin (OC) and collagen α-1 (I) chain (COL1A1) mRNA expression, and suppressed transforming growth factor (TGF)-β, phosphorylated (p)-Smad2 and collagen type IV α1 chain (COL4A1) protein expression in BMSCs. Additionally, downregulation of miR-214-5p increased the ALP, Runx2, OC and COL1 mRNA expression and increased TGF-β, Smad2 and COL4A1 protein expression in BMSCs. Furthermore, a TGF-β inhibitor was employed to inhibit TGF-β expression in BMSCs following miR-214-5p downregulation, which led to reduced Smad2, TGF-β and COL4A1 protein expression, and ALP, Runx2, OC and COL1 mRNA expression was also reduced, compared with the miR-214-5p downregulation only group. It was demonstrated that miR-214-5p may weaken osteogenic differentiation of BMSCs through regulating COL4A1. In conclusion, the results of the present study indicated that miR-214-5p may promote the adipogenic differentiation of BMSCs through regulation of the TGF-β/Smad2/COL4A1 signaling pathway, and potentially may be used to develop a novel drug for postmenopausal osteoporosis.
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Affiliation(s)
- Jiang Qiu
- Division of Organ Transplantation, The First Affiliated Hospital of Sun Yat‑sen University, Guangzhou, Guangdong 510080, P.R. China
| | - Gang Huang
- Division of Organ Transplantation, The First Affiliated Hospital of Sun Yat‑sen University, Guangzhou, Guangdong 510080, P.R. China
| | - Ning Na
- Division of Organ Transplantation, The Third Affiliated Hospital of Sun Yat‑sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Lizhong Chen
- Division of Organ Transplantation, The First Affiliated Hospital of Sun Yat‑sen University, Guangzhou, Guangdong 510080, P.R. China
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Kastner M, Perrier L, Munce SEP, Adhihetty CC, Lau A, Hamid J, Treister V, Chan J, Lai Y, Straus SE. Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis. Osteoporos Int 2018; 29:5-17. [PMID: 29043392 DOI: 10.1007/s00198-017-4248-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 09/26/2017] [Indexed: 01/06/2023]
Abstract
Osteoporosis is affecting over 200 million people worldwide. Despite available guidelines, care for these patients remains sub-optimal. We developed an osteoporosis tool to address the multiple dimensions of chronic disease management. Findings from its evaluation showed a significant increase from baseline in osteoporosis investigations and treatment, so we are revising this tool to include multiple chronic conditions including an update of evidence about osteoporosis. Our objectives were to conduct a systematic review of osteoporosis interventions in adults at risk for osteoporosis. We searched bibliometric databases for randomized controlled trials (RCTs) in any language evaluating osteoporosis disease management interventions in adults at risk for osteoporosis. Reviewer pairs independently screened citations and full-text articles, extracted data, and assessed risk of bias. Analysis included random effects meta-analysis. Primary outcomes were osteoporosis investigations and treatment, and fragility fractures. Fifty-five RCTs and one companion report were included in the analysis representing 165,703 patients. Our findings from 55 RCTs and 18 sub-group meta-analyses showed that complex implementation interventions with multiple components consisting of at least education + feedback + follow-up significantly increased the initiation of osteoporosis medications, and interventions with at least education + follow-up significantly increased the initiation of osteoporosis investigations. No significant impact was found for any type of intervention to reduce fracture. Complex interventions that include at least education + follow-up or feedback have the most potential for increasing osteoporosis investigations and treatment. Patient education appears to be an important component in osteoporosis disease management.
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Affiliation(s)
- M Kastner
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - L Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - S E P Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - C C Adhihetty
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - A Lau
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - J Hamid
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - V Treister
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - J Chan
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Y Lai
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - S E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Chao AS, Chen FP, Lin YC, Huang TS, Fan CM, Yu YW. Application of the World Health Organization Fracture Risk Assessment Tool to predict need for dual-energy X-ray absorptiometry scanning in postmenopausal women. Taiwan J Obstet Gynecol 2016; 54:722-5. [PMID: 26700992 DOI: 10.1016/j.tjog.2015.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of the World Health Organization Fracture Risk Assessment Tool, excluding bone mineral density (pre-BMD FRAX), in identifying Taiwanese postmenopausal women needing dual-energy X-ray absorptiometry (DXA) examination for further treatment. MATERIALS AND METHODS The pre-BMD FRAX score was calculated for 231 postmenopausal women who participated in public health education workshops in the local Keelung community, Taiwan. DXA scanning and vertebral fracture assessment (VFA) were arranged for women classified as intermediate or high risk for fracture using the pre-BMD FRAX fracture probability. RESULTS Pre-BMD FRAX classified 26 women as intermediate risk and 37 as having high risk for fracture. Subsequent DXA scans for these 63 women showed that 36 were osteoporotic, 19 were osteopenic, and eight had normal bone density. Concurrent VFA revealed 25 spine factures in which 14 were osteoporotic, seven were osteopenic, and four had normal bone density. The efficacy of the pre-BMD FRAX score to identify those patients with low bone mass by DXA was 87.3% (55/63). When VFA was combined with BMD to identify those patients with high risk (osteopenia, osteoporosis, or spinal fracture), the efficacy of the pre-BMD score increased to 93.7% (59/63). According to the National Osteoporosis Foundation, the overall concordance between pre-BMD FRAX and BMD, expressed through the kappa index, was 0.967. Compared with the evaluation when BMD was used alone, there was a significant increase in efficacy in identifying women who need treatment using BMD plus VFA or FRAX plus BMD. Furthermore, the highest efficacy was achieved when FRAX with BMD and VFA was used. CONCLUSION The pre-BMD FRAX score not only efficiently predicts postmenopausal patients who are potentially at risk and might require treatment but also reduces unnecessary DXA use. Concurrent VFA during DXA use increases spine fracture detection. This improvement in diagnostic efficacy allows clinicians to provide the most appropriate therapeutic recommendation.
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Affiliation(s)
- An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Fang-Ping Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan.
| | - Yu-Ching Lin
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Ting-Shuo Huang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Chih-Ming Fan
- Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - Yu-Wei Yu
- Department of Medical Research and Development, Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
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