Pharmacist-provided quantitative heel ultrasound screening for rural women at risk of osteoporosis

Osteoporosis screening in Australian community pharmacies: A mixed methods study

ISSUES ADDRESSED

Osteoporosis and poor bone health impact a large proportion of the Australian population, but is drastically underdiagnosed and undertreated. Community pharmacies are a strategic location for osteoporosis screening services due to their accessibility and the demographic profile of customers. The aim of this study was to develop, implement and evaluate a community pharmacy health promotion service centred on encouraging consumers to complete an anonymous osteoporosis screening survey called Know Your Bones.

METHODS

The implementation process was documented using the REAIM (reach, effectiveness, adoption, implementation, maintenance) framework. Uptake of the Know Your Bones screening tool was monitored anonymously with website traffic. Surveys and interviews were designed to capture consumer outcomes after screening. Semi-structured interviews were conducted with Australian community pharmacy stakeholders during design and implementation phases to explore their perspectives of the barriers and facilitators.

RESULTS

The service was implemented in 27 community pharmacies. There were 448 visits to the screening website. Interviews were conducted with 41 stakeholders. There were a range of factors that appeared to influence implementation of the service. Perceived acceptability was critical, which depended on staff training, pharmacists' altruism, and remuneration. Staff relied heavily on their existing close relationships with consumers. No consumers completed non-anonymous surveys or agreed to participate in interviews post-screening.

CONCLUSION

Using an implementation science approach, a community pharmacy osteoporosis screening service for the Australian context was designed and found to be acceptable to pharmacy staff and effective in reaching the target population. SO WHAT?: This low-cost and non-invasive health promotion has potential to sustainably increase national screening rates for osteoporosis.

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

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

Gender Disparities in Osteoporosis Screening and Management Among Older Adults

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

How Can Osteoporosis Patients Benefit More from Their Therapy? Adherence Issues with Bisphosphonate Therapy

Objective:

To review the evidence on adherence with bisphosphonates and evolving dosing strategies for osteoporosis treatment.

Data Sources:

Articles were identified by searching MEDLINE (1975–December 2005) using the following terms: osteoporosis, postmenopausal, fracture, adherence, compliance, persistence, drug therapy, bisphosphonates, alendronate, risedronate, ibandronate, and zoledronate. Additional data included bibliographies from identified articles.

Study Selection and Data Extraction:

All pertinent English-language articles that discussed adherence issues in patients with osteoporosis were included. Both those that reviewed overall issues of medication adherence in osteoporosis and those that focused specifically on adherence to bisphosphonates were included, as were articles that addressed strategies for overcoming nonadherence.

Data Synthesis:

Inadequate diagnosis and treatment of osteoporosis result in a higher risk of fractures than is necessary. Even patients who are diagnosed and beginning treatment often do not persist with their osteoporosis medication because they perceive their fracture risk to be low and, given the asymptomatic nature of osteoporosis, do not experience the benefit of symptom reduction after taking the drugs. Factors that affect adherence to osteoporosis therapy include drug costs, adverse effects, dosing frequency, disease education, patient follow-up, and patient involvement in treatment decisions.

Conclusions:

By considering and implementing strategies that can improve adherence and persistence, primary care providers and pharmacists (via counseling) may enhance long-term outcomes for patients with osteoporosis.

The role of community pharmacists in screening and subsequent management of chronic respiratory diseases: a systematic review

OBJECTIVE

The purpose of this review was to evaluate the role of community pharmacists in provision of screening with/without subsequent management of undiagnosed chronic obstructive pulmonary disease (COPD) and uncontrolled asthma.

METHODS

An extensive literature search using four databases (ie. Medline, PubMed, International Pharmaceutical Abstracts (IPA) and Scopus) with search terms pharmacy, screening, asthma or COPD was conducted. Searches were limited to the years 2003-2013, those in English and those reporting research with humans. Data retrieval, analysis and result presentation employed a scoping review method.

RESULTS

Seventeen articles met the inclusion/exclusion criteria, of which fifteen studies were based on people with asthma and two were based on people with COPD. Only seven asthma studies and one COPD study involved screening followed by subsequent management. More than half of the people screened were found to be poorly controlled and up to 62% of people were identified at high risk for COPD by community pharmacists. The studies varied in the method and type of asthma control assessment/screening, the type of intervention provided and the outcomes measured. The limitations of the reviewed studies included varying definitions of asthma control, different study methodologies, and the lack of long-term follow-up. While many different methods were used for risk assessment and management services by the pharmacists, all the studies demonstrated that community pharmacists were capable of identifying people with poorly controlled asthma and undiagnosed COPD and providing them with suitable interventions.

CONCLUSIONS

The literature review identified that community pharmacists can play an effective role in screening of people with poorly controlled asthma and undiagnosed COPD along with delivering management interventions. However, there is very little literature available on screening for these chronic respiratory conditions. Future research should focus on development of patient care delivery model incorporating a screening protocol followed by targeted management interventions delivered by the community pharmacist.

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening for major diseases in community pharmacies: a systematic review

OBJECTIVES

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

METHOD

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

KEY FINDINGS

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

CONCLUSION

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

Review of services provided by pharmacies that promote healthy living

BACKGROUND

The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities.

AIM

To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required.

METHOD

A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed.

RESULTS

A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development.

CONCLUSION

There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.

The impact of pharmacist interventions on osteoporosis management: a systematic review

We completed a systematic review of the literature to examine the impact of pharmacist interventions in improving osteoporosis management. Results from randomized controlled trials suggest that pharmacist interventions may improve bone mineral density testing and calcium intake among patients at high risk for osteoporosis.

INTRODUCTION

Pharmacists play a key role in many healthcare systems by helping patients manage chronic diseases. We completed a systematic review of the literature to identify randomized controlled trials (RCTs) that have examined the impact of pharmacy interventions in narrowing two gaps in osteoporosis management: identifying at-risk individuals and improving adherence to therapy.

METHODS

We searched the electronic databases of EMBASE, HealthStar, International Pharmaceutical Abstracts, MEDLINE, and PubMed from database development to April 2010, examined grey literature, and completed manual searches of reference lists to identify English-language research that examined osteoporosis management interventions within pharmacy practice. Results from RCTs were abstracted and assessed for bias.

RESULTS

We identified 25 studies that examined pharmacist interventions in osteoporosis management: 16 cohort, 5 cross-sectional, 1 historical/ecological control, and 3 RCTs. RCT interventions included osteoporosis educational and counseling programs, screening by pharmacists based on risk factor assessment or bone mineral density testing, and physician contact or recommendations for patients to follow-up with a general practitioner. Results from the three RCTs suggest that pharmacist interventions may improve bone mineral density testing (targeted screening) and calcium intake among patients at high risk for osteoporosis. However, two of the three RCTs had high risk of bias, and no study examined the impact of pharmacist intervention on osteoporosis treatment adherence.

CONCLUSIONS

Data support the potential role for pharmacists to help reduce gaps in osteoporosis management through improved identification of high-risk patients. More research is needed to examine pharmacist interventions on osteoporosis treatment adherence.

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

SUMMARY

This study evaluated the effect of a multifaceted intervention (screening and patient education) by community pharmacists on testing or treatment of osteoporosis. One hundred and twenty-nine patients randomized to receive the intervention were compared to 133 patients who did not receive the intervention. Twice as many patients who got the intervention received further testing or treatment for osteoporosis.

INTRODUCTION

The objective of this study was to determine the effect of a community pharmacist screening program on testing and treatment of osteoporosis.

METHODS

In this randomized, controlled trial, 262 patients meeting bone mineral density (BMD) testing guidelines [men or women aged > or = 65 years or 50-64 years with one major risk factor including previous fracture, family history of osteoporosis, glucocorticoids for > 3 months, or early menopause] were allocated to intervention (129) or control (133). Intervention consisted of printed materials, education, and quantitative ultrasound. Primary outcome was a composite endpoint of BMD or prescription for osteoporosis medication within 4 months.

RESULTS

Primary endpoint of BMD or osteoporosis treatment was achieved by 28 intervention patients (22%) compared with 14 controls (11%) (RR 2.1, 95% CI 1.1-3.7). This was driven by BMD testing (28 (22%) vs. 13 (10%) for controls, p = 0.011). Calcium intake increased more among intervention patients than controls (30% vs. 19%, RR 1.6, 95% CI 1.0-2.5). There was no effect on knowledge or quality of life.

CONCLUSION

A pharmacist screening program doubled the number of patients tested for osteoporosis. Nevertheless, many patients eligible for BMD did not receive appropriate care suggesting more intensive interventions are needed.