Compliance with osteoporosis treatment guidelines in postmenopausal women

Are we ready for conformance checking in healthcare? Measuring adherence to clinical guidelines: A scoping systematic literature review

Clinical guidelines are recommendations of how to diagnose, treat, and manage a patient's medical condition. Health organizations must measure adherence to clinical guidelines to enhance the quality of service, but due to the complexity of the medical environment, there is no simple way of measuring adherence to clinical guidelines. This scoping review will systematically assess the criteria used to measure adherence to clinical guidelines in the past 20 years and explore the suitability of using process mining techniques. We will use a workflow protocol based on declarative and temporal constraints to translate the narrative text rules in the publications into a high-level process model. This approach will enable us to explore the main patterns and gaps identified when measuring adherence to clinical guidelines and how they affect the adoption of process mining techniques. The main contributions of this paper are a) a comprehensive analysis of the criteria used for measuring adherence, considering a diverse set of medical conditions b) a framework that will classify the level of complexity of the rules used to measure adherence based on declarative and temporal constraints c) list of key trends and gaps identified in the literature and how they relate to the use of process mining techniques in healthcare.

Interprofessional care for patients with osteoporosis in a continuing care retirement community

OBJECTIVES

To assess the quality of care provided to patients with osteoporosis in a continuing care retirement community (CCRC) after implementation of an interprofessional osteoporosis clinic (OPC). Specifically, quality measures were evaluated, including dual-emission X-ray absorptiometry (DXA) screening, calcium and vitamin D supplementation, and prescription treatment of osteoporosis and low bone mass in an ambulatory independent living community.

SETTING

Large family medicine teaching practice that provides primary care for residents in one main practice, 5 rural satellite practices, and 2 CCRCs. An interprofessional OPC was developed at the main practice in 2005. Patients at all of the organization's sites could be referred to the main practice for osteoporosis management. A needs assessment conducted at one of the CCRCs in 2011 revealed that rates of screening and treatment were suboptimal for its residents despite availability of an off-site OPC.

PRACTICE INNOVATION

In 2012, a new interprofessional OPC including a physician, medical assistant, and pharmacist was replicated on-site at the CCRC so that residents had access to this service within their medical home.

EVALUATION

Quality measures were evaluated after implementation of the team-based OPC on-site at a CCRC and included: 1) DXA screening; 2) calcium and vitamin D supplementation; and 3) prescription treatment of osteoporosis and low bone mass.

RESULTS

Twenty-nine patients were seen in the new OPC from January 2012 to August 2013. Ninety-three percent had appropriate DXA testing after OPC implementation. Patients accepted pharmacist recommendations regarding calcium and vitamin D supplementation 90% and 86% of the time, respectively. All but 4 patients received appropriate treatment for osteoporosis or low bone mass.

CONCLUSION

Providing a team-based OPC on site in a CCRC improved quality measures for screening and treatment of osteoporosis and low bone mass.

Italian association of clinical endocrinologists (AME) position statement: drug therapy of osteoporosis

Treatment of osteoporosis is aimed to prevent fragility fractures and to stabilize or increase bone mineral density. Several drugs with different efficacy and safety profiles are available. The long-term therapeutic strategy should be planned, and the initial treatment should be selected according to the individual site-specific fracture risk and the need to give the maximal protection when the fracture risk is highest (i.e. in the late life). The present consensus focused on the strategies for the treatment of postmenopausal osteoporosis taking into consideration all the drugs available for this purpose. A short revision of the literature about treatment of secondary osteoporosis due both to androgen deprivation therapy for prostate cancer and to aromatase inhibitors for breast cancer was also performed. Also premenopausal females and males with osteoporosis are frequently seen in endocrine settings. Finally particular attention was paid to the tailoring of treatment as well as to its duration.

Assessment of the presence and quality of osteoporosis prevention education among at-risk internal medicine patients

OBJECTIVE

Appropriate calcium and vitamin D intake for the prevention of osteoporosis represents an important component of osteoporosis prevention education (OPE). We sought to assess the presence and quality of OPE among osteoporotic and at-risk inpatients.

DESIGN

Prospective chart review plus cross-sectional interview.

SETTING

One academic tertiary referral medical center in Rochester, Minnesota.

PARTICIPANTS

Adults admitted to an inpatient medicine service who were determined to be at risk for osteoporosis based on an investigator-developed screening tool or previously diagnosed with osteoporosis. Four hundred sixtyfour patients were screened, 192 patients were approached for participation, and 150 patients consented to be interviewed for the study.

MAIN OUTCOME MEASURES

Source of OPE, rates of appropriate calcium intake and supplementation.

RESULTS

OPE from a health care provider was reported by 31.3% of patients, with only one patient reporting education from a pharmacist. Self OPE and no OPE were received by 29.3% and 39.3% of patients, respectively. Appropriate overall calcium intake was found in 30.7% of patients, and only 21.3% of patients were taking an appropriate calcium salt.

CONCLUSION

Patients with osteoporosis and risk factors for osteoporosis lack adequate education from health care providers regarding appropriate intake of dietary and supplemental calcium and vitamin D. A particular deficit was noted in pharmacist-provided education. Specific education targeting elemental calcium amounts, salt selection, and vitamin D intake should be provided to increase the presence of appropriate overall calcium consumption.

Prevalence, determinants, and inappropriateness of calcium supplementation among men and women in a Spanish Mediterranean area: cross-sectional data from the ESOSVAL cohort

Recently, safety concerns about calcium supplementation have arisen. In this situation, ensuring appropriateness of use is highly important. We aimed to describe the use of calcium and vitamin D supplements, the factors related to it, and to assess the appropriateness of calcium prescription among men and women aged 50 years or older. We performed a cross-sectional study in 2009-2010 including 11,035 adults who belong to the ESOSVAL cohort and attend 272 primary healthcare centers in the Valencia region of Spain. Criteria for the inappropriateness of calcium prescription, based on guidelines and recent evidence, were: excessive or insufficient daily total intake (diet plus supplements), excessive single doses of supplements, excessive or insufficient association with vitamin D, and overall inappropriateness. Calcium and/or vitamin D were prescribed to about 17% of the population. Older age, antiosteoporotic treatment, use of glucocorticoids, and a diagnosis of osteoporosis were related to prescription. The presence of other secondary causes of osteoporosis determined supplementation only in men. Calcium dietary intake was not related to the prescription of supplements. Among calcium users, 85.8% met at least one criterion of inappropriate prescription; 29% had an inappropriate daily total intake mainly resulting from excessive consumption (>2000 mg/day); 53.8% of patients were given calcium supplements in quantities higher than 500 mg per dose; and 38.9% of individuals receiving calcium supplements had inappropriate (absent or below 800 UI/day) vitamin D supplementation (all of them at high risk). In conclusion, we found high inappropriateness of calcium supplementation, mainly because of calcium overdosing, and also to undertreatment and underdosing of vitamin D in high-risk patients. Physicians should be encouraged to assess calcium dietary intakes before supplementation, recommending intake from food whenever possible, and to prescribe low calcium doses and high vitamin D doses when given in fixed-dose combinations, or vitamin D alone when calcium is not necessary.

Treatment and Management of Postmenopausal Osteoporosis within an Ambulatory Care Network

Background:

Postmenopausal osteoporosis (PMO) is associated with substantial morbidity and mortality. Despite established guidelines for the care of PMO, the treatment and management of this disease remain suboptimal.

Objective:

To examine the treatment and management of PMO in a community-based ambulatory care setting.

Methods:

Women with a new diagnosis of PMO (International Classification of Diseases, 9th Revision, code 733.01) were identified through the electronic health records (EHR) of a community-based ambulatory care network in northern California between January 1, 2007, and December 31, 2008. Patients were included if they were 65 years of age or older and had EHR activity 26 months or more after diagnosis. They were excluded if they had a diagnosis of osteoporosis (ICD-9:733.xx) prior to the study period. A retrospective review of the EHR and medical charts was performed to identify patients who were prescribed FDA-approved pharmacotherapy, who received bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DXA), and who experienced a fracture.

Results:

One hundred thirty-one PMO patients were identified who met study eligibility criteria. Fifty-nine patients (45%) were prescribed FDA-approved pharmacotherapy at diagnosis. Ninety patients (69%) were prescribed pharmacotherapy at any point during follow-up. Sixty-four patients (49%) had a baseline DXA scan and 95 patients (73%) had 1 or more DXA scans during follow-up. Seventeen of 90 patients (19%) who received pharmacotherapy had 2 DXA scans within 2 years of follow-up. Nineteen fractures were reported among 16 patients during the study period.

Conclusions:

The proportion of patients with PMO who received pharmacologic treatment at diagnosis and had a baseline DXA scan was relatively low; however, the majority of these patients received treatment and had 1 or more DXA scans at some point during the 26-month follow-up period. Future studies should be conducted to assess the role of early BMD testing and pharmacologic intervention in optimizing outcomes among women with PMO.

Effect of distributing an evidence-based guideline for prevention of osteoporosis on health education programs in municipal health centers: a randomized controlled trial

BACKGROUND

Current health education programs for osteoporosis prevention are not strictly evidence-based. We assessed whether distribution of an evidence-based guideline improved such programs at municipal health centers.

METHODS

This randomized controlled trial evaluated 100 municipal health centers throughout Japan that were randomly selected from those that planned to revise osteoporosis prevention programs. The implementation status of educational items recommended by the guideline was assessed before and after the intervention by evaluators blinded to the allocation. After the pre-intervention assessment, centers were randomly allocated in a 1:1 ratio to intervention and control groups by a minimization method defining region and city/town as stratification factors. Centers in the intervention group were given copies of the guideline; centers in the control group were instructed to use any information except the guideline. Analyses were performed on an intention-to-treat basis.

RESULTS

The guideline was used by 50% of the intervention group. Before the intervention, there was no significant difference in the evidence-based status of health education between the groups. The post-intervention assessment showed that the implementation rates of health education on dietary calcium intake for postmenopausal women and exercise for elderly persons were higher in the intervention group. Specific advice on intakes of calcium and vitamin D and exercise became more evidence-based in the intervention group.

CONCLUSIONS

The findings suggest that the guideline helped healthcare professionals to improve health education programs by making them more evidence-based. However, the improvements seemed to be limited to items that the professionals felt prepared to improve.

Evaluation of compliance with osteoporosis treatment guidelines after initiation of a pharmacist-run osteoporosis service at a family medicine clinic

BACKGROUND

Osteoporosis affects more than 10 million Americans, and fracture complications are devastating to patients and society. Despite the availability of guidelines and performance measures, osteoporosis is not optimally managed. Pharmacists have been pivotal in management of other disease states, and a multidisciplinary approach to osteoporosis management may improve patient outcomes.

OBJECTIVE

To establish a pharmacist-run osteoporosis service at a family medicine clinic and to evaluate short-term compliance with osteoporosis treatment guidelines before and after initiation of the service.

METHODS

A pharmacist-run osteoporosis service was established in October 2008. Adults with the diagnosis of osteoporosis before initiation of the service were included in evaluation of short-term compliance with treatment guidelines, including appropriate dual-energy X-ray absorptiometry (DEXA) scan frequency, pharmacotherapy, calcium and vitamin D supplementation, and nonpharmacologic education. Of 42 referred patients, 22 were eligible for inclusion. A retrospective chart review was conducted, and patients served as their own controls, with data from before and after establishment of the service evaluated.

RESULTS

Of the 22 patients evaluated, 8 (36%) received DEXA scans at the appropriate frequency before the service was established, versus 18 (82%) after the service was initiated. Seven (32%) patients were taking appropriate pharmacotherapy before the service, versus 17 (77%) after the service. Nine (41%) patients were taking calcium and vitamin D before the service, versus 22 (100%) after the service. Three (33%) of these patients were taking the appropriate dose and salt of calcium before the service, versus 20 (91%) after the service. Five (56%) of the 9 patients were taking the appropriate vitamin D dose before the service, versus 21 (95%) after the service. No patient had documented nonpharmacologic education prior to the service, compared with all patients after the service. All differences were significant (p < 0.05).

CONCLUSIONS

A pharmacist-run osteoporosis service significantly improved short-term compliance with guidelines, including appropriate DEXA scan frequency, pharmacotherapy, calcium and vitamin D supplementation, and nonpharmacologic education.