Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education

Notable lacking of bone mineral density measurement in cushing syndrome: a nationwide study based on the US insurance claim database

This study examined the underuse of bone mineral density (BMD) testing in Cushing's syndrome patients, using a US insurance claims database. Despite osteoporosis risks, only 6.40% of 53,101 patients received BMD testing. The study underscores significant care gaps, particularly among males and older adults, necessitating improved screening efforts.

BACKGROUND

Cushing syndrome (CS) is caused by long-term exposure to elevated glucocorticoid levels, primarily due to chronic steroid use, though it can also result from pituitary tumors. This condition leads to significant bone mineral density (BMD) loss and a heightened risk of osteoporosis. Despite guidelines for BMD testing in at-risk patients, osteoporosis has remained underdiagnosed in CS. The prevalence of BMD measurement in this group in the US continues to be unknown, indicating a gap in care.

METHODS

We conducted a retrospective study using data from the PearlDiver Patient Records Database (2010-2020). Patients diagnosed with Cushing's syndrome who underwent BMD testing were included, while those with prior osteoporosis diagnoses were excluded. We analyzed patient demographics, comorbidities, and outcomes using t-tests, chi-squared tests, and logistic regression with significance set at p < 0.001.

RESULTS

Among 53,101 identified Cushing's syndrome patients, only 6.40% underwent bone mineral density (BMD) testing within two years of diagnosis. Females were significantly more likely to be tested (7.85% vs. 2.58%; p < 0.001), and those tested were younger (mean age: 62.79 vs. 65.21 years; p < 0.001). The Midwest region had the highest testing rate at 7.1%, and patients with commercial insurance had the highest testing frequency at 7.5%. Factors associated with reduced BMD testing included male gender (OR = 0.31; p < 0.001), older age (OR = 0.96; p < 0.001), and higher Elixhauser Comorbidity Index (ECI) scores (OR = 0.89; p < 0.001). Conversely, obesity (OR = 1.51; p < 0.001) and chronic kidney disease (OR = 1.38; p < 0.001) increased the likelihood of testing. Among those tested, 12.56% were diagnosed with osteoporosis, with older age and tobacco use significantly increasing the odds of diagnosis.

CONCLUSION

Despite guideline recommendations, only 6.40% of patients with Cushing's syndrome underwent BMD screening. Among those screened, 12.56% were diagnosed with osteoporosis.. These findings highlight the need for improved adherence to screening guidelines, particularly for high-risk populations, to better manage and prevent osteoporosis in Cushing's syndrome patients.

Incidence of Secondary Fractures After Implementation of Different Models of FLS Secondary Prevention Programs: Scoping Review

BACKGROUND

As the number of programs aimed at preventing fragility fractures and mitigating the phenomenon of cascade fractures is increasing worldwide, so it is necessary to evaluate the effectiveness of such programs to seek their feasible implementation at regional and global levels.

AIMS

This paper aims to provide an overview focusing on the incidence of secondary fractures after the implementation of any type of fracture liaison service (FLS). To this end, a scoping review was conducted focusing on the identification of clinical evidence reported in systematic reviews of the medical literature in this area.

METHODS

A total of 230 titles were obtained through structured searches in four electronic libraries (updated to September 2023), from which a total of 11 systematic reviews were selected.

RESULTS

Tables of methodological characteristics were developed. Different programs such as orthogeriatric units, educational strategies, exercise strategies, screening strategies using DXA or FRAX, and specialist intervention by orthopedic specialists or osteoporosis nurses were found in 20 different countries. The reported incidence of secondary fractures varies between populations and strategies compared depending on the data collected and the type of methodological design used. The incidence of secondary fractures in these 11 systematic reviews ranged from 0 to 37%.

CONCLUSION

The incidence by intervention is described in the Supplementary Tables of the primary studies.

Academic Detailing Interventions and Evidence-Based Prescribing: A Systematic Review

Importance

Academic detailing (interactive educational outreach) is a widely used strategy to encourage evidence-based prescribing by clinicians.

Objective

To evaluate academic detailing programs targeted at improving prescribing behavior and describe program aspects associated with positive outcomes.

Evidence Review

A systematic search of MEDLINE from April 1, 2007, through December 31, 2022, was performed for randomized trials and nonrandomized studies of academic detailing interventions to improve prescribing. Academic detailing was defined as evidence-based medication education outreach delivered interactively to individuals or small groups of prescribers. Only studies that measured prescribing outcomes were included. Two investigators independently assessed studies for risk of bias using validated assessment tools. Among all studies rated as having low risk of bias and randomized trials rated as having moderate risk of bias, the absolute change in the proportion of patients using the targeted medications and the proportion of studies that led to significant changes in 1 or more prescribing outcome were determined. The data analysis was performed between January 25, 2022, and November 4, 2024.

Findings

The 118 studies identified varied by setting (eg, inpatient, outpatient) and academic detailing delivery (eg, individual vs groups of prescribers). The most common therapeutic targets were antibiotic overuse (32 studies [27%]), opioid prescribing (24 studies [20%]), and management of mental health conditions (16 studies [14%]) and cardiovascular disease (13 studies [11%]). Most studies (66 [56%]) combined academic detailing with other interventions (eg, audit and feedback, electronic health record reminders). Among 36 studies deemed to have the lowest risk of bias, 18 interventions (50%; 95% CI, 33%-67%) led to significant improvements in all prescribing outcomes, and 7 (19%; 95% CI, 8%-36%) led to significant improvements in 1 or more prescribing outcomes. The median absolute change in the proportion of patients using the targeted medication or medications was 4.0% (IQR, 0.3%-11.3%) in the intended direction.

Conclusions and Relevance

In this systematic review of academic detailing interventions addressing evidence-based prescribing, most interventions led to substantial changes in prescribing behavior, although the quality of evidence varied. These findings support the use of academic detailing to bring about more evidence-based prescribing in a variety of clinical settings.

Fracture liaison service-a multidisciplinary approach to osteoporosis management

A fracture liaison service is a systems-level multidisciplinary approach designed to reduce subsequent fracture risk in patients who recently sustained fragility fractures. It is estimated that one in three women and one in five men over the age of 50 years old have osteoporosis. Nonetheless, only 9 to 20% of patients who sustain an initial fragility fracture eventually receive any osteoporosis treatment. With the aim of preventing subsequent fractures, a fracture liaison service (FLS) works through identifying patients presenting with fragility fractures to the hospital and providing them with easier access to osteoporosis care through referrals for bone health and fracture risk assessment and recommendation or initiation of osteoporosis treatment. Currently, there are four major types of FLS models ranging from services that only identify at-risk patients and inform and educate the patient but take no further part in communicating their findings to other stakeholders in patients' care, to services that identify, investigate, and initiate treatment at the other end of the spectrum. In this article, we review the benefits, challenges, and outcomes of FLS in the American healthcare system with further exploration of the roles each member of the multidisciplinary team can play in improving patients' bone health.

Perspectives of healthcare providers on osteoporosis, falls and fracture risk: a systematic review and thematic synthesis of qualitative studies

OBJECTIVE

Osteoporosis and falls are major risk factors for osteoporotic fractures, with significant detriment to patients' quality of life. We aimed to describe healthcare provider (HCP) perspectives and experiences in the diagnosis, management and prevention of osteoporosis, falls and fractures obtained through primary qualitative research.

METHODS

Thematic synthesis was performed on articles identified through a search of electronic databases (MEDLINE, Embase, PsychINFO and CINAHL), which were searched from inception to May 2023.

RESULTS

Twenty-seven studies including 1662 HCPs, including general practitioners (GPs), physicians, surgeons, physiotherapists (PTs), occupational therapists (OTs), pharmacists and nurses, were included, with identification of six themes: overshadowed as a disease entity, uncertainty in decision making, frustration with interdisciplinary and systemic tension, avoiding medical paternalism, desire for improved care and embracing the responsibility.

CONCLUSION

Osteoporotic fracture and fall prevention in routine clinical care is hampered by inadequate priority and lack of perceived connection with morbidity and mortality, deficits in interdisciplinary collaboration, lack of clinical confidence and health resourcing. However, HCPs acknowledge their role in promoting healthy ageing, thus providing support through appropriate continuing education, resourcing and public health campaigns that are significant future directions, which may improve osteoporotic fracture prevention.

Pharmacist interventions in osteoporosis management: a systematic review

Internationally, there is an osteoporosis treatment gap, which pharmacists may assist in closing. This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness. Pharmacist interventions are shown to improve osteoporosis management in terms of increasing investigation and treatment commencement and osteoporosis therapy adherence.

INTRODUCTION

This review identifies pharmacist interventions for improving osteoporosis management and evaluates their effectiveness.

METHODS

A literature search using PubMed, Embase, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was undertaken from database inception to June 2022. Randomised controlled trials were eligible, if they included adults diagnosed with or at risk of osteoporosis and assessed pharmacist interventions to improve osteoporosis management. Outcomes regarding investigation, treatment, adherence and patient knowledge were evaluated using qualitative analysis. The quality of included studies was assessed using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration tool to assess the risk of bias (Rob 2.0).

RESULTS

Sixteen articles (12 different studies) with a total of 16,307 participants, published between 2005 and 2018 were included. Pharmacist interventions were classified into two categories, those targeting investigation and treatment (n = 10) and those targeting adherence (n = 2). The impact of the intervention on patient knowledge was considered by studies targeting both investigation and treatment (n = 2) and adherence (n = 1). Pharmacist interventions demonstrated benefit for all outcomes; however, the extent to which conclusions can be drawn on their effectiveness is limited by the heterogeneity of interventions employed and methodological issues identified. Patient education and counselling were identified as a cornerstone of pharmacist interventions targeting both investigation and treatment and adherence, along with the importance of pharmacist and physician collaboration.

CONCLUSION

Pharmacist interventions show promise for improving osteoporosis management. The potential for pharmacists to contribute to closing the osteoporosis treatment gap through undertaking population screening has been identified.

Efficiency of coordinator-based osteoporosis intervention in fragility fracture patients: a prospective randomized trial

We examined the effectiveness of coordinators' interventions to prevent secondary fractures in patients with fragility fractures. These coordinator-based interventions improved bone density assessment implementation and treatment rates, and enhanced treatment persistence rates in the early stages following fractures.

INTRODUCTION

This study aimed to determine the efficiency of coordinator-based osteoporosis intervention in fragility fracture patients during a 2-year period.

METHODS

A prospective intervention randomized control study was conducted at seven medical facilities from January 2015 to March 2017. Postmenopausal women and men over 50 years old with fragility fractures were randomly divided into the coordinator intervention (LI; 70 patients) and without intervention (non-LI; 71 patients) groups. The osteoporosis treatment rate, osteoporosis treatment persistence rate, fall rate, fracture incidence rate, and bone density measurement rate 3 months, 6 months, 1 year, and 2 years after registration were compared between the two groups. Non-parametric tests were used to analyze data at each inspection period.

RESULTS

The osteoporosis treatment initiation rate was significantly higher in the LI group than in the non-LI group (85.7% vs. 71.8%; p = 0.04). The LI group had significantly higher bone density assessment implementation rates than the non-LI group at the time of registration (90.0% vs. 69.0%; p = 0.00) and 6 months after registration (50.0% vs. 29.6%; p = 0.01), but not 1 or 2 years after registration. In addition, no significant differences in fall or fracture incidence rates were found between the two groups.

CONCLUSION

The coordinator-based interventions for fragility fractures improved bone density assessment implementation and treatment rates and enhanced treatment persistence rates in the early stages following bone fractures. The findings suggest that liaison intervention may help both fracture and osteoporosis physicians for the evaluation of osteoporosis and initiation and continuation of osteoporosis medication.

Delivering fracture prevention services to rural US veterans through telemedicine: a process evaluation

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.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Interventions to improve osteoporosis care: a systematic review and meta-analysis

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.

The impact of a musculoskeletal training program on residents' recognition and treatment of osteoporosis

BACKGROUND

Osteoporosis is inadequately treated in primary care settings. Under-recognition of the condition among male Veterans may contribute to this problem. In order to improve understanding of bone health in older male patients, we developed the "Musculoskeletal (MSK) Education Week", a multidisciplinary clinical training initiative within a primary care ambulatory rotation for internal medicine (IM) residents at the Salt Lake City VA Medical Center. The objective of this study was to evaluate the impact of this program on trainees' recognition of osteoporosis or treatment of this condition following the training experience.

METHODS

We examined several clinical behaviors of post-graduate year 1 (PGY-1) IM trainees following their participation in the MSK Education Week between July 1-April 30, 2014. To determine the prevalence of these clinical behaviors, we conducted an observational study of patients age 50 and older enrolled at the Salt Lake City VA Healthcare System from July 1, 2013 to May 31, 2014. We used time-dependent multivariable Cox proportional hazard models to evaluate the impact of the training program on 4 osteoporosis-related outcomes: (1) completion of dual energy X-ray absorptiometry (DXA) scan, (2) diagnosis of osteopenia, (3) diagnosis of osteoporosis, and (4) initiation of osteoporosis medications.

RESULTS

Twenty-six PGY-1 IM residents participated in the MSK Education Week, and 43,678 Veterans were identified over these periods of observation. In the Veterans cohort, 1154 had an encounter with a provider who had completed the training (and were therefore "exposed" to the training) and 42,524 Veterans did not. After adjusting for confounders, the effect of the provider training program was significant for DXA (HR = 1.78, 95% CI: 1.11, 2.87), osteoporosis diagnosis (HR = 3.90, 95% CI: 2.09, 7.29), and initiation of medications (HR = 2.87, 95% CI: 2.02, 4.09) outcomes.

CONCLUSIONS

We have shown that IM residents' participation in the MSK Education Week was associated with significantly improvements in their completion of DXA scans, diagnosis of osteoporosis, and initiation of fracture-reducing medications in a population of US Veterans. Long-term follow up is needed to determine whether these initial results are followed by actual reductions in osteoporotic fractures.

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

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.

Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study

Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors.

PURPOSE

The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care.

METHODS

Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models.

RESULTS

In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031).

CONCLUSIONS

Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care.

TRIAL REGISTRATION

The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

Complex interventions can increase osteoporosis investigations and treatment: a systematic review and meta-analysis

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.

Development of fracture liaison services: What have we learned?

Due to dramatic improvements in life expectancy we are seeing a rapidly growing population of older people. Increasing frailty and susceptibility to fragility fractures are becoming pressing issues for both the individuals that suffer them as well as society, through pressures on health and social care budgets. The success of fracture liaison services, co-ordinated programmes enhancing the management of the fracture, osteoporosis, frailty and falls risk, is undisputed. To achieve optimal outcomes, however, it is important to have a standardisation of design, scope and structure of the service. Experience has taught us that by delegating responsibility for the holistic care of the patient to a trained and adequately resourced professional/team (fracture prevention practitioner) with clear standards against which benchmarking occurs, is the optimal model of delivery. Future challenges include how best to measure the success of services in imparting a reduction in fractures at a local population level as well as how to detect those patients with unmet need who do not uniformly present to health care services, such as those with vertebral fractures. The implementation of fracture liaison services however, is a clear demonstration of how collaboration between health care, social care and charity organisations, among others, has materially improved the health and well-being of the population.

Fracture liaison services: improving outcomes for patients with osteoporosis

Fragility fractures are sentinels of osteoporosis, and as such all patients with low-trauma fractures should be considered for further investigation for osteoporosis and, if confirmed, started on osteoporosis medication. Fracture liaison services (FLSs) with varying models of care are in place to take responsibility for this investigative and treatment process. This review aims to describe outcomes for patients with osteoporotic fragility fractures as part of FLSs. The most intensive service that includes identification, assessment and treatment of patients appears to deliver the best outcomes. This FLS model is associated with reduction in re-fracture risk (hazard ratio [HR] 0.18–0.67 over 2–4 years), reduced mortality (HR 0.65 over 2 years), increased assessment of bone mineral density (relative risk [RR] 2–3), increased treatment initiation (RR 1.5–4.25) and adherence to treatment (65%–88% at 1 year) and is cost-effective. In response to this evidence, key organizations and stakeholders have published guidance and framework to ensure that best practice in FLSs is delivered.

Role of Side Effects, Physician Involvement, and Patient Perception in Non-Adherence with Oral Bisphosphonates

INTRODUCTION

The benefits of osteoporosis therapy are compromised by low adherence, thus requiring a better understanding of its barriers and unmet needs. The objective of this study was to assess reasons for non-adherence with oral bisphosphonates among osteoporotic women.

METHODS

A cross-sectional patient survey of women who initiated therapy with risedronate or alendronate between the years 2010 and 2012 were non-adherent [Medication Possession Ratio (MPR) <70%] or switched therapy within the first year. Survey participants were identified using Maccabi Health Services computerized database. Patients who gave informed consent completed a 20-min telephonic survey, assessing reasons for discontinuation or switching, including physician involvement, side effects, administration regimen, perceptions of bone health, and medications' efficacy.

RESULTS

The study population included 493 females (mean age = 66 ± 7) of whom 40% discontinued all anti-osteoporotic therapy (mean MPR = 19%), 9% remained on initial therapy (mean MPR = 47%), and 51% switched therapy (mean MPR = 62%). Family history, fracture history, socioeconomic status, and index drug class and frequency were similar in all groups. The most common reasons for switching or discontinuation of the first-line therapy were gastrointestinal side effects, such as heartburn, acid reflux or other (40.0%), and physician recommendation (26.7%). The major reasons for complete discontinuation of therapy were side effects (26.9%) and physician recommendation (20.0%). Perceived low importance was more commonly mentioned than high cost of medication (14% vs. 3%).

CONCLUSION

Our findings highlight the importance of low tolerability to non-adherence with osteoporosis therapy and underlines poor patients' awareness and sub-optimal physicians' involvement in conveying the importance of this therapy.

FUNDING

Merck & Co Inc.

Osteoporosis-Related Health Behaviors in Men With Prostate Cancer and Survivors: Exploring Osteoporosis Knowledge, Health Beliefs, and Self-Efficacy

This descriptive study aimed to (a) determine the extent of osteoporosis knowledge, perceived health beliefs, and self-efficacy with bone healthy behaviors in men with prostate cancer and survivors and (b) identify how dietary bone healthy behaviors are associated with these psychobehavioral and psychosocial factors. Three different questionnaires were used to measure osteoporosis knowledge, health beliefs, and self-efficacy in a group of men with prostate cancer and survivors. Bone health was assessed via dual-energy X-ray absorptiometry and calcium intake using a diet history. The prevalence of osteoporosis and low bone mass was high at over 70%. Participants had inadequate osteoporosis knowledge with a mean score of 43.3% ( SD = 18%) on the Facts on Osteoporosis Quiz. Participants scored low on the subscale measuring barriers to exercise (median = 11; interquartile range [IQR] = 6.5), indicating minimal barriers to exercise participation, and the subscale measuring the benefits of exercise scored the highest (median = 24; IQR = 3.5) compared with the other subscales. Men with prostate cancer and survivors were highly confident in their exercise and calcium self-efficacy (83.0%, IQR = 24.0% and 85.7%, IQR = 27.0%, respectively). Participants did not meet their calcium requirements or consume enough dairy products for optimum bone health. Men with prostate cancer and survivors have poor osteoporosis knowledge, but are confident in their self-efficacy of undertaking bone healthy behaviors. This confidence did not translate to specific dietary behaviors as they did not meet their calcium or dairy intake requirements. Implications for cancer survivors is that there is a need for bone health education programs among prostate cancer survivors. These programs should go beyond education and empowerment to provide practical guidance to maximize uptake of bone healthy behaviors.

Evaluation of a Nationwide Pharmacist-Led Phone Outreach Program to Improve Osteoporosis Management in Older Women with Recently Sustained Fractures

BACKGROUND

Osteoporosis-related fractures are a considerable economic burden on the U.S. health care system. Since 2008, the Centers for Medicare Medicaid Services have adopted a Medicare Part C Five-Star Quality Rating measure to ensure that a woman's previously unaddressed osteoporosis is managed appropriately after a fracture. Despite the effort to improve this gap in care, the 2013 CMS plan ratings fact sheet reported an average star rating of 1.4 stars for the osteoporosis measure, the lowest score for any measure across all health plans.

OBJECTIVE

To evaluate the impact of conducting a pharmacist-led, telephone outreach program to members or their providers to improve osteoporosis management in elderly women after experiencing fractures. 

METHODS

This was a prospective, randomized study to evaluate the effectiveness of 3 different intervention strategies within a nationwide managed care population. Women aged 66 years and older who experienced a new bone fracture between January 1, 2012-August 31, 2012, were identified through medical claims. Women who were treated with an osteoporosis medication or received a bone mineral density (BMD) test within a year of their fractures were excluded. Study patients were randomized into 3 intervention cohorts: (1) baseline intervention consisting of member educational mailing and provider educational mail or fax notification; (2) baseline intervention plus a live outbound intervention call to members by a pharmacist; and (3) baseline intervention plus a pharmacist call to members' providers to recommend starting osteoporosis therapy and/or a bone mineral density (BMD) test. An intent-to-treat and per protocol analyses were employed, and appropriate osteoporosis management (initiation of osteoporosis therapy and/or BMD testing) 120 days after the baseline intervention and 180 days after a fracture were measured.

RESULTS

The study identified 6,591 members who were equally randomized into 3 cohorts. The baseline demographics in each cohort were similar. Results of the intent-to-treat analysis showed more members in cohort 3 receiving appropriate osteoporosis management (13.0%) compared with those in cohort 2 (10.3%, P  less than  0.005) or compared with those in cohort 1 (9.1%, P  less than  0.001). No difference was detected between those receiving additional member calls (cohort 2) and those receiving only the baseline intervention (cohort 1). Similar results were observed utilizing the 180 days after fracture time frame. 

CONCLUSIONS

The effectiveness of a pharmacist-led telephone intervention directed at providers or members was examined in this randomized study. Pharmacist calls to members did not improve osteoporosis management over member and provider mail and fax notifications. Greater impact was demonstrated by performing a pharmacist call intervention with providers rather than with members.

Professional interventions for general practitioners on the management of musculoskeletal conditions

BACKGROUND

Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.

OBJECTIVES

To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. 

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.

MAIN RESULTS

Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.

AUTHORS' CONCLUSIONS

There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

Fracture liaison services: promoting enhanced bone health care

The high prevalence of osteoporotic fractures and their major effect on morbidity and mortality emphasizes the critical need to optimize bone health care. Patients presenting with fragility fractures are at high risk of subsequent fracture, but treatment rates have remained low for these patients. Recently developed fracture liaison services have successfully increased osteoporosis treatment, with improved patient outcomes. We review factors contributing to the treatment gap in osteoporosis, the function of fracture liaison services in reducing this gap, and lessons learned from the literature on effective formats, key elements, and suggestions for managing challenges in implementation of a fracture liaison service.

Comparison of interactive voice response, patient mailing, and mailed registry to encourage screening for osteoporosis: a randomized controlled trial

Guidelines recommend screening for osteoporosis with bone mineral density (BMD) testing in menopausal women, particularly those with additional risk factors for fracture. Many eligible women remain unscreened. This randomized study demonstrates that a single outreach interactive voice response phone call improves rates of BMD screening among high-risk women age 50-64.

INTRODUCTION

Osteoporotic fractures are a major cause of disability and mortality. Guidelines recommend screening with BMD for menopausal women, particularly those with additional risk factors for fracture. However, many women remain unscreened. We examined whether telephonic interactive voice response (IVR) or patient mailing could increase rates of BMD testing in high risk, menopausal women.

METHODS

We studied 4,685 women age 50-64 years within a not-for-profit health plan in the United States. All women had risk factors for developing osteoporosis and no prior BMD testing or treatment for osteoporosis. Patients were randomly allocated to usual care, usual care plus IVR, or usual care plus mailed educational materials. To avoid contamination, patients within a single primary care physician practice were randomized to receive the same intervention. The primary endpoint was BMD testing at 12 months. Secondary outcomes included BMD testing at 6 months and medication use at 12 months.

RESULTS

Mean age was 57 years. Baseline demographic and clinical characteristics were similar across the three study groups. In adjusted analyses, the incidence of BMD screening was 24.6% in the IVR group compared with 18.6% in the usual care group (P < 0.001). There was no difference between the patient mailing group and the usual care group (P = 0.3).

CONCLUSIONS

In this large community-based randomized trial of high risk, menopausal women age 50-64, IVR, but not patient mailing, improved rates of BMD screening. IVR remains a viable strategy to incorporate in population screening interventions.

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.

The PAADRN study: a design for a randomized controlled practical clinical trial to improve bone health

INTRODUCTION

To describe the rationale and design of an NIH funded randomized controlled trial: the Patient Activation after DXA Result Notification (PAADRN) study. The aim of this trial is to evaluate the effect that a direct mailing of Dual-Energy X-ray Absorptiometry (DXA) results from bone density testing centers to patients will have on patients' knowledge, treatment and self-efficacy.

METHODS

We will enroll approximately 7500 patients presenting for DXA at three study sites, the University of Iowa, the University of Alabama at Birmingham, and Kaiser Permanente of Atlanta, Georgia. We will randomize providers (and their respective patients) to either the intervention arm or usual care. Patients randomized to the intervention group will receive a letter with their DXA results and an educational brochure, while those randomized to usual care will receive their DXA results according to standard practice. The seven discrete outcomes are changes from baseline to 12-weeks and/or 52-weeks post-DXA in: (1) guideline concordant pharmacologic and non-pharmacologic therapy; (2) knowledge of DXA results; (3) osteoporosis-specific knowledge; (4) general health-related quality of life; (5) satisfaction with bone-related health care, (6) patient activation; and, (7) osteoporosis-specific self-efficacy.

CONCLUSION

This trial will offer evidence of the impact of a novel approach-direct-to-patient mailing of test results-to improve patient activation in their bone health care. The results will inform clinical practice for the communication of DXA and other test results.

Predictors of bone mineral density testing in patients at high risk of osteoporosis: secondary analyses from the OSTEOPHARM randomized trial

In a randomized trial, we demonstrated that a community pharmacist osteoporosis screening intervention doubled the rates of bone mineral density (BMD) testing in high-risk patients. The purpose of this secondary analysis was to evaluate the potentially modifiable factors associated with BMD testing. From 2005 to 2007, 15 pharmacies randomized 262 patients to intervention (education, pamphlets, point-of-care quantitative heel ultrasound [QUS]) or usual care. The main outcome was BMD testing within 4mo. Multivariate regression was used to determine independent correlates of BMD testing. The median age of the cohort was 62yr, 65% were women, and 49% (n=129) were randomized to intervention. Compared with patients who were not tested, those with BMD were more likely to be women (p=0.007) and have excellent or very good health (p<0.001). Postrandomization correlates of BMD test were intervention (p=0.017), greater osteoporosis knowledge (p=0.004), and osteoporosis-specific physician visits (p<0.001). In adjusted analyses, only female sex (adjusted odds ratio [aOR]: 3.0; 95% confidence interval [CI]: 1.3-7.4) and osteoporosis-specific visits (aOR: 3.2; 95% CI: 1.4-7.8) were independently associated with BMD testing. In analyses restricted to intervention patients, abnormal QUS (aOR: 3.7, 95% CI: 1.4-9.1) was the only independent predictor of BMD test. Future interventions should incorporate the finding that osteoporosis-specific visits and abnormal QUS results were strongly associated with getting a BMD testing and should give greater attention to men.

Closing the gap in postfracture care at the population level: a randomized controlled trial

BACKGROUND

Postfracture care is suboptimal, and strategies to address this major gap in care are necessary. We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care.

METHODS

We conducted a randomized controlled trial (ClinicalTrials.gov identifier NCT00594789) in the province of Manitoba, Canada, from June 2008 to May 2010. Using medical claims data, we identified 4264 men and women age 50 years or older who recently reported major fractures, and who had not undergone recent bone mineral density testing or treatment for osteoporosis. Participants were randomized to three groups: group 1 received usual care (n = 1480), patients in group 2 had mailed notification of the fracture sent to their primary care physicians (n = 1363), and group 3 had notifications sent to both physicians and patients (n = 1421). Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented.

RESULTS

Among participants in group 1 (usual care), 15.8% of women and 7.6% of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis. Outcome measures improved among participants in group 2 (30.3% of women and 19.0% of men, both p < 0.001) and group 3 (34.0% of women and 19.8% of men, both p < 0.001). No additional benefit was seen with patient notification in addition to physician notification. Combining groups 2 and 3, the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9% (16.4% among women, 11.8% among men). The number needed to notify to change patient care was 7 (6 for women, 6 for men). The adjusted odds ratio (OR) to change patient care in group 2 was 2.45 (95% confidence interval [CI] 2.01-2.98); for group 3 the OR was 2.82 (95% CI 2.33-3.43).

INTERPRETATION

This notification system provides a relatively simple way to enhance post-fracture care.

Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis

This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis. Eight electronic databases and six gray literature sources were searched. Randomized controlled trials, controlled clinical trials, quasi-randomized trials, controlled before-after studies, and interrupted time series written in English or French from 1985 to 2009 were considered. Eligible studies had to include patients at risk (women ≥ 65 years, men ≥ 70 years, and men/women ≥ 50 years with at least one major risk factor for osteoporosis) or at high risk (men/women using oral glucocorticoids or with previous fragility fractures) for osteoporosis and fractures. Outcomes included bone mineral density (BMD) testing, osteoporosis treatment initiation, and fractures. Data were pooled using a random effects model when applicable. Thirteen studies were included. The majority were multifaceted and involved patient educational material, physician notification, and/or physician education. Absolute differences in the incidence of BMD testing ranged from 22% to 51% for high-risk patients only and from 4% to 18% for both at-risk and high-risk patients. Absolute differences in the incidence of osteoporosis treatment initiation ranged from 18% to 29% for high-risk patients only and from 2% to 4% for at-risk and high-risk patients. Pooling the results of six trials showed an increased incidence of osteoporosis treatment initiation (risk difference (RD) = 20%; 95% CI: 7-33%) and of BMD testing and/or osteoporosis treatment initiation (RD = 40%; 95% CI: 32-48%) for high-risk patients following intervention. Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements are often clinically modest.

A comparison of statistical approaches for physician-randomized trials with survival outcomes

This study compares methods for analyzing correlated survival data from physician-randomized trials of health care quality improvement interventions. Several proposed methods adjust for correlated survival data; however the most suitable method is unknown. Applying the characteristics of our study example, we performed three simulation studies to compare conditional, marginal, and non-parametric methods for analyzing clustered survival data. We simulated 1000 datasets using a shared frailty model with (1) fixed cluster size, (2) variable cluster size, and (3) non-lognormal random effects. Methods of analyses included: the nonlinear mixed model (conditional), the marginal proportional hazards model with robust standard errors, the clustered logrank test, and the clustered permutation test (non-parametric). For each method considered we estimated Type I error, power, mean squared error, and the coverage probability of the treatment effect estimator. We observed underestimated Type I error for the clustered logrank test. The marginal proportional hazards method performed well even when model assumptions were violated. Nonlinear mixed models were only advantageous when the distribution was correctly specified.

PRO-OSTEO Project (improving osteoporosis management in the acute hospital setting): a pilot single-centre study

Osteoporosis affects many people and has a large impact on health. As the condition is known to be poorly managed, a project was undertaken to improve treatment results in a hospital setting. The project succeeded in improving management of osteoporosis in patients who are admitted to hospital with broken bones.

PURPOSE

Osteoporosis is an inadequately managed condition around the world with high mortality and morbidity resulting from major fractures. Assessment and treatment rates for this condition are low, including hospital settings after minimal trauma fractures. The PRO-OSTEO project was set up to improve assessment and treatment rates of osteoporosis in patients admitted to Frankston Hospital's (Peninsula Health) orthopaedic ward with minimal trauma fractures.

METHOD

An osteoporosis assessment and treatment algorithm was introduced into inpatient practice in March 2010. This was accompanied by a multifaceted intervention, which included posters, presentations promoting the project and one on one academic detailing to ward pharmacists, orthopaedic, endocrinology and aged care junior medical staff. Three time periods were retrospectively reviewed to determine assessment and treatment rates, before and after the introduction of the algorithm, as well as 3 months following the introduction of the algorithm, to observe the sustainability of the intervention in a new group of doctors who had not received academic detailing.

RESULTS

Initially, the introduction of the algorithm increased treatment and assessment rates from 19.7% and 50% at baseline to 71.6% and 87.8%, respectively (p < 0.0005), with the results declining in the following period, 3 months after initial intervention and after medical/surgical staff change over, to 47.8% and 54.3%, respectively (p < 0.0005).

CONCLUSION

An algorithm-based approach linked with academic detailing and education of the multidisciplinary team in acute hospital environment provides a clinically significant and effective strategy to improve osteoporosis management of patients with minimal trauma fractures.

Postfracture interventions disseminated through health care and drug insurers: attempting to integrate fragmented health care delivery

Osteoporosis care after a fracture is often suboptimal. Suboptimal treatment seems to be most common in fragmented health care systems. We examined the literature to assess possible causes for suboptimal postfracture osteoporosis care within fragmented health care systems. The review of the literature did not attempt to meta-analyze prior studies. We found several possible methods for improving postfracture osteoporosis care in a fragmented health care system. These include changes in health care financing, application of information technology, incorporation of case management, the use of system champions, and dissemination of performance measures. The strengths and weaknesses of each of these potential levers for improvement were explored. Postfracture osteoporosis care is sub-optimal and challenging to improve in fragmented health care delivery systems.

The effect of the addition of osteoporosis education to a bone health screening program for older adults

Osteoporosis affects approximately 26% of women and 4% of men after the age of 65 years. However, the diffusion of knowledge about osteoporosis risk factors, prevention and treatment remains low. The purpose of this longitudinal study was to investigate the value of adding initial and refresher osteoporosis education classes to a bone health screening program. A convenience sample of 376 men (n = 62) and women (n = 314) over the age of 62 years was assigned randomly to the Screening plus Education (n =193) or Screening only (n = 183) groups. Participants in both study groups demonstrated an increase in knowledge about osteoporosis, regardless of group assignment and other factors, over the two years of the study. Self-reported calcium use increased for all women and for men in the education group from baseline to year one, with a decline thereafter. There was no effect on exercise behaviors. This study points out the critical need for a more comprehensive and personalized bone health program that includes more than classroom-based education.

Impact of a primary care physician workshop on osteoporosis medical practices

SUMMARY

Attendance at a fragility-fractures-prevention workshop by primary care physicians was associated with higher rates of osteoporosis screening and treatment initiation in elderly female patients and higher rates of treatment initiation in high-risk male and female patients. However, osteoporosis management remained sub-optimal, particularly in men.

INTRODUCTION

Rates of osteoporosis-related medical practices of primary care physicians exposed to a fragility-fractures-prevention workshop were compared with those of unexposed physicians.

METHODS

In a cluster cohort study, 26 physicians exposed to a workshop were matched with 260 unexposed physicians by sex and year of graduation. For each physician, rates of bone mineral density (BMD) testing and osteoporosis treatment initiation among his/her elderly patients 1 year following the workshop were computed. Rates were compared using multilevel logistic regression models controlling for potential patient- and physician-level confounders.

RESULTS

Twenty-five exposed physicians (1,124 patients) and 209 unexposed physicians (9,663 patients) followed at least one eligible patient. In women, followed by exposed physicians, higher rates of BMD testing [8.5% versus 4.2%, adjusted OR (aOR) = 2.81, 95% CI 1.60-4.94] and treatment initiation with bone-specific drugs (BSDs; 4.8% vs. 2.4%, aOR = 1.95, 1.06-3.60) were observed. In men, no differences were detected. In patients on long-term glucocorticoid therapy or with a previous osteoporotic fracture, higher rates of treatment initiation with BSDs were observed in women (12.0% vs. 1.9%, aOR = 7.38, 1.55-35.26), and men were more likely to initiate calcium/vitamin D (5.3% vs. 0.8%, aOR = 7.14, 1.16-44.06).

CONCLUSIONS

Attendance at a primary care physician workshop was associated with higher rates of osteoporosis medical practices for elderly women and high-risk men and women. However, osteoporosis detection and treatment remained sub-optimal, particularly in men.

Community based intervention to optimize osteoporosis management: randomized controlled trial

Background

Osteoporosis-related fractures are a significant public health concern. Interventions that increase detection and treatment of osteoporosis are underutilized. This pragmatic randomised study was done to evaluate the impact of a multifaceted community-based care program aimed at optimizing evidence-based management in patients at risk for osteoporosis and fractures.

Methods

This was a 12-month randomized trial performed in Ontario, Canada. Eligible patients were community-dwelling, aged ≥55 years, and identified to be at risk for osteoporosis-related fractures. Two hundred and one patients were allocated to the intervention group or to usual care. Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing, patient education and patient-specific recommendations for osteoporosis treatment. The primary outcome was the implementation of appropriate osteoporosis management.

Results

101 patients were allocated to intervention and 100 to control. Mean age of participants was 71.9 ± 7.2 years and 94% were women. Pharmacological treatment (alendronate, risedronate, or raloxifene) for osteoporosis was increased by 29% compared to usual care (56% [29/52] vs. 27% [16/60]; relative risk [RR] 2.09, 95% confidence interval [CI] 1.29 to 3.40). More individuals in the intervention group were taking calcium (54% [54/101] vs. 20% [20/100]; RR 2.67, 95% CI 1.74 to 4.12) and vitamin D (33% [33/101] vs. 20% [20/100]; RR 1.63, 95% CI 1.01 to 2.65).

Conclusions

A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care.

Trial Registration

This trial has been registered with clinicaltrials.gov (ID: NCT00465387)

Multivariate-adjusted pharmacoepidemiologic analyses of confidential information pooled from multiple health care utilization databases

PURPOSE

Mandated post-marketing drug safety studies require vast databases pooled from multiple administrative data sources which can contain private and proprietary information. We sought to create a method to conduct pooled analyses while keeping information private and allowing for full confounder adjustment.

METHODS

We propose a method based on propensity score (PS) techniques. A set of propensity scores are computed in each data-contributing center and a PS-adjusted analysis is then carried out on a pooled basis. The method is demonstrated in a study of the potentially negative effects of concurrent initiation of clopidogrel and proton pump inhibitors (PPIs) in four cohorts of patients assembled from North American claims data sources. Clinical outcomes were myocardial infarction (MI) hospitalization and hospitalization for revascularization procedure. Success of the method was indicated by equivalent performance of our PS-based method and traditional confounder adjustment. We also implemented and evaluated high-dimensional propensity scores and meta-analytic techniques.

RESULTS

On both a pooled and individual cohort basis, we saw substantially similar point estimates and confidence intervals for studies adjusted by covariates and from privacy-maintaining propensity scores. The pooled, adjusted OR for MI hospitalization was 1.20 (95% confidence interval 1.03, 1.41) with individual variable adjustment and 1.16 (1.00, 1.36) with PS adjustment. The revascularization OR estimates differed by < 1%. Meta-analysis and pooling yielded substantially similar results.

CONCLUSIONS

We observed little difference in point estimates when we employed standard techniques or the proposed privacy-maintaining pooling method. We would recommend the technique in instances where multi-center studies require both privacy and multivariate adjustment.

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.

Strategies for treatment to prevent fragility fractures in postmenopausal women

The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy.

Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions

BACKGROUND

Imaging is commonly performed for musculoskeletal conditions. Identifying interventions to improve the appropriate use of imaging for musculoskeletal conditions could potentially result in improved health outcomes for patients and reduced health care costs.

OBJECTIVES

To determine the effects of interventions that aim to improve the appropriate use of imaging for people with musculoskeletal conditions.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (June 2007), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (January 1966 to June 2007), EMBASE (January 1980 to June 2007) and CINAHL (January 1982 to June 2007). We also searched reference lists of included studies and relevant reviews. We undertook citation searches of all included studies, contacted authors of included studies, and contacted other experts in the field of effective professional practice.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled clinical trials and interrupted time-series analyses that evaluated interventions designed to improve the use of imaging for musculoskeletal symptoms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty eight studies met our inclusion criteria. The majority of the studies were for the management of osteoporosis or low back pain, and most evaluated interventions aimed at health professionals. To improve the use of imaging in the management of osteoporosis, the effect of any type of intervention compared to no-intervention controls was modest (absolute improvement in bone mineral density test ordering +10%, IQR 0.0 to +27.7). Patient mediated, reminder, and organisational interventions appeared to have most potential for improving imaging use in osteoporosis. For low back pain studies, the most common intervention evaluated was distribution of educational materials and this showed varying effects. Other interventions in low back pain studies also showed variable effects. For other musculoskeletal conditions, distribution of educational materials, educational meetings and audit and feedback were not shown to be effective for changing imaging ordering behaviour. Across all conditions, increasing the number of intervention components did not increase effect.

AUTHORS' CONCLUSIONS

For improving the use of imaging in osteoporosis, most professional interventions demonstrated benefit, and patient mediated, reminder, and organisational interventions appeared to have most potential for benefit. For low back pain studies interventions showed varying effects. For other musculoskeletal conditions, no firm conclusions can be drawn.

Management of osteoporosis-related bone fractures: an integrated concept of care

INTRODUCTION

Multidisciplinary medical management of osteoporosis and osteoporosis-related fractures is still an important treatment issue today. In view of ethiopathology of osteoporosis and the future demographic development an increasing socioeconomic burden has to be estimated. A prerequisite for an effective secondary prophylaxis of osteoporotic fractures is the implementation of a treatment network, with inclusion of all partners involved in patient's care. Therefore, special attention should be paid to formation and establishment of centres with multidisciplinary and integrated treatment concepts. This paper outlines the concept of a clinical centre for diagnosis and therapy of osteoporosis established 4 years ago. Furthermore, a concept of integrated care of osteoporosis-related fractures is introduced and the obtained data of a 2-year follow-up analysis will be presented.

METHODS

The establishment of an osteoporosis centre at a university teaching hospital as well as certification according to the Dachverband Osteologie (DVO) guidelines were necessary. Recruitment of contract partners on both sides, health insurances and outpatient general practitioners as well as specialist doctors, was also essential. The implementation of an osteoporosis coordinator was a step to put the treatment concept into practice.

RESULTS AND DISCUSSION

Based on the recommendations of DVO guidelines, all diagnostic and therapeutic requirements of osteoporosis can be met by the team of consultant specialists at a clinical osteoporosis centre. In the described treatment concept of integrated care, 44 patients suffering of osteoporosis with a consecutive fracture could be included. Mean age was 77. Inclusion criteria were spinal fractures (61%), proximal femoral fractures (27%) and peripheral fractures (12%). Fifty percent of patients included into the contract had not received previous osteoporosis medication. Sixty-eight patients who met the inclusion criteria could not be included due to the lack of compliance (42%), patients' disapproval (34%) or incomplete treatment and documentation algorithm (24%). Special attention should focus on the completion of standardised diagnosis and documentation. The high amount of time and personnel required has proven the importance of the introduction of an osteoporosis coordinator to be essential.

High-risk patients' readiness to undergo BMD testing for osteoporosis diagnosis in Pennsylvania

The objective of this study was to better understand high-risk patients' readiness to engage in bone mineral density (BMD) testing to diagnose osteoporosis. Six hundred thirty-six participants in a randomized control trial for patients at high-risk for osteoporosis were surveyed. BMD screening readiness was measured by a three-item summative index. Multivariable linear regression examined the relationship between patients' scores on the index and constructs of osteoporosis and BMD testing knowledge, concern for developing osteoporosis and self-efficacy to engage in fall prevention behaviors. Participants had a mean age of 79 years, 96% were female and 80% were white. Greater concern for developing osteoporosis and better knowledge about BMD testing were significant predictors of a higher score on the index. Improving high-risk patients' knowledge about osteoporosis and the importance of BMD testing may enhance patients' readiness to undergo BMD testing. We found several correlates of readiness to undergo BMD screening that may be used to design effective interventions.

Factors associated with osteoporosis screening and recommendations for osteoporosis screening in older adults

BACKGROUND

Osteoporosis screening rates are low, and it is unclear which patient factors are associated with screening and physician recommendations for screening.

OBJECTIVE

To identify patient characteristics associated with osteoporosis screening recommendations and receipt of screening in older adults.

DESIGN

Cross-sectional mailed survey.

PARTICIPANTS

Women and men > or =60 years old living in or near western Pennsylvania.

MEASUREMENTS

Sociodemographic characteristics and osteoporosis-related data, including risk factors, physician recommendations for screening, and receipt of screening. Multivariable logistic regression analyses were performed to determine odds ratios for receipt of screening and screening recommendations for individuals with particular osteoporosis risk factors, adjusting for sociodemographic and other risk factors.

RESULTS

Surveys were completed by 1,268 of the 1,830 adults to whom surveys were mailed (69.3%). Most respondents were white (92.9%), female (58.7%), and believed they were in good to excellent health (88.2%). Only 47.6% said their physician recommended osteoporosis screening, and 62.6% of all respondents reported being screened. Screening recommendations were less likely for older respondents than younger ones (OR, 0.87 per 5-year increase in age; 95% CI, 0.77-0.97). Individuals with osteoporosis risk factors of a history of oral steroid use for >1 month, height loss >2.54 cm, or history of low-trauma fracture were no more likely to report screening recommendations than individuals without these characteristics. Receipt of screening was no more likely for more elderly respondents or respondents with a history of oral steroid use for >1 month than for respondents without these characteristics.

CONCLUSIONS

Individuals with several known osteoporosis risk factors are not being sufficiently targeted for screening.

Quality health care gaps in osteoporosis: how can patients, providers, and the health system do a better job?

A significant gap exists between evidence-based advances and real-world clinical practice in the diagnosis and prevention of osteoporosis. The goal of osteoporosis care is to prevent fractures and improve health-related quality of life, and ideally lower mortality. Despite recent advances in osteoporosis detection and treatment options, studies suggest underdiagnosis and undertreatment of osteoporosis, even among those who have already sustained fractures. The challenges in translating knowledge into practice are multifaceted, with efforts directed at the patient, provider, and health care system levels achieving variable success at the population level. Methods to improve quality of care in osteoporosis need to be multipronged, with emphasis on clinical process improvement and reliance on interdisciplinary teams. We review the growing literature on quality of care for osteoporosis.

Patient and physician predictors of post-fracture osteoporosis management

BACKGROUND

Undertreatment of osteoporosis after hip or wrist fracture has been well documented, but the reasons for current patterns of care are poorly understood.

OBJECTIVE

We tested the role of physician and patient characteristics in predicting undertreatment when osteoporosis management was clearly indicated after a hip or wrist fracture in women over age 65.

METHODS

We assembled a cohort of 9,698 female Medicare beneficiaries aged > or = 65 years who experienced hip or wrist fracture between 2000 and 2004 and their prescribing physicians.

MEASUREMENTS

The dominant prescriber was identified as the physician prescribing at least 50% of patient prescriptions in the year after the fracture. Multivariate logistic regression estimated the role of physician and patient characteristics on osteoporosis management after hip or wrist fracture.

RESULTS

Patients older than 90 and black patients were less likely to be treated for osteoporosis relative to patients aged 65-69 and white patients. Female providers were more likely to manage osteoporosis. Models including patient characteristics discriminated well between managed and unmanaged patients (C statistic 0.81), while adding physician predictors to the model provided no additional discriminatory ability (C statistic 0.81).

CONCLUSIONS

Our findings highlight that osteoporosis management rates are similar across providers, but vary considerably by patient types.

The capture-mark-recapture technique can be used as a stopping rule when searching in systematic reviews

OBJECTIVE

Researchers have no empirically based search stopping rule when looking for potentially relevant articles for inclusion in systematic reviews. We tested a stopping strategy based on capture-mark-recapture (CMR; i.e., the Horizon Estimate) statistical modeling to estimate the total number of articles in the domain of clinical decision support tools for osteoporosis disease management using four large bibliographic databases (Medline, EMBASE, CINAHL, and EBM reviews).

STUDY DESIGN AND SETTING

Retrospective evaluation of the Horizon Estimate using a systematic review of randomized controlled trials (RCTs) at two levels of article screening: title and abstract (1,246 potentially relevant articles) and full text (42 potentially relevant articles).

RESULTS

The CMR model suggests that the total number of potential articles was 1,838 for the first level of screening, and 49 for the full-text level. The four databases provided 68% of known articles for the first level of screening and 81% for full-text screening.

CONCLUSIONS

The CMR technique can be used in systematic reviews to estimate the closeness to capturing the total body of literature on a given topic. More studies are needed to objectively determine the usefulness of Horizon Estimates as a stopping rule strategy for systematic review searching.