Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions

Low screening rates and high prevalence of osteoporosis in cirrhosis: A real-world retrospective analysis

BACKGROUND

Patients with cirrhosis are at increased risk for osteoporosis, and those who suffer a fracture are at high risk for mortality. Despite this, osteoporosis is often overlooked and undertreated. This study aimed to evaluate osteoporosis screening, management, and adverse osteoporosis medication events in patients with cirrhosis.

METHODS

We performed a retrospective chart review of adult outpatients with compensated and decompensated cirrhosis seen in single health system over a 6-year period. Patient demographics, liver and bone health comorbidities, DEXA scan results, and medications were abstracted.

RESULTS

In total, 5398 patients met criteria. The cohort was predominately white (79.1%) and older (age 59). 44.4% were female. 64.6% had decompensated cirrhosis. Median MELD-Na score was 12.8. 23.5% had a DEXA scan ordered, approximately 50% completed this test. Patients who were older, female, white, with more severe liver disease, and other osteoporosis risk factors were more likely to have a DEXA scan ordered. 48.5% of patients had osteopenia and 30.2% had osteoporosis on DEXA scan. Only 22.6% of patients with osteoporosis received treatment, most commonly oral bisphosphonates. Oral bisphosphonate prescription was not associated with variceal bleeding (8.4% without vs. 4.8% with, p = 0.487).

CONCLUSION

A minority of patients with cirrhosis were screened for osteoporosis. The majority screened had osteopenia or osteoporosis on DEXA scan. Less than a quarter of patients with osteoporosis were started on treatment. Real-world experience of oral bisphosphonate use did not reveal higher rates of gastrointestinal bleeding. There is room for improvement in all aspects of bone health care in cirrhosis.

Comparisons Between Different Anti-osteoporosis Medications on Postfracture Mortality: A Population-Based Study

CONTEXT

Osteoporosis is becoming a global epidemic in aging societies. Anti-osteoporotic medications can prevent fractures, and their pleiotropic effect on mortality is interesting but not well compared among each other.

OBJECTIVE

To provide real-world evidence on the pleiotropic effect of different anti-osteoporotic medications on all-cause mortality, stratified by fracture site, sex, and age.

METHODS

This longitudinal population-based postfracture cohort study, included mega-data from subjects ≥40 years of age with osteoporotic fracture who used anti-osteoporotic medications as recorded in Taiwan's National Health Insurance Research Database from 2009 to 2017 and followed until 2018. A multivariate Cox proportional hazards model with immortal time bias was used to assess the relationship between fracture sites and mortality stratified by anti-osteoporosis medication.

RESULTS

A total of 46 729 subjects with an average age of 74.45 years (80.0% female) and a mean follow-up period of 4.73 years were enrolled. In the total fracture group, compared with raloxifene and bazedoxifene, we found that alendronate/risedronate (hazard ratio [HR] 0.83; 95% CI, 0.79-0.88), denosumab (HR 0.86; 95% CI, 0.81-0.91), and zoledronic acid (HR 0.78; 95% CI, 0.73-0.84) resulted in significantly lower mortality. Similar trends were observed in the hip, vertebral, or nonhip/nonvertebral fracture groups. Subjects receiving long-acting zoledronic acid showed the lowest mortality in the subanalysis according to sex or age over 65 years.

CONCLUSION

This real-world mega-data study suggests that the usage of osteoporotic medication, especially a long-acting regimen, may lower postfracture mortality.

Protocol for the models of primary osteoporosis screening in men (MOPS) cluster randomized trial

Current guidelines recommend primary osteoporosis screening for at-risk men to reduce the morbidity, mortality, and cost associated with osteoporotic fractures. However, analyses in a national Veterans Health Administration cohort of over 4,000,000 men demonstrated that primary osteoporosis screening as it is currently operationalized does not benefit most older Veterans due to inefficient targeting and low subsequent treatment and adherence rates. The overall objective of this study is to determine whether a new model of primary osteoporosis screening reduces fracture risk compared to usual care. We are conducting a pragmatic group randomized trial of 38 primary care teams assigned to usual care or a Bone Health Service (BHS) screening model in which screening and adherence activities are managed by a centralized expert team. The study will: 1) compare the impact of the BHS model on patient-level outcomes strongly associated with fracture rates (eligible proportion screened, proportion meeting treatment criteria who receive osteoporosis medications, medication adherence, and femoral neck bone mineral density); 2) quantify the impact on provider and facility-level outcomes including change in DXA volume, change in metabolic bone disease clinic volume, and PACT provider time and satisfaction; and 3) estimate the impact on health system and policy outcomes using Markov models of screening program cost per quality adjusted life year based from health system and societal perspectives.

Effect of Dosing Interval on Compliance of Osteoporosis Patients on Bisphosphonate Therapy: Observational Study Using Nationwide Insurance Claims Data

Only a few studies are available on the effect of the dosing interval of bisphosphonate on drug compliance. We analyzed the data of patients who were newly prescribed bisphosphonate using a national insurance claims database. Drug compliance was assessed by calculating medication possession ratio (MPR) over a minimum of a 1-year follow-up. This analysis included 281,996 new bisphosphonate users with a mean age of 68.9 years (92% women). The patients were divided into daily, weekly, monthly, 3-monthly, and switch groups (who changed the drug to other dosing intervals). The average MPR was the highest in the switch group (66%), and the longer the dosing interval, the higher the compliance (3-monthly, 56% vs. daily, 37%). “Non-compliant” was defined as an MPR under 80%. Various factors which were possibly associated with “non-compliant” MPR were investigated using multiple regression analysis. Multivariate analysis showed that male patients were more likely to be non-compliant with pharmacotherapy than female patients, with as odds ratio of 1.389. Younger patients had a significantly lower likelihood of being non-compliant than older patients for age 60–69 vs. age 80+. Long dosing intervals were recommended to improve compliance and special attention was given to older and male patients.

Use of anti-osteoporosis medication dispensing by patients with hip fracture: could we do better?

Although Scandinavian countries have the highest incidence of hip fracture in the world, trends in anti-osteoporosis medication use have not been studied. We found less than one-third of Danish hip fracture patients had dispensing of anti-osteoporosis medication over a 10-year period using routinely collected data from population-based registries.

INTRODUCTION

To examine trend in dispensing of anti-osteoporosis medication before and after hip fracture surgery in Denmark over a 10-year period using routinely collected data from population-based registries.

METHODS

From the Danish Multidisciplinary Hip Fracture Registry, we included 65,011 patients aged 65 years or older with an incident hip fracture in 2005-2015. We calculated, for each calendar year of hip fracture diagnosis, the prevalence of use of anti-osteoporosis medication (at least one dispensing of bisphosphonates, strontium ranelate, denosumab, selective estrogen receptor modulators, or teriparatide) in the year before and in the year following hip fracture diagnosis. Among those without a dispensing in the year before hip fracture, we computed 1-year cumulative incidence of use following hip fracture. We treated death as a competing risk and stratified the analysis on sex, age, and comorbidity.

RESULTS

The prevalence of use before hip fracture varied between 7 and 12%, increasing slightly from 2005 to 2015. The cumulative incidence of use following hip fracture decreased from 16% in 2005 to 13% in 2010, whereupon it increased to 20%. A similar pattern was seen with each stratum of sex, age groups, and comorbidity. The overall prevalence of use after hip fracture was below 22% in all calendar years.

CONCLUSIONS

Less than one-third of hip fracture patients had dispensing of anti-osteoporosis medication up to 1 year after hip fracture. We observed only a slight increase in dispensing after hip fracture over the study period, irrespective of patient sex, age, and comorbidity at the time of hip fracture.

Gender differences in anti-osteoporosis drug treatment after osteoporotic fractures

This study examined differences between men and women in factors affecting anti-osteoporosis drug treatment after osteoporotic fracture. Using a national claims database, we analyzed patients aged 50 years and older who experienced their first osteoporotic fracture between January 1, 2008, and December 31, 2012. We examined whether patients were prescribed anti-osteoporosis drugs within 6 months post-fracture. Factors associated with treatment status were identified using multivariate logistic regression. Among a total of 556,410 patients aged 50 and older, only 37% were prescribed anti-osteoporosis drugs within 6 months post-fracture. Female patients with fractures were more likely to receive pharmacotherapy than male patients (41.7 vs. 19.3%). Older age significantly increased the likelihood of receiving anti-osteoporosis drugs after osteoporotic fracture. For men, the adjusted odds ratio for receiving therapy was greatest in those aged 80 years and older (OR 6.4), and for women, it was largest in those aged 70-79 (OR 3.33). Both men and women were more likely to be prescribed drugs after a spine fracture, with men having significantly greater odds of receiving drug therapy (men, OR 7.1, 95% CI 6.5-7.9; women 4.79, CI 4.63-4.96). Patients with rheumatic disease or other osteoporosis-inducing comorbid disease were more likely to be prescribed anti-osteoporosis drugs. Our findings indicate that a lack of anti-osteoporosis pharmacotherapy after fracture remains a problem in Korea, especially among men, highlighting the need for effective quality improvement interventions to maximize post-fracture treatment rates.

Limited Osteoporosis Screening Effectiveness Due to Low Treatment Rates in a National Sample of Older Men

OBJECTIVE

To determine the association between dual-energy x-ray absorptiometry (DXA) testing for osteoporosis and subsequent fractures in US male veterans without a previous fracture.

PATIENTS AND METHODS

This is a propensity score-matched observational study using Centers for Medicare and Medicaid Services and Veterans Affairs (VA) data from January 1, 2000, through December 31, 2010, with a mean follow-up time of 4.7 years (range, 0-10 years). Men receiving VA primary care aged 65 to 99 years without a previous fracture (N=2,539,812) were included. Men undergoing DXA testing were propensity score matched with untested controls in a 1:3 ratio, indicating the probability of DXA testing within the next year. Time to first clinical fracture was the primary outcome. Comorbidities, demographic characteristics, medications, DXA results, and osteoporosis treatment were defined using administrative data and natural language processing. A landmark analysis contingent on surviving to 12 months after screening was completed, accounting for competing risk of mortality.

RESULTS

During follow-up of 153,311 men tested by DXA and 390,158 controls, 56,083 (10.3%) had sustained a fracture and 111,774 (20.6%) died. Overall, DXA testing was not associated with a decrease in fractures; conclusions are limited by unmeasured confounders and low medication initiation and adherence in those meeting treatment thresholds (12% of follow-up time). In contrast, DXA testing in prespecified subgroups was associated with a lower risk of fracture in comparison to the overall population who underwent DXA testing: androgen deprivation therapy (hazard ratio [HR], 0.77; 95% CI, 0.66-0.89), glucocorticoids (HR, 0.77; 95% CI, 0.72-0.84), age 80 years and older (HR, 0.85; 0.81-0.90), 1 or more VA guideline risk factors (HR, 0.91; 95% CI, 0.87-0.95), and high Fracture Risk Assessment Tool using body mass index score (HR, 0.90; 95% CI, 0.86-0.95).

CONCLUSION

Current VA DXA testing practices are ineffective overall; interventions to improve treatment adherence are needed. Targeted DXA testing in higher-risk men was associated with a lower fracture risk.

Osteoporosis Assessment and Treatment in Older Patients who Have Sustained a Hip Fracture

Background and aims

Currently fracture sufferers are not being assessed or treated for osteoporosis. Osteoporosis guidelines differ in their secondary prevention recommendations, with the Scottish Intercollegiate Guideline Network (SIGN) advocating bone densitometry in all fracture patients and anti-resorptive treatment only if evidence-based criteria are confirmed, but the National Institute of Clinical Excellence (NICE) technology appraisal recommends treatment for all older females without this bone densitometry confirmation. We aimed to determine the rate of referral for bone densitometry, the numbers achieving SIGN criteria for anti-resorptive therapy, and the rate of osteoporosis treatment in patients with hip fracture

Methods

A retrospective review of all patients older than 65 years who had sustained a hip fracture in Tayside between April 2003 and July 2005 was performed

Results

Only 8.6% of hip fracture patients underwent bone densitometry, of which 90.6% of females older than 75 years met SIGN criteria for anti-resorptive treatment. 74.3% of all patients referred for bone densitometry were treated with an anti-resorptive agent, compared to only to 12.7% of the large majority group who were not assessed for osteoporosis

Conclusion

Osteoporosis investigation and therefore treatment remains sub-optimal in hip fracture patients. Almost all females, older than 75 years, with a hip fracture met evidence-based criteria for anti-resorptive treatment. NICE guidance, recommending anti-resorptive treatment without bone densitometry confirmation of reduced bone mineral density, should maybe be implemented for this specific group of patients in an attempt to increase osteoporosis treatment rates.

Association of gastrointestinal events and osteoporosis treatment initiation in newly diagnosed osteoporotic Israeli women

BACKGROUND

The objective was to examine the association of gastrointestinal (GI) events and osteoporosis treatment initiation patterns among postmenopausal women following an osteoporosis diagnosis from an Israeli health plan.

METHODS

This retrospective analysis of claims records included women aged ≥ 55 years with ≥ 1 osteoporosis diagnosis (date of first diagnosis was index date). Osteoporosis treatment initiation was defined as use of osteoporosis therapy (oral bisphosphonates or other) during 12 months postindex. GI events (diagnosis of GI conditions) were reported for 12 months preindex and postindex (from index to treatment initiation or 1 year postindex, whichever occurred first). The association of postindex GI events (yes/no) with the initiation of osteoporosis treatment (yes/no) and with type of therapy initiated (oral bisphosphonate vs. other) were examined with logistic regression and Cox proportional hazard regression (as sensitivity analysis).

RESULTS

Among 30,788 eligible patients, 17.5% had preindex GI events and 13.0% had postindex GI events. About 70.6% of patients received no osteoporosis therapy within 1 year of diagnosis, 24.9% received oral bisphosphonates and 4.5% received other medications. Postindex GI events were associated with lower odds of osteoporosis medication initiation (85-86% reduced likelihood; p < 0.01). Upon treatment initiation, postindex GI was not significantly associated with the type of osteoporosis therapy initiated, controlling for baseline GI events and patient characteristics.

CONCLUSIONS

Among newly diagnosed osteoporotic women from a large Israeli health plan, 70.6% did not receive osteoporosis treatment within 1 year of diagnosis. The presence of GI events was associated with reduced likelihood of osteoporosis treatment initiation.

Improving bone mineral density reporting to patients with an illustration of personal fracture risk

Background

To determine patients’ preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations.

Methods

Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration.

Results

Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most “clear,” “clean,” and “easy to read”. The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category.

Conclusions

Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference.

Trial Registration

ClinicalTrials.gov Identifier: NCT01507662

Osteoporosis treatment disparities: a 6-year aggregate analysis from national survey data

We studied factors to determine the receipt of osteoporosis treatment in individuals with osteoporosis. Treatment was associated with age, gender, race, body mass index (BMI), family history, arthritis and thyroid problems, daily glucocorticoid use, number of prescriptions and healthcare visits, and insurance type.

INTRODUCTION

Osteoporosis is underrecognized and undertreated. Few studies have examined factors associated with osteoporosis treatment in a large, national sample of men and women.

METHODS

We aggregated National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 and created a subsample which included individuals 50 years or older who were identified to have osteoporosis either by self-report data or by bone density measurements. The primary outcome was the receipt of osteoporosis treatment either from self-report or from prescription records. Covariates included sociodemographics, clinical characteristics, and access to healthcare variables. Logistic regression analyses were performed to determine factors that associate with osteoporosis treatment.

RESULTS

From a sample of 31,0134 participants, 1,133 subjects (3.65 %) met the study criteria. Treatment was associated with age (odds ratio (OR) = 1.14), gender (OR = 13.25), race (OR = 2.23, White vs. Black; OR = 1.76, other vs. Black), BMI (OR = 1.67, normal vs. obese; OR = 2.68, overweight vs. obese), family history of osteoporosis (OR = 1.94), arthritis (OR = 1.43), daily glucocorticoid use (OR = 1.43), number of prescriptions (OR = 1.01), and number of healthcare visits in the past year (OR = 1.44, 4-9 vs. 0-3 visits). All odds ratios were statistically significant.

CONCLUSION

A large number of individuals diagnosed with osteoporosis above the age of 50 remain untreated. It is important for healthcare providers to better assess older adults with osteoporosis, including individuals who frequently receive medical care.

Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009

BACKGROUND

Clinical practice recommendations state that patients with fragility fractures should be evaluated for osteoporosis and treated for the disease if it is present. The purpose of this study was to assess osteoporosis evaluation and treatment patterns for patients with fragility fractures and assess whether anti-osteoporosis pharmacotherapy initiated immediately following a fragility fracture is associated with improved adherence to the treatment protocol.

METHODS

This retrospective cohort study involved data from a large commercially insured population seen in the period from 2001 through 2009. Patients were community-dwelling individuals aged fifty years or older who had a new low-energy fracture at the hip, vertebra, wrist, or humerus with no evidence of a fragility fracture, osteoporosis treatment, malignant disease, or Paget disease for twelve months preceding the fracture. Rates of diagnostic testing and pharmacotherapy for osteoporosis within twelve months post-fracture were evaluated. Patients treated with oral bisphosphonates were evaluated to determine whether twelve-month adherence to the treatment protocol differed between those who had initiated therapy sooner (at zero to ninety days) and those who initiated it later (at ninety-one to 365 days) following the fracture.

RESULTS

The 88,571 women and 41,984 men had an average age of 72.3 years and 70.5 years, respectively. Nineteen percent (16,464) of the women and 10% (4014) of the men initiated osteoporosis pharmacotherapy, and 30% (26,481) of the women and 15% (6427) of the men underwent diagnostic testing and/or pharmacotherapy following fracture. Treatment rates were highest following vertebral fracture and lowest following wrist or humeral fracture. Treatment rates significantly decreased over time (from 2001 through 2009). The average twelve-month adherence (medication possession ratio) was 56% and 61% among women and men, respectively. Adherence was similar between patients who had initiated treatment sooner after the fracture and those who had initiated it later after the fracture.

CONCLUSIONS

Clinical guidelines for evaluation and treatment following fragility fracture were met for less than one-third of women and less than one-sixth of men. While primary fracture prevention remains the ideal, secondary prevention is critical and there is a need to reverse the downward trend in adherence to post-fracture guidelines.

An opportunity for improving osteoporosis treatment in home health care

PURPOSE

To examine osteoporosis prevention and treatment among home health care (HHC) patients at risk of fragility fracture in a large, Midwestern integrated HHC system.

METHODS

All patients who received HHC services in 2006 were identified. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes and pharmaceutical data were examined between January 1, 2004 and December 31, 2005 to determine risk status (high vs average) for fragility fracture. Patients with a documented diagnosis of osteoporosis, osteopenia, previous fragility fracture, stroke, or those taking a glucocorticoid were categorized as high risk. Pharmaceutical data (eg, estrogen, bisphosphonates) were obtained during the same 2-year period to determine treatment status. Descriptive statistics documented the proportion at high risk and treatment status. Inferential statistics tested differences in characteristics (age, gender, race, number of comorbidities) among high-risk patients with and without treatment.

RESULTS

2798 patients were seen in HHC during 2006 and had utilization data available in 2004 and 2005. Of these, 754 were categorized as high risk and 2044 as average risk. Approximately one third (34%) of high-risk patients received osteoporosis medication compared to 4% of average risk (P < .0001). We found no treatment differences based on age. Those with higher comorbidity profiles were less likely to receive treatment (P < .0001).

CONCLUSION

Only 34% of HHC patients at high risk for fracture received adequate treatment. Patients with more comorbidities were least likely to receive treatment. Since these individuals are receiving medical and nursing care, an opportunity exists to increase treatment rates for those at greatest risk.

Hip fracture and other predictors of anti-osteoporosis drug use in Norway

This study aims to find predictors of anti-osteoporosis drug (AOD) use. Known risk factors of osteoporosis, i.e., age, hip fracture, and corticosteroid use were found to be predictors of AOD use, in addition to a number of other drugs used. Higher socioeconomic position did not favor the use of AOD.

INTRODUCTION

This study deals with studying predictors of anti-osteoporosis drug treatment in Norwegian women and men.

METHODS

All Norwegian women and men≥50 years were included (n=1,407,392). Data were taken from different data sources, (1) the Norwegian Prescription Database (drug use in 2004-2005); (2) the Nationwide Census 2001 (marital status, education and resident county); (3) the National Hip Fracture Database (hip fractures 2003-2005); and (4) the National Population Register (date of death/emigration). We estimated the hazard ratios (HR) for incident treatment by Cox proportional hazard regression.

RESULTS

In 2005, 10,332 women (1.5%) and 1,387 men (0.2%) were new users of anti-osteoporosis drugs (incident treatment). Age was a statistically significant predictor of incident treatment in both women and men, with HR ranging from 1.7 to 3.2 (per 10 years). A middle educational level in men strongly predicted incident treatment [HR 2.0 (CI 1.1-3.8)], but not in women after full adjustment. A previous hip fracture, increasing number of drugs used and use of corticosteroids were all predictors of incident treatment in both genders after adjustments. Corticosteroid use [HRwomen=4.0 (CI 3.8-4.2)] had a higher HR for incident treatment than hip fracture [HRwomen=2.0 (CI 1.8-2.3)]. Marital status and area of residency were not predictors of incident treatment in either gender, after adjustments. The predictors of prevalent treatment were only slightly different from incident treatment in 2005.

CONCLUSIONS

Age, previous hip fracture, number of drugs used, and use of corticosteroids were positively related to treatment in both genders. In men, a middle educational level predicted treatment.

Cost and management of males with closed fractures

The purpose of this study was to examine the medical costs and the management of osteoporosis in the 12 months after a closed fracture for men aged ≥ 45 years. The mean medical cost per fracture was high ($6,078-$30,900), and osteoporosis management post fracture was inadequate in the majority of men.

INTRODUCTION

This study was conducted in order to examine the medical costs following fracture in males and the management of osteoporosis post fracture.

METHODS

Administrative claims from a large, national health plan were analyzed. Men ≥ 45 years were included if they had ≥ 1 medical claim for a new closed fracture between January 1, 2005 and December 31, 2008. Commercially insured (COM) and Medicare Advantage Plan (MAP) members were analyzed separately. Costs were calculated as paid amounts and adjusted to 2010 dollars. Both the differences between the individual patients' 12-month pre-fracture and 12-month post-fracture costs and the costs directly attributed to the fracture were reported. The prevalence of dual-energy X-ray absorptiometry (DXA) scan and/or osteoporosis pharmacotherapy treatment was evaluated in the 12 months post fracture.

RESULTS

We identified 18,917 (COM, 16,191; MAP, 2,726) men with new closed fractures. Non-hip, non-vertebral fractures (NHNV) were the most common fracture in both COM and MAP populations. Fracture costs ranged from $7,121 to $15,830 for vertebral fractures, from $22,601 to $30,900 for hip fractures, and from $6,078 to $8,344 for NHNV fractures. In the COM and MAP populations, respectively, 8.5 and 15.5 % had a DXA scan and/or osteoporosis pharmacotherapy in the 12 months following the fracture.

CONCLUSIONS

Healthcare costs associated with fractures in men are substantial. About 1 in 12 men ≥ 45 years in the COM population were provided adequate follow-up for osteoporosis post fracture. While this rate improved to about one in six men in the MAP population, osteoporosis management in men post fracture is far from optimal.

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.

Treatment for older men with fractures

Less than 10% of men receive osteoporosis treatment, even after a fracture. A study of 17,683 men revealed that older men, those with spinal fractures, and those taking steroids or antidepressants are more likely to receive treatment after a fracture. Seeing a primary care physician also increases osteoporosis treatment rates.

INTRODUCTION

In 2000, the FDA approved bisphosphonates for the treatment of osteoporosis in men. The purpose of this study is to estimate the frequency of bisphosphonate therapy within 12 months following a fracture and describe patient/physician factors associated with treatment.

METHODS

Health insurance claims for 17,683 men ≥ 65 years of age, who had a claim for an incident fracture from 2000 to 2005, were followed for at least 6 months post-fracture for the initiation of treatment with a bisphosphonate. Patient characteristics, diagnostic procedures, therapies, co-morbidities, and provider characteristics were compared for men who received treatment with those who did not.

RESULTS

Eight percent of men (n = 1,434) received bisphosphonate therapy. Overall treatment increased from 7% in 2001 to 9% in 2005 (p < 0.001). Treatment for hip fractures remained at 7% (p = 0.747). Treatment increased with age: 6% in men aged 65-69 compared to 11.6% in men aged 85-89 (p < 0.001). Factors associated with treatment included: diagnosis of osteoporosis (OR = 8.8; 95% CI, 7.7, 10.4), glucocorticoid therapy (OR = 3.2; 95% CI, 2.4, 4.3), bone mineral density measurement (OR = 3.4; 95% CI, 2.9, 4.0), and antidepressant therapy with tricyclics (OR = 2.0; 95% CI, 1.2, 3.5) or selective serotonin reuptake inhibitors (OR = 1.7; 95% CI, 1.3, 2.4). Men with vertebral fractures (OR = 2.2; 95% CI, 1.8, 2.6) and men seen by primary physicians (OR = 2.6; 95% CI, 2.3, 3.1) were more likely to receive treatment.

CONCLUSIONS

Less than 10% of men received bisphosphonate therapy following a low-impact fracture. Men with a primary physician were more likely to receive bisphosphonate therapy; however, <25% of men were seen by a primary physician.

Factors associated with treatment of women with osteoporosis or osteopenia from a national survey

BACKGROUND

Health outcomes could be improved if women at high risk for osteoporotic fracture were matched to effective treatment. This study determined the extent to which treatment for osteoporosis/osteopenia corresponded to the presence of specific risk factors for osteoporotic fracture.

METHODS

This retrospective analysis of the United States 2007 National Health and Wellness Survey included women age ≥ 40 years who reported having a diagnosis of osteoporosis (69% of 3276) or osteopenia (31% of 3276). Patients were stratified by whether they were or were not taking prescription treatment for osteoporosis/osteopenia. Using 34 patient characteristics as covariates, logistic regression was used to determine factors associated with treatment.

RESULTS

Current prescription treatment was reported by 1800 of 3276 (54.9%) women with osteoporosis/osteopenia. The following factors were associated with receiving prescription treatment: patient-reported diagnosis of osteoporosis (versus osteopenia); previous bone mineral density test; ≥ 2 fractures since age 50; older age; lower body mass index; better physical functioning; postmenopausal status; family history of osteoporosis; fewer comorbidities; prescription insurance coverage; higher total prescription count; higher ratio of prescription costs to monthly income; higher income; single status; previous visit to a rheumatologist or gynecologist; and 1 or 2 outpatient visits to healthcare provider (vs. none) in the prior 6 months. Glucocorticoid, tobacco, and daily alcohol use were risk factors for fracture that were not associated with treatment.

CONCLUSIONS

There is a mismatch between those women who could benefit from treatment for osteoporosis and those who are actually treated. For example, self-reported use of glucocorticoids, tobacco, and alcohol were not associated with prescription treatment of osteoporosis. Other clinical and socioeconomic factors were associated with treatment (e.g. prescription drug coverage and higher income) or not (e.g. comorbid osteoarthritis and anxiety) and could be opportunities to improve care.

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.

Appraising osteoporosis care gaps

To evaluate physician response to dual-energy X-ray absorptiometry (DXA) report within the Geisinger Medical Center's Mobile DXA Program and treatment adherence at 1 year. Between 10/01/2004 and 3/30/2005, 1381 DXA scans were performed in our Mobile DXA Program. Within this cohort, we identified 366 high-risk, drug-naive patients and report the percentage of patients placed on prescription drug therapy within 90 days of DXA result. Additionally, we identified 191 patients with Z-score of -1.0 or worse and report whether laboratory tests were ordered within 90 days of DXA results in this group. Finally, we determined treatment adherence at 1 year. 269 patients (74%) were offered prescription therapy within 3 months of DXA results. Of those, 210 (57%) were still adherent to drug therapy at 1 year. The main reason for discontinuation of treatment was an adverse drug side effect. Additionally, in 50% cases, physicians ordered 1 or more laboratory tests to evaluate low Z-score. Within our Mobile DXA Program, 74% of high-risk, drug-naïve patients were treated. Interestingly, in 50% cases, when a low Z-score was reported, our physicians ordered 1 or more laboratory tests. Treatment adherence was 57% at 1 year.

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.

Predictors of very low adherence with medications for osteoporosis: towards development of a clinical prediction rule

We developed a clinical prediction rule score to predict medication non-adherence for women prescribed osteoporosis treatment. When combined into a summative score, 62% with seven or more points on the score demonstrated very low adherence. This compares with 17% subjects with fewer than seven points (c-statistic = 0.74).

INTRODUCTION

Medication non-adherence is extremely common for osteoporosis; however, no clear methods exist for identifying patients at risk of this behavior. We developed a clinical prediction rule to predict medication non-adherence for women prescribed osteoporosis treatment.

METHODS

Women undergoing bone mineral density testing and fulfilling WHO criteria for osteoporosis were invited to complete a questionnaire and then followed for 1 year. Adjusted logistic regression models were examined to identify variables associated with very low adherence (medication possession ratio <20%). The weighted variables, based on the logistic regression, were summed, and the score was compared with the proportion of subjects with very low adherence.

RESULTS

One hundred forty two women participated in the questionnaire and were prescribed an osteoporosis medication. After 1 year, 36% (n = 50) had very low adherence. Variables associated with very low adherence included prior non-adherence with chronic medications, agreement that side effects are concerning, agreement that she is taking too many medications, lack of agreement that osteoporosis is a worry, lack of agreement that a fracture will cause disability, lack of agreement that medications help her stay active, and frequent use of alcohol. When combined into a summative score, 36 of the 58 subjects (62%) with seven or more points on the score demonstrated very low adherence. This compares with 14 of the 84 (17%) subjects with fewer than seven points (c-statistic = 0.74).

CONCLUSION

We developed a brief clinical prediction rule that was able to discriminate between women likely (and unlikely) to experience very low adherence with osteoporosis medications.

Osteoporosis and cardiovascular disease care in systemic lupus erythematosus according to new quality indicators

OBJECTIVES

Quality indicators (QIs) for the assessment of care of patients with systemic lupus erythematosus (SLE) have been proposed. We evaluated care according to these proposed QIs for osteoporosis and cardiovascular disease (CVD) in patients with SLE in our rheumatology practice.

METHODS

We selected 200 patients with SLE according to American College of Rheumatology Criteria and ≥2 visits to our practice in 2007 to 2008. We performed a structured medical record review and collected demographics, SLE and past medical history, medications, laboratories and data concerning osteoporosis, and CVD management. We employed univariable analyses and multivariable regression analyses to test for factors associated with care meeting the proposed QIs.

RESULTS

Ninety-four percent of patients were female and 64% were white. Mean age was 46.3 years and mean lupus duration was 15.3 years. Twenty-nine percent were taking ≥7.5 mg prednisone per day for ≥3 months. The proportions of patients for whom care met the proposed QIs were as follows: 59% for bone mineral density testing, 62% for calcium and vitamin D supplementation, and 86% for antiresorptive or anabolic osteoporosis medications. Only 3% had 5 cardiac risk factors assessed within the year and 26% had 4 cardiac risk factors assessed annually. Smoking, fasting lipid panels, and diabetes mellitus were rarely assessed annually. Having a primary care physician within our health care network increased care meeting QIs.

CONCLUSIONS

Care according to newly proposed QIs for osteoporosis and CVD was suboptimal in our academic center. To standardize and improve care of patients with SLE, we suggest specific changes to the proposed QIs.

Primary-care prescribing of anti-osteoporotic-type medications following hospitalisation for fractures

PURPOSE

We examined the prescribing of antiosteoporotic medications pre- and post hospital admission in patients with fragility fractures as well as factors associated with prescribing of these treatments following admission.

METHODS

We identified all patients aged ≥ 55 years at a large teaching hospital between 2005 and 2008 with a fracture using the Hospital In-Patient Enquiry (HIPE) system. These data were linked to prescribing data from the Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) scheme before and after discharge (821 patients). Logistic regression analysis was used to examine the likelihood of prescription of antiosteoporotic medication pre- and post discharge in relation to year of discharge, age, gender, and type of fracture.

RESULTS

Prescribing of antiosteoporotic treatment before fracture increased from 2.6% [95% confidence interval (CI) 2.23-2.93%] in 2005 to 10.6% (95% CI 9.32-11.86) by 2008, whereas post fracture prescribing increased from 11% (95% CI 9.64-12.36) to 47% (95% CI 43.6-50.3). In patients discharged from hospital in 2007, postfracture prescribing was 31.8% (95% CI 28.66-35.02) at 12 months, increasing to 50.3% (95% CI 46.6-53.9) at 24 months. The highest rate of prescribing was in the 65- to 69-year age group [odds ratio (OR) 8.51, 95% CI 1.75-41.35]. Patients discharged in 2008 were eight times more likely to be treated than patients discharged in 2005 (OR 8.01, 95% CI 4.55-14.09).

CONCLUSION

The percentage of patients on antiosteoporotic treatment post fracture increased significantly from 2005 to 2008. This may be largely due to the introduction of the Osteoporosis Clinic to the hospital in 2005.

Identifying cost-effective treatment with raloxifene in postmenopausal women using risk algorithms for fractures and invasive breast cancer

INTRODUCTION

The National Osteoporosis Foundation (NOF) recommends considering treatment in women with a 20% or higher 10-year probability of a major fracture. However, raloxifene reduces both the risk of vertebral fractures and invasive breast cancer so that raloxifene treatment may be clinically appropriate and cost-effective in women who do not meet a 20% threshold risk. The aim of this study was to identify cost-effective scenarios of raloxifene treatment compared to no treatment in younger postmenopausal women at increased risk of invasive breast cancer and fracture risks below 20%.

METHOD

A micro-simulation model populated with data specific to American Caucasian women was used to quantify the costs and benefits of 5-year raloxifene treatment. The population evaluated was selected based on 10-year major fracture probability as estimated with FRAX® being below 20% and 5-year invasive breast cancer risk as estimated with the Gail risk model ranging from 1% to 5%.

RESULTS

The cost per QALY gained ranged from US $22,000 in women age 55 with 5% invasive breast cancer risk and 15-19.9% fracture probability, to $110,000 in women age 55 with 1% invasive breast cancer risk and 5-9.9% fracture probability. Raloxifene was progressively cost-effective with increasing fracture risk and invasive breast cancer risk for a given age cohort. At lower fracture risk in combination with lower invasive breast cancer risk or when no preventive raloxifene effect on invasive breast cancer was assumed, the cost-effectiveness of raloxifene worsened markedly and was not cost-effective given a willingness-to-pay of US $50,000. At fracture risk of 15-19.9% raloxifene was cost-effective also in women at lower invasive breast cancer risk.

CONCLUSIONS

Raloxifene is potentially cost-effective in cohorts of young postmenopausal women, who do not meet the suggested NOF 10-year fracture risk threshold. The cost-effectiveness is contingent on their 5-year invasive breast cancer risk. The result highlights the importance of considering a woman's full risk profile when considering anti-osteoporosis treatment.

Pharmacologic undertreatment of osteoporosis in Austrian nursing homes and senior's residences

Osteoporosis is a classical age-related disease. Although significant progress in treatment has been achieved and antifracture efficacy proven over the past years undertreatment is still a general problem. There are only few published data available regarding osteoporosis and its treatment encountered in Austrian nursing homes and seniors' residences where fractures are especially frequent. We therefore conducted a survey in 89 participating institutions in order to assess frequency of documented osteoporosis as well as prevalence status of anti-osteoporotic drug usage in this special population. Data were acquired using a questionnaire and analyzed in a descriptive manner. Mean age of the residents was 82 years and the majority was female (76%). Half of the subjects took 5-8 different drugs per day and 23% received more than 8. Almost one-fourth (21.2%) of the residents had a diagnosis of osteoporosis. A history of hip fracture or other fractures was documented in 10.4% and 13.2%, respectively. Only 8.2% of the residents were treated with calcium, 6.2% with vitamin D and 9.3% received a combination of vitamin D and calcium. Specific osteoporosis treatment was prescribed to 7.2% only. In conclusion, this study reflects a high degree of continuing unawareness toward a diagnosis of osteoporosis in Austrian nursing homes and seniors' residences. The data of this survey further indicate that undertreatment is still very common in this population at very high risk of fractures.

Consultative DXA reporting improves guideline-driven quality of care-implications for increasing DXA reimbursement

Since 2001, Geisinger Health System densitometrists have interpreted dual-energy X-ray absorptiometries (DXAs) in a guideline-driven, consultative fashion. We believe that this approach results in more patients receiving appropriate treatment. Recently, one of our DXA centers chose to stop consultative reporting, providing us an opportunity to review the care rendered with 2 different styles of DXA reporting formats: Consultative vs Results Only. In this retrospective chart review, 100 consecutive DXAs with Consultative reporting and 100 consecutive DXAs with Results Only reporting were identified. The electronic health record was reviewed for a 3-mo interval after DXA result to identify whether a prescription medication was prescribed per system guidelines. Logistic regression compared the proportion of patients receiving a prescription treatment between the 2 groups. The Consultative report group received more prescription treatment compared with Results Only format (72% vs 50%) after controlling for patients' age and gender, odds ratio=2.64, 95% confidence interval=1.45-4.79 (p=0.0014). Our study demonstrates that Consultative DXA reporting results in better care. Importantly, Consultative reporting takes additional time; yet, reimbursement for these efforts and expertise has been dramatically reduced. To appropriately reward the value of DXA testing and interpretation, Consultative reporting should be reimbursed at the previous higher reimbursement rate.

Efficacy of vitamin D3 supplementation in preventing fractures in elderly women: a meta-analysis

BACKGROUND

The efficacy of vitamin D(3) in preventing fractures and falls has been explored in a number of clinical trials. However, recent evidence revealed new questions about the adequate doses of vitamin D(3) supplementation and its efficacy in fracture prevention independent of calcium supplements for various types of fractures.

OBJECTIVE

To conduct a meta-analysis to estimate the effectiveness of 800 IU daily vitamin D(3) supplementation for increasing bone mineral density (BMD) and preventing fractures in postmenopausal women.

METHODS

Medline and EMBASE were searched for controlled trials comparing the effectiveness of cholecalciferol (vitamin D(3)) against placebo with or without background calcium supplementation in the treatment of postmenopausal women.

RESULTS

Eight controlled trials evaluating the effect of vitamin D(3) supplementation with or without calcium were assessed. Of 12 658 women included in a Bayesian meta-analysis, 6089 received vitamin D(3) (with or without calcium) and 6569 received placebo (with or without calcium). Compared to placebo, vitamin D(3) with calcium supplementation showed beneficial effects on the incidence of non-vertebral (odds ratio [OR] 0.77, 95% credibility limit [CL] 0.6-0.93) and hip (OR 0.70, 95% CL 0.53-0.90) fractures, while the effects on non-vertebral-non-hip fractures (OR 0.84, 95% CL 0.67-1.04) % point increase) were associated with more uncertainty. Vitamin D(3) supplementation showed a 70% probability of being a better treatment than placebo for the prevention of non-vertebral fractures, hip fractures, and non-vertebral, non-hip fractures. Compared to calcium supplementation, vitamin D(3) plus calcium reduced non-vertebral fractures (OR 0.68, 95% CL 0.43-1.01) and non-vertebral, non-hip fractures (OR 0.64, 95% CL 0.38-0.99), but did not reduce hip fractures (OR 1.03, 95% CL 0.39-2.25). Key limitations to this analysis include a small number of studies and heterogeneity in the study populations.

CONCLUSIONS

This meta-analysis supports the use of vitamin D3 of 800 IU daily to reduce the incidence of osteoporotic non-vertebral, hip, and non-vertebral-non-hip fractures in elderly women. Vitamin D(3) with calcium appears to achieve benefits above those attained with calcium supplementation alone for non-vertebral and non-vertebral-non-hip fractures.

Glucocorticoid-induced osteoporosis in rheumatic diseases

The aim of this article is to review rheumatological diseases that are associated with glucocorticoid-induced osteoporosis or fractures and to perform a critical analysis of the current guidelines and treatment regimens. The electronic database MEDLINE was searched using the date range of July 1986 to June 2009 and the following search terms: osteoporosis, bone mineral density, fractures, systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, vasculitis, juvenile rheumatoid arthritis, juvenile idiopathic arthritis and juvenile dermatomyositis. Osteopenia and osteoporosis respectively account for 1.4 to 68.7% and 5.0 to 61.9% of adult rheumatological diseases. Among juvenile rheumatological disorders, the frequency of low bone mass ranges from 38.7 to 70%. In general, fracture rates vary from 0 to 25%. Although glucocorticoid-induced osteoporosis has a high rate of prevalence among rheumatic diseases, a relatively low number of patients on continuous glucocorticoid treatment receive adequate diagnostic evaluation or preventive therapy. This deficit in patient care may result from a lack of clear understanding of the attributed risks by the patients and physicians, the high complexity of the treatment guidelines and poor patient compliance.

Adherence to weekly oral bisphosphonate therapy: cost of wasted drugs and fractures

In an observational cohort of patients treated with biphosphonates (BP), we observed that poor adherence to these drugs causes important expenditures in terms of avoidable fractures. Of particular interest are the amounts of money wasted by patients who did not take their BPs long enough to obtain a clinical benefit.

INTRODUCTION

A large proportion of patients initiated with oral weekly BP therapy stop their treatment within the first year. The objective of this study was to estimate the impact of the poor adherence to BPs in terms of drug wasted and avoidable fractures.

METHODS

The study was done on primary and secondary prevention cohorts from the Régie de l'assurance maladie du Québec (Québec). The concept of the "point of visual divergence" was used to determine the amount of wasted drug. The risk of fracture was estimated using Cox regression models. The hazard ratios of compliant patients (+80%) versus non compliant patients were used to estimate the number of fractures saved.

RESULTS

The cost of wasted drugs was $25.87 per patient initiated in the primary prevention cohort and $30.52 in the secondary prevention cohort. If all patients had been compliant, 110 fractures would have been avoided in the primary prevention cohort and 19 fractures in the secondary prevention cohort. The cost of these avoidable fractures per patient initiated on BP therapy was $62.95 in primary prevention cohort and $330.84 in secondary prevention cohort.

CONCLUSIONS

This study confirms that poor adherence to oral BPs leads to a significant waste of money and avoidable fractures.

Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender

BACKGROUND

Undertreatment of osteoporosis has been recognized as a common problem in selected patient subgroups. However, primary prevention has been hampered by limited risk assessment tools that can be applied to large populations.

OBJECTIVES

Using clinical risk factors with a new tool from the World Health Organization (FRAX) and recommendations from the National Osteoporosis Foundation (NOF), we evaluated fracture risk and osteoporosis treatment in a US cohort.

PARTICIPANTS

African Americans and Caucasians recruited from 2003-7 across the US as part of a longitudinal study.

DESIGN

Cross-sectional.

MEASURES

The number of persons receiving prescription osteoporosis medications was assessed by race, sex, and fracture risk. Multivariable logistic regression evaluated the association between receipt of osteoporosis medications and fracture risk after controlling for potential confounders.

RESULTS

Among 24,783 participants, estimated fracture risk was highest for Caucasian women. After multivariable adjustment for fracture-related risk factors, the likelihood of receipt of osteoporosis medications among African Americans was lower than among Caucasians [odds ratio (OR) = 0.44, 95% confidence interval (CI) 0.37, 0.53] and for men compared to women (OR = 0.08, 95% CI 0.06-0.10). Even for the highest risk group, Caucasian women with 10-year hip fracture risk > or = 3% (n = 3,025, 39.7%), only 26% were receiving treatment.

CONCLUSIONS

A substantial gap exists between 2008 NOF treatment guidelines based on fracture risk and the receipt of prescription osteoporosis medications. This gap was particularly notable for African Americans and men. FRAX is likely to be useful to assess risk at a population level and identify high-risk persons in need of additional evaluation.

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.

2008 Santa Fe Bone Symposium: update on osteoporosis

The Ninth Annual Santa Fe Bone Symposium was held on August 1-2, 2008, in Santa Fe, New Mexico, USA. The symposium faculty presented the current best evidence on selected topics of clinical relevance in the fields of osteoporosis, metabolic bone disease, and assessment of skeletal health. The educational venues were in the form of didactic presentations, panel discussions, challenging cases, and numerous interactive discussions. Knowledge of basic science and clinical trials was applied to real-world patient scenarios that were discussed by faculty experts and clinician participants. Topics included an update on the rationale and development of new agents for the treatment of osteoporosis, the use of bone turnover markers in clinical practice, hospital-based pathways for the management of hip fracture patients, injectable bisphosphonates for the treatment of osteoporosis, combination therapy with anabolic and antiresorptive agents, and assessment of skeletal health with devices other than central dual-energy X-ray absorptiometry. This is a collection of scientific essays based on presentations and discussions at the 2008 Santa Fe Bone Symposium.

Denosumab: an investigational drug for the management of postmenopausal osteoporosis

Denosumab (AMG 162) is an investigational fully human monoclonal antibody with a high affinity and specificity for receptor activator of nuclear factor-kappaB ligand (RANKL), a cytokine member of the tumor necrosis factor family. RANKL, the principal mediator of osteoclastic bone resorption, plays a major role in the pathogenesis of postmenopausal osteoporosis and other skeletal disorders associated with bone loss. Denosumab inhibits the action of RANKL, thereby reducing the differentiation, activity, and survival of osteoclasts, and lowering the rate of bone resorption. Clinical trials have shown that denosumab increases bone mineral density (BMD) and reduces bone turnover in postmenopausal women with low BMD. Studies to evaluate the fracture risk benefit and long-term safety of denosumab in women with postmenopausal osteoporosis (PMO) are ongoing. Denosumab is a potential treatment for PMO and other skeletal disorders.

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.

Quality of care in the rheumatic diseases: current status and future directions

PURPOSE OF REVIEW

To review the recent literature examining quality of care for several prevalent rheumatic conditions, including rheumatoid arthritis, osteoarthritis, gout and osteoporosis, and to summarize quality measurement and improvement initiatives relevant to rheumatology in the USA.

RECENT FINDINGS

In recent years, research has identified a significant gap between ideal and actual clinical practice in the USA. Consistent with trends seen in the US healthcare system as a whole, research suggests deficits in healthcare quality for populations with rheumatic conditions. We review the growing literature on quality of care for rheumatoid arthritis, osteoarthritis, gout and glucocorticoid-induced osteoporosis.

SUMMARY

Existing evidence suggests suboptimal healthcare quality for four common rheumatic conditions, a finding that parallels trends in the healthcare system as a whole.

Recognizing osteoporosis and its consequences in Quebec (ROCQ): Background, rationale, and methods of an anti-fracture patient health-management programme

Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) is an ongoing patient health-management programme aimed at evaluating the diagnostic and treatment care gaps for osteoporosis following a fragility fracture, and subsequently initiating and measuring interventions to decrease these gaps in women 50 years of age and over. Hospitals servicing approximately half of the population of the Province of Quebec (Canada) are participating in the ROCQ programme. Women with fragility and traumatic fractures are approached during their visit to a cast or outpatient clinic and are subsequently contacted by telephone 0 to 16 weeks after their fracture (phase 1). During the first phone contact, they are invited to answer a questionnaire aimed at identifying the specific circumstances of their fracture and asked to participate in an observational study that could last up to 18 months. Based on this initial questionnaire, patients are classified as having either experienced a fragility or traumatic fracture. During the first phone contact, there is no reference about the possible association between the fracture and osteoporosis and no investigation or intervention is proposed. Six to eight months after the fracture event (phase 2), women are again contacted by phone to complete a questionnaire that evaluates the diagnostic and treatment rates for osteoporosis. At this phase of the programme, women with fragility fractures are randomized to one of the three following intervention groups: 1) Educational Video Group, 2) Documentation Group and 3) Control Group. Participants are contacted 12 to 14 months after the intervention (phase 3) to evaluate the efficacy of the interventions on the diagnosis and treatment rates of osteoporosis. All participants with fragility or traumatic fractures who consent will be followed for 20 years using data from the Québec Ministry of Health database to measure the association between the index fracture and future fracture risk.

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

We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. There was no difference in the probability of the primary composite endpoint (BMD test or osteoporosis medication) or in either of its components comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26).

INTRODUCTION

Fractures from osteoporosis are associated with substantial morbidity, mortality, and cost. However, only a minority of at-risk older adults receives screening and/or treatment for this condition. We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients, primary care physicians, or both.

MATERIALS AND METHODS

We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. The at-risk patients were women >or=65 yr of age, men and women >or=65 yr of age with a prior fracture, and men and women >or=65 yr of age who used oral glucocorticoids. The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis. The secondary outcome was a hip, humerus, spine, or wrist fracture.

RESULTS

We randomized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms. Physician and patient characteristics were very similar across all four groups. Across all four groups, the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups (p = 0.5). In adjusted Cox proportional hazards models, there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). There was also no difference in either of the components of the composite endpoint. The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment (p = 0.9).

CONCLUSIONS

In this trial, a relatively brief program of patient and/or physician education did not work to improve the management of osteoporosis. More intensive efforts should be considered for future quality improvement programs for osteoporosis.

Osteoporosis practice patterns in 2006 among primary care physicians participating in the NORA study

This study investigated osteoporosis management trends from 1998 to 2006 among 808 primary care physicians involved in the US-based NORA (National Osteoporosis Risk Assessment) study. These results suggest some significant improvements in osteoporosis management over the past eight years.

INTRODUCTION

The purpose of this study was to investigate osteoporosis management trends among a large cohort of primary care physicians (PCPs) involved in the US-based NORA (National Osteoporosis Risk Assessment) study.

METHODS

In 2006, we undertook a resurvey of the 2,836 NORA PCPs who completed a baseline survey in 1998. Of the 2,199 PCPs for whom we had current contact information and who were still practicing, we collected usable surveys from 808 (37% response rate).

RESULTS

From 1998 to 2006, more than double the percentage of NORA PCPs reported using BMDs "often" (35% vs. 87%). There was a doubling of the percentage of NORA PCPs who reported that a T-score of < or = -2.5 was the threshold indicating the presence of osteoporosis (34% vs. 67%). The percentage of NORA PCPs who reported using bone turnover markers to screen, diagnosis, or monitor osteoporosis almost tripled (19% vs. 55%). The percentage of patients prescribed or recommended hormone therapy dropped sixfold (67% to 11%), and the percentage of patients prescribed bisphosphonates increased fourfold from 15% to 59%.

CONCLUSION

These results suggest some significant improvements in osteoporosis management over the past eight years.

Assessment of the clinical management of fragility fractures and implications for the new HEDIS osteoporosis measure

BACKGROUND

Rates of screening for and treatment of osteoporosis have been low, even among those with fractures who are at greatest risk for new fractures.

OBJECTIVE

The objective of this study was to examine trends in the clinical management of patients with fragility fractures to provide baseline data for future assessments of the impact of the new Health Plan Employer Data and Information Set (HEDIS) measure.

RESEARCH DESIGN

The MarketScan Medicare Supplemental and Coordination of Benefits (COB) database was used to examine adherence to the 2004 HEDIS guidelines by measuring the percent of women age 67 and older who were screened and/or treated after a fracture from 2000 through 2005. Clinical, demographic, and provider characteristics were assessed to determine the correlates of being screened and treated.

RESULTS

The overall unadjusted percent of women screened and treated remains low, with just 10.2% screened and 12.9% treated in 2005. Multivariate analyses, which controlled for fracture location, patient characteristics, physician specialty, and region indicated small, albeit statistically significant, increases in treatment and screening over time. Women fracturing in 2005 were 27% more likely to be screened and 15% more likely to receive treatment relative to those fracturing in the year 2000.

CONCLUSIONS

Although our study found some improvements in the screening for and treatment of osteoporosis among Medicare beneficiaries with a fragility fracture from 2000 through 2005, the overall percent of women screened and/or treated remained low. These data provide a baseline for assessing the impact of the new HEDIS measure in the coming years.

A randomized study of the effect of 5-year and lifetime hip fracture risk information on physician recommendations for management of low bone density

Although risk prediction tools providing absolute fracture risk information are currently under development, little is known about US physicians' current thresholds for osteoporosis treatment or the potential effect of fracture risk information on treatment decisions. To investigate this, a random sample of US primary care physicians was surveyed. Treatment recommendations for 4 patient scenarios depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) were elicited. Physicians were randomly assigned to receive all scenarios with either a basic BMD report or an augmented BMD report containing 5-yr and lifetime absolute hip fracture risk estimates. Over 95% of physicians recommended prescription pharmacologic treatment of a 70-yr-old patient with osteoporosis. For 3 scenarios depicting women with T-scores of -1.01, treatment recommendations ranged from 30% to 44%. There were no statistically significant differences between physicians who received augmented and basic BMD reports, although those with augmented BMD reports were less likely to recommend prescription treatments. Physician specialty had inconsistent and small effects on recommendations. We conclude that nearly all of a random sample of US primary care physicians recommend pharmacologic treatment of osteoporosis, but a substantial minority also recommend treatment for patients who would not fit current guidelines. A BMD report including absolute hip fracture risk estimates did not change treatment recommendations.

Randomized trial to improve fracture prevention in nursing home residents

BACKGROUND

Interventions to improve the fracture prevention in nursing homes are needed.

METHODS

Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.

RESULTS

No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.

CONCLUSIONS

Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

Factors associated with pharmacologic treatment of osteoporosis in an older home care population

BACKGROUND

A number of studies have shown low rates of osteoporosis treatment. Few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. Our objective was to examine which sociodemographic, clinical, and functional characteristics are associated with pharmacotherapy for osteoporosis among community-based seniors.

METHODS

The study sample included 48,689 home care clients aged >/= 65 years in Ontario, Canada. Treatment coverage (calcium and vitamin D and/or anti-osteoporotic drugs) was assessed in two subgroups, clients with a diagnosis of osteoporosis (without fracture) and those with a prevalent fracture. Sociodemographic, health, and functional measures available from the Resident Assessment Instrument for Home Care (RAI-HC) were assessed as correlates of treatment in multivariable logistic regression analyses.

RESULTS

Approximately 59% of clients with a diagnosis of osteoporosis were receiving pharmacotherapy, compared with 27% of those with a prevalent fracture. For both subgroups, treatment coverage was significantly lower among clients with at least three chronic conditions, health instability, fewer than nine medications, functional impairment, and depressive symptoms and among those clients who were widowed. Among clients with a diagnosis of osteoporosis, treatment was positively associated with cognitive impairment and negatively associated with confinement to a wheelchair or bed. Men with a prevalent fracture were significantly less likely to receive treatment, particularly in the absence of an osteoporosis diagnosis.

CONCLUSIONS

Many older adults with presumed osteoporosis in our study were not receiving drug therapy for this condition. Indicators of clinical instability and functional decline appear to represent influential factors in treatment decisions. Despite a lower likelihood of treatment among men with a prevalent fracture, this sex difference in treatment largely disappeared in the presence of an osteoporosis diagnosis.

Minimal error in self-report of having had DXA, but self-report of its results was poor

OBJECTIVE

To examine the validity of both self-report of having had dual-energy x-ray absorptiometry (DXA) and self-reported DXA test results.

METHODS

Participants were recruited in 2003 and 2004 from a population-based study of women aged 65-90 years examining osteoporosis management in Ontario, Canada (N=871). Women reporting having had a DXA were eligible and asked to report the results of their most recent test. Participant responses were compared against DXA reports obtained from physicians.

RESULTS

We obtained 413 (81%) physician records among the 510 women who reported having had a DXA test. Of these, the positive predictive value for self-report of having had a DXA was 93%. The weighted kappa statistic for the agreement between self-report and actual DXA results was 0.42 (95% confidence interval=0.34-0.49). Although 84% of those with normal bone reported this, only 29% of those with osteopenia and 62% with osteoporosis reported their results correctly. Self-report of a clinical diagnosis of osteoporosis was better among those with a low trauma fracture, yet underestimated osteoporosis prevalence by 24%.

CONCLUSION

There is minimal measurement error in self-report of having had a DXA test. Self-report of DXA results will underestimate osteoporosis prevalence and is not a good proxy for clinical diagnosis.

Prescriptions for vitamin D among patients taking antiresorptive agents in Canada

BACKGROUND

Data on the rate of concomitant vitamin D use with antiresorptive medications are limited. Such information is important because vitamin D is indicated in patients with osteoporosis, including those receiving bisphosphonates, and there is evidence of inadequate use by these patients.

OBJECTIVE

To examine prescription vitamin D utilization patterns.

RESEARCH DESIGN AND METHODS

A retrospective analysis of patients aged > or = 65 years was conducted in a Canadian pharmacy-insurance organization (RAMQ) who received at least one prescription for an antiresorptive agent (i.e., alendronate, risedronate, raloxifene) from January 1, 1996, through December 31, 2003, and did not switch to any other agent during the 1-year post period. Data on prescriptions of vitamin D formulations on the RAMQ formulary (e.g., alfacalcidol, calcitriol, cholecalciferol, doxercalciferol, ergocalciferol) were also captured. No data on generic or over-the-counter vitamin D preparations were available. A vitamin D and antiresorptive agent possession ratio (R(P)) was computed as: R(P) = SigmaD(SPVD) / SigmaD(SARR) where SigmaD(SPVD) = the sum of the days of supply with prescription vitamin D and SigmaD(SARR) = the sum of days of supply with alendronate, risedronate, or raloxifene A vitamin D and antiresorptive agent overlap ratio (R(0)) was computed as: R(0) = SigmaD(SPVDOARR) / SigmaD(SARR) where SigmaD(SPVDOARR) = the sum of days of supply of prescription vitamin D overlapping with alendronate, risedronate, or raloxifene, and SigmaD(SARR) = the sum of the days of supply with alendronate, risedronate, or raloxifene.

RESULTS

A total of 46,226 antiresorptive treatment users were identified, > 90% of whom were women. A total of 17,151 (37.1%) had concomitant vitamin D prescriptions. The average duration of prescription therapy with alendronate, risedronate, or raloxifene was 247 days; and the mean duration of prescription vitamin D therapy was 83 days. Patients had a supply of vitamin D for 55% of days of antiresorptive agents therapy (R(P) = 0.55) and a vitamin D supply overlapping with 24% of their days on antiresorptive agents (R(o) = 0.24). Possession and overlap ratios were significantly higher in patients receiving once-weekly bisphosphonate prescriptions compared with once-daily regimens (bisphosphonates or raloxifene). Vitamin D prescriptions were also significantly more likely in patients receiving prescriptions for once-weekly bisphosphonates (odds ratio (OR) = 4.65; 95% CI = 4.29-5.05; p < 0.0001) and once-daily bisphosphonates (OR = 1.91; 95% CI = 1.76-2.07; p < 0.0001) compared with once-daily raloxifene.

CONCLUSIONS

Despite the benefits of vitamin D for osteoporosis, most patients ( approximately 63%) receiving prescriptions for antiresorptive agents were not taking vitamin D, indicating a substantial treatment gap. The study is limited by including data only on (1) pharmacy claims, which do not equate to patient behaviors, such as filling or refilling prescriptions and/or taking the medications; and (2) prescription (but not generic or over-the-counter) vitamin D formulations.

A single zoledronic acid infusion reduces bone resorption markers more rapidly than weekly oral alendronate in postmenopausal women with low bone mineral density

Early data suggest that an annual i.v. infusion of zoledronic acid (ZOL) might have therapeutic use in women with osteoporosis. In this randomized, double-blind, double-dummy, multicenter, 24-week trial, we evaluated the onset of action of a single infusion of ZOL 5 mg (n=69) compared with weekly oral alendronate (ALN) 70 mg (n=59) in postmenopausal women with low bone mineral density (T score< or =-2 by DXA) as assessed by reductions in urine N-telopeptide of type I collagen (NTX) at week 1. The effects of these therapies on other markers of bone turnover, patient preference for once yearly i.v. vs. oral weekly treatment, and adverse events were also assessed. At week 1, ZOL 5 mg resulted in a significantly greater reduction in mean urine NTX from baseline than ALN 70 mg (P<0.0001). Significantly greater reduction in urine NTX and serum beta-C-telopeptide of type I collagen (beta-CTX) were also observed in the ZOL 5 mg group at all post-baseline time points. Bone-specific alkaline phosphatase (BSAP) levels showed a more gradual reduction in both the ZOL 5 mg and ALN 70 mg groups, reaching premenopausal range by week 12. A comparable proportion of patients reported adverse events in each treatment group (ZOL 5 mg, 91.3%; ALN 70 mg, 86.4%). Transient, flu-like symptoms were the most common adverse events in the ZOL 5 mg group and resulted in a higher frequency of adverse events in this group during the first 3 days of treatment. After 3 days, adverse event rates were similar in the 2 groups. The majority of patients, including those experiencing flu-like symptoms, expressed a preference for annual i.v. therapy (66.4%) compared with weekly oral therapy (19.7%). We conclude that a single i.v. infusion of ZOL 5 mg reduced urine NTX levels more rapidly than weekly oral ALN 70 mg. The majority of study patients preferred an i.v. treatment regimen of ZOL 5 mg over weekly osteoporosis therapy with ALN 70 mg.