Assessment of physician responses to abnormal results of bone densitometry studies

Screening and management of osteoporosis: a survey of knowledge, attitude, and practice among healthcare professionals in Egypt-a study by the Egyptian Academy of Bone Health

Secondary-level healthcare professionals, mainly rheumatologists and orthopedic surgeons, were invited to participate in an online survey questionnaire to assess knowledge and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. About 51% of the participants admit that they do not implement specific guidelines for the management of osteoporosis in their standard practice and depend on their experience and their clinical judgments. Moreover, although a good percentage (58%) had satisfactory knowledge levels in domains on the risk of osteoporotic fractures and investigations of osteoporosis, 47.5% of the participants did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

INTRODUCTION

A recently published study demonstrated a treatment gap among those eligible for osteoporosis therapy in Egypt of about 82.1% in postmenopausal women and 100% in men. The current survey aimed to address some of the factors that may contribute to this wide gap.

METHODS

This was a cross-sectional study of secondary care healthcare professionals (both physicians and orthopedic surgeons) who were invited to complete an online questionnaire, which gathered information about physicians' socio-demographic data, knowledge, and compliance with osteoporosis management guidelines and strategies, as well as self-reported quality of care. Additionally, a knowledge score was calculated for all the participants.

RESULTS

A good percentage (58%) had a satisfactory knowledge level in domains on the risk of osteoporotic fractures and investigations of osteoporosis; however, 47.5% did not score satisfactorily in questions on pharmacotherapy, especially for those patients at high risk for fractures.

CONCLUSIONS

This work has identified some of the barriers to implementing guidelines for osteoporosis and fragility fracture management. In the meantime, it highlights the urgency of intensifying efforts to develop the knowledge and attitude of the healthcare professionals dealing with this condition in Egypt.

Correlates of use of antifracture therapy in older women with low bone mineral density

BACKGROUND

Guidelines exist for treatment of low bone mineral density (BMD). Little is known about patient characteristics associated with use of treatment.

OBJECTIVES

To determine patient-related correlates of medication use following screening dual x-ray absorptiometry (DXA) of older adults.

DESIGN

Secondary analysis of a prospective cohort study.

SETTING

Pittsburgh, PA and Memphis, TN.

PARTICIPANTS

Community-dwelling women between the ages 70 and 79 years enrolled in the Health, Aging, and Body Composition (Health ABC) Study.

MEASUREMENTS

Risk factors for fracture and BMD of the hip were assessed at baseline. Patients and their community physicians were supplied the results of the DXA scan. Prescription and over-the-counter medication use was collected at annual exams for 2 years.

RESULTS

Of 1,584 women enrolled in Health ABC, 378 had an indication for antifracture therapy and were not receiving such treatment at baseline. By the second annual follow-up examination, prescription antiresorptive medication was reported in 49 (13.0%), whereas 65 (17.2%) received calcium and/or vitamin D supplementation. In adjusted models, the strongest predictor for use of any antifracture medicine was presence of osteoporosis [vs osteopenia, odds ratio (OR), 2.9 (1.7 to 4.7)], white race [OR, 2.6 (1.5 to 4.8)], and receipt of the flu shot [OR, 2.2 (1.3 to 3.8)]. Neither a history of falls nor prior fracture was associated with use of antifracture medications.

CONCLUSION

Even when physicians of study participants were provided with DXA scan results, 70% of older high-functioning women with an indication for therapy did not start or remain on an antifracture therapy. Substantial room for improvement exists in fracture prevention following a diagnosis of low BMD-especially among women with a history of falls, prior fractures, and among black women.

Correlation between patient recall of bone densitometry results and subsequent treatment adherence

Treatment of osteoporosis is often inadequate. One reason can be insufficient patient education following diagnostic bone densitometry (DXA). Therefore, we studied how patients are informed and treated following their first DXA. Individuals who had DXA at a rural hospital in Wisconsin were surveyed with a questionnaire regarding their post-test education and prescribed treatment. Their DXA results and the specialty of their clinician were also recorded. Eighty percent of the 1,014 participants were informed of their results. Of the 341 participants who had normal bone mineral density (BMD), 63% reported correct results, while only 31% of the 309 who had osteopenia and 50% of the 364 who had osteoporosis reported correct results. Accuracy in reporting was not affected by the patients' age or the specialty of their clinicians. Following DXA, 339 patients (33%) were started on medications; 86% of those remained on some prescribed therapy for osteoporosis, but 140 (41%) did not continue the initial medication. Reasons for discontinuation included side effects (48%) and cost (26%). Patients with low BMD who correctly reported their results were more likely to have received a medication and to continue to take it ( p <0.0001). Calcium supplements were recommended to 65% of those not taking calcium prior to DXA. Internists were more likely than family practitioners to recommend calcium, and their patients reported better medication adherence, as did those with osteoporosis compared with osteopenia. We conclude that, while most participants are informed of the results of their DXAs, the retained information may not be accurate. Correct understanding of DXA results may lead to higher treatment rates and better adherence to treatment among patients with low BMD.

Strategies for the prevention of hip fracture

Hip fractures are associated with 10% to 20% excess mortality in the first year and cause functional disability in most survivors. An estimated 17% of white women in the United States will sustain a hip fracture after the age of 50 years. Despite the availability of evidence-based guidelines for hip fracture prevention, routine screening and preventive measures have not been incorporated into standard primary care practice. Many physicians lack adequate knowledge to initiate bone mineral density testing and treatment with preventive medications to decrease the incidence of osteoporosis and fractures. Furthermore, patients are less likely to request information about bone health than about diseases for which systematic screening and prevention protocols have been established. This review describes preventive measures to decrease hip fracture in postmenopausal women, including screening by bone mineral density testing, risk factor assessment, and chemoprevention. Existing guidelines are summarized, and dilemmas regarding their implementation are discussed.

Hip fracture patients are not treated for osteoporosis: a call to action

OBJECTIVE

To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis.

METHODS

Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment.

RESULTS

DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate.

CONCLUSION

Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.

Secondary causes of osteoporosis

Secondary causes of bone loss are not often considered in patients who are diagnosed as having osteoporosis. In some studies, 20% to 30% of postmenopausal women and more than 50% of men with osteoporosis have a secondary cause. There are numerous causes of secondary bone loss, including adverse effects of drug therapy, endocrine disorders, eating disorders, immobilization, marrow-related disorders, disorders of the gastrointestinal or biliary tract, renal disease, and cancer. Patients who have undergone organ transplantation are also at increased risk for osteoporosis. In many cases, the adverse effects of osteoporosis are reversible with appropriate intervention. Because of the many treatment options that are now available for patients with osteoporosis and the tremendous advances that have been made in understanding the pathogenesis and diagnosis of the condition, it is important that medical disorders are recognized and appropriate interventions are undertaken. This article provides the framework for understanding causes of bone loss and approaches to their management.

Physician treatment of osteoporosis in response to heel ultrasound bone mineral density reports

Optimal information that should be included in ultrasound (US) heel bone mineral density (BMD) reports is not known. If additional information about further evaluation of patients with low heel BMD were included in reports, would responses for treatment improve? We screened people at health fairs using the Sahara heel US machine. For those with a T-score of </= 1.0, letters were sent to their primary care physician notifying them of the result. Physicians were randomly assigned to (1) a standard letter, which recommended central bone density screening (dual X-ray absorptiometry [DXA]) and treatment if the BMD was low; or (2) an extended letter, which also outlined treatment strategies based on recommended subsequent central DXA scan results for a T-score of < 1.50 and also if < 2.00. The extended letter only increased the frequency of DXA testing from 30.1 to 37.2% (not a significant increase). Of 88 people with heel BMD </= 1.00 and not previously on any treatment, 25 of 45 (56%) were treated (calcium, estrogens, bisphosphonates, or calcitonin or a combination) after physicians received a standard letter and 30 of 43 (70%) after an extended letter (one-sided p = 0.084). Of people with T </= 1.9, and initially taking nothing more than calcium, 5 of 36 (13.9%) received additional treatment after physicians received a standard letter vs 9 of 41 (22.0%) after an extended letter (one-sided p = 0.180). For those with T </= 1.0 because of the screen 25 of 197 (12.7%) received additional treatment. One hundred forty-six of 194 (75%) individuals and received treatment with calcium or other medications, and 74 of 173 (43%) of individuals before screening and 141 of 195 (72%) after physicians received letters took calcium. Physicians regarded calcium alone as adequate treatment in many cases. There was no marked increase in treatment when additional information was provided to physicians regarding evaluation and treatment for low US heel BMD results.