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Liu CS, Feasel AL, Kline GA, Billington EO. Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study. Osteoporos Int 2021; 32:1421-1427. [PMID: 33462652 DOI: 10.1007/s00198-021-05823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/04/2021] [Indexed: 12/21/2022]
Abstract
UNLABELLED Group medical visits for osteoporosis can improve access to care while being highly accepted by patients. In this study, a similar proportion of women planned to initiate pharmacotherapy after attending a group or traditional one-on-one osteoporosis consultation, indicating that the group consultation model does not produce unexpected treatment decisions. INTRODUCTION Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation. METHODS In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician. RESULTS We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009). CONCLUSION Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.
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Affiliation(s)
- C S Liu
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A L Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
| | - G A Kline
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - E O Billington
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada.
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Riar S, Feasel AL, Aghajafari F, Frohlich D, Symonds CJ, Kline GA, Billington EO. Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review. CMAJ Open 2021; 9:E711-E717. [PMID: 34162663 PMCID: PMC8248580 DOI: 10.9778/cmajo.20200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences. METHODS We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%-19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories. RESULTS Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%-25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%-43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients. INTERPRETATION Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.
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Affiliation(s)
- Shivraj Riar
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - A Lynn Feasel
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Fariba Aghajafari
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Dean Frohlich
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Christopher J Symonds
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Greg A Kline
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta
| | - Emma O Billington
- Division of Endocrinology & Metabolism (Riar, Symonds, Kline, Billington), Cumming School of Medicine, University of Calgary; Dr. David Hanley Osteoporosis Centre (Feasel, Symonds, Kline, Billington), Alberta Health Services; Departments of Family Medicine and Community Health Sciences (Aghajafari), Cumming School of Medicine, and Department of Radiology (Frohlich), University of Calgary, Alta.
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Wilton-Clark MS, Feasel AL, Kline GA, Billington EO. Autonomy begets adherence: decisions to start and persist with osteoporosis treatment after group medical consultation. Arch Osteoporos 2020; 15:138. [PMID: 32888079 DOI: 10.1007/s11657-020-00809-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Many individuals prescribed osteoporosis pharmacotherapy either do not start or do not persist with treatment. In this study, women who attended a group medical visit at an osteoporosis center which involved fracture risk assessment and focused on autonomous decision-making made treatment decisions with high confidence. Those who started pharmacotherapy were highly persistent. PURPOSE Adherence and persistence with osteoporosis pharmacotherapy is low, possibly reflecting lack of confidence in physicians' treatment recommendations. We evaluated treatment decisions, decisional confidence, and 12-month treatment adherence among women who attended a group bone health consultation that fostered autonomous decision-making. METHODS We prospectively assessed postmenopausal women referred to an osteoporosis clinic who chose to attend a group medical visit in lieu of one-on-one consultation. The group visit was facilitated by a specialist physician and nurse, involving estimation of 10-year major osteoporotic fracture risk (using FRAX®) and extensive education regarding fracture consequences and potential advantages and disadvantages of pharmacotherapy. No direct advice was given by the specialist. Post-consult, participants made an autonomous decision regarding treatment intent and followed up with their family physician to enact their chosen plan. Intentions to initiate pharmacotherapy were assessed immediately post-consult. Treatment status and decisional confidence were evaluated 3 and 12 months later. Three-month treatment status was considered to reflect final treatment decision. Persistence was defined as proportion of participants on treatment at 3 months who remained treated at 12 months. RESULTS One hundred one women (mean (SD) age, 62.7 years (5.8); median (IQR) FRAX®, 10.7% (8.3-17.6)) participated. Immediately post-consult, 27 (26.7%) intended to initiate treatment. At 3 months, 23 (22.8%) were treated, and at 12 months, 21 (91.3%) remained persistent. Of 89 questionnaire respondents at 12 months, 85 (95.5%) reported confidence in their treatment decision. CONCLUSION When postmenopausal women are provided with individualized fracture risk estimates and enabled to make autonomous decisions regarding pharmacotherapy, ultimate decisions to receive treatment are made with confidence and result in high persistence at 12 months.
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Affiliation(s)
- Madeline S Wilton-Clark
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A Lynn Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada.,Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta, T2T 5C7, Canada
| | - Gregory A Kline
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada.,Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta, T2T 5C7, Canada.,Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emma O Billington
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada. .,Richmond Road Diagnostic and Treatment Centre, 1820 Richmond Road SW, Calgary, Alberta, T2T 5C7, Canada. .,Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Billington EO, Feasel AL, Kline GA. At Odds About the Odds: Women's Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds. J Gen Intern Med 2020; 35:276-282. [PMID: 31625042 PMCID: PMC6957614 DOI: 10.1007/s11606-019-05384-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/22/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values. OBJECTIVE We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds. DESIGN AND PARTICIPANTS This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center. INTERVENTION A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated1 their 10-year MOF and hip fracture risk using FRAX and2 their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation. MAIN MEASURES We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%). KEY RESULTS Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105). CONCLUSIONS Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.
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Affiliation(s)
- Emma O Billington
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada.
| | - A Lynn Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Calgary, Alberta, Canada
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Werle J, Dobbelsteyn L, Feasel AL, Hancock B, Job B, Makar L, Manning H, Quigley S, Teppler A, Smith C, Kelly S, Wasylak T. A study of the effectiveness of performance-focused methodology for improved outcomes in Alberta public healthcare. Healthc Manage Forum 2011; 23:169-74. [PMID: 21739818 DOI: 10.1016/j.hcmf.2010.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This study evaluates the effectiveness of a performance-focused methodology for engaging multidisciplinary, frontline healthcare teams in making behavioural changes that improve patient care and health system efficiency. Results include significant declines in average length of stay in hospital and waiting time for surgery, and a dramatic increase in early patient ambulation. Performance-focused methodology using key performance indicators, targets, measurement, and ongoing feedback, supported by non-monetary incentives, can quickly improve healthcare outcomes.
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Affiliation(s)
- Jason Werle
- Rockyview General Hospital, Calgary, Alberta, Canada
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