Osteoporosis Clinical Guidelines Research Articles

Incorporating postmenopausal women's perspectives into osteoporosis clinical guidelines: a systematic review

ObjectivesTo assess the inclusion of individuals’ perspectives in the development of osteoporosis Clinical Practice Guidelines (CPGs) for primary fracture prevention in postmenopausal women. Study Design and SettingWe performed a comprehensive systematic search across guideline databases and (CPGs) developing organizations websites. Using the AGREE II tool, we assessed the quality of the guidelines, with particular emphasis on the inclusion of patients, or representatives in the development process. We also examined if women's perspectives were considered at the recommendations level and explored the potential association between the inclusion of patients' values and preferences with the quality of the CPGs. ResultsWe retrieved a total of 491 eligible CPGs, of which 33 were finally included. The majority of the CPGs were developed by scientific societies (63.6%), primarily from Europe (39.4%) and North America (30.3%). One in every four (24.2%) guidelines explicitly included individuals' perspectives in their development, and one in ten (12.1%) included research evidence about this aspect to support their recommendations. The domains with the lowest mean scores in the quality assessment were applicability (42.4%), rigor of development (44.7%), and stakeholder involvement (45.7%), and 61% were recommended for use according to our assessment. Guidelines of higher quality were more likely to include women's perspective in their development (mean difference 39.31, P = .003). ConclusionThe incorporation of women's perspectives into the process of developing guidelines for primary fracture prevention in osteoporosis remains inadequate. Our findings serve as a call for guideline developers to improve this situation, and for users, and policymakers to be aware of these limitations, when using or implementing guidelines in this field.

Osteoporosis guideline awareness among Iranian nurses: results of a knowledge and attitudes survey.

SummaryIntroductionOsteoporosis is a chronic and progressive disease associated with gradual bone loss and elevated risk of fracture. Role of health care professional especially nurses in lowering burden of osteoporosis via patients and public education is critical. Current study conducted to evaluate knowledge and attitude regarding osteoporosis among the nurses in orthopedic wards and their experience with national clinical osteoporosis guideline.MethodsA cross-sectional study was conducted from August to December 2016 among all nurses in orthopedic ward of hospitals affiliated to Shiraz University of Medical Sciences. The 23- item self-administered scale consisted of knowledge and attitude questions were used. Moreover, data regarding participation in osteoporosis training courses and awareness of the national osteoporosis clinical guideline were collected as a measure of nurses’ experience with guideline. The gathered data were analyzed using SPSS (V. 16), student t-test was used to compare total knowledge and attitude scores between categorical demographic and professional data. Pearson test was used to calculate the correlation between total knowledge and attitude scores and years of practice. A p-value < 0.05 was considered statistically significant.ResultsFrom total of 160 nurses, 143 of them completed the questionnaire (response rate: 89.3%). The total mean ± SD knowledge and attitude scores were 11.60 ± 3.10 and 3.47 ± 0.92 respectively. Six nurses (4.2%) had participated in osteoporosis training courses after graduation, and 39 (27.3%) had been aware of the national osteoporosis clinical guideline. Knowledge and attitude scores among nurses who practice in private hospitals was higher than those practices in the teaching hospitals. These differences were statistically significant based on student t-test. According to Pearson correlation coefficient, there was positive and significant correlation between nurses’ knowledge and attitude score (Correlation coefficient: 0.199, p-value = 0.037).ConclusionOur findings reveal that nurses’ knowledge and attitude regarding osteoporosis was not satisfactory. Most of them were not aware of national osteoporosis clinical guideline and had not participated in osteoporosis training courses after their graduation. We need more empowered nurses to lowering burden of osteoporosis and its consequences in the future.

P118 Co-design of a model Fracture Liaison Service consultation: a Delphi survey with patients and clinicians

Abstract Background/Aims Fracture Liaison Services (FLSs) are recommended to deliver best practice in secondary fracture prevention. As part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) research programme this study aimed to 1) co-design content for a ‘model FLS consultation’ and 2) gain consensus on the appropriateness of osteoporosis clinical guidelines in the context of FLSs. Methods Three rounds of modified Delphi survey were sent to patients with osteoporosis and/or fragility fractures, carers, and clinicians. Participants were presented with potential consultation content derived from an evidence synthesis of current guidelines, frameworks and theories of shared decision-making, communication and medicine adherence, and stakeholder consultation. Participants were asked to rate their perception of the importance of each statement on a 5-point Likert scale and elaborate using free-text boxes. In Round 2, participants were shown mean scores of importance from Round 1. Statements identified as of ‘low importance’ at the end of Rounds 1 and 2 were discussed by the study team, including patient contributors, and were removed or amended. In Round 3, participants were asked whether the statement was ‘essential’ or ‘optional’ in a time-limited FLS consultation. Percentage agreement with each statement was ranked. The threshold for ‘essential’ versus ‘optional’ was determined by the study team. Results 391 invitations to participate were sent, with 72, 49, and 52 responders to Rounds 1, 2 and 3 respectively. Throughout Rounds 1-3 participants considered 122 statements. By Round 3, 81 statements were deemed essential, with an additional 14 optional statements. Essential statements were distilled into 18 recommendations constituting the ‘model FLS consultation’. Statements related to stages of the consultation, including: introductions; gather information; consider therapeutic options; elicit patient perceptions; establish shared decision-making preferences; share information about condition and treatment; check understanding; and signpost next steps. There was consensus that FLS clinicians should discuss the benefits and risks of oral and intravenous bisphosphonates and denosumab. Optional consultation content included a statement suggesting clinicians should observe the patient to look for signs of fractures in their spine, with free-text responses suggesting that FLS clinicians may not ‘be best qualified’ to perform physical examinations. Removed statements included those relating to the discussion of Hormone Replacement Therapy, Raloxifene and Teriparatide, with free-text statements suggesting that ‘specialists’ (e.g. Rheumatologists) should discuss these medications. Additionally, statements that described the potential consequences of fracture (e.g. ‘the clinician should explain that one in ten patients with a hip fracture will die within 12 months of fracture.’) were removed. Free-text comments described these statements as potentially ‘scary’. Conclusion The Delphi survey has informed iFraP intervention development by highlighting essential and optional FLS consultation content. Findings also provide insight into aspects of current osteoporosis clinical guidelines deemed appropriate in nurse/allied health professional led FLSs. Disclosure L. Bullock: None. C. Jinks: Grants/research support; CJ is part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. F. Crawford-Manning: Grants/research support; FCM is part funded by the NIHR Clinical Research Network Scholar Programme. S. Leyland: None. J. Fleming: None. E.M. Clark: None. E. Cottrell: None. J. Edwards: Grants/research support; JE is an NIHR Academic Clinical Lecturer in Primary Care (CL-2016-10-003). Z. Paskins: Grants/research support; ZP is funded by the NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

SummaryGuidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.PurposeMinimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.MethodsWe conducted a structured comparative analysis of existing CPGs in the AP region using a “5IQ” model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.ResultsEighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.ConclusionThe 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Pilot study of 10-year absolute fracture risk assessment tool (FRAX®) introduction into the structure of undegraduate practical training "physician assistant” course

Background: high fracture rates throughout the Eastern Europe and Central Asia region have been reported. Major fractures rate increasing, primary care physicians need to be aware of risk assessment and prevention tools.&#x0D; Aims: The aim of this pilot study was to assess main issues of FRAX tool introduction into undergraduate medical education.&#x0D; Material and methods: Russian version of the IOF approved presentation on FRAX application procedure, results assessment and interpretation as well as Russian Association for Osteoporosis clinical guidelines and reference to www.osteoporoz.ru site have been provided to 248 undergraduate medical students. To increase osteoporosis related issues study motivation the students were asked to apply the Russian version of on-line FRAX calculator to assess risk fracture in their close relatives of appropriate age. Also the students were asked to create a FRAX assessment based patient management program.&#x0D; Results: 207 FRAX assessment reports were received as feedback. Derived intervention threshold was reached in 41 cases (19.8%), while in 45 reports (21.7%) body mass index (BMI) value was mistaken for a 10-year fracture risk. There were 123 cases of the students’ parents assessments. These subjects appeared to be quite young (median 48, range 42 – 62) and relatively healthy to report no fracture risk factors. The students’ grandparents or great-grandparents (68 cases) were assessed on rare occasions due to lack of information or absence of personal contacts between students and their relatives. The students reported appreciable difficulties in decision making. Lifestyle and diet modification were not included in 165 of recommendations, while calcium and vitamin D prescriptions were severely biased by TV advertising. The students reported that it was quite difficult for them to give the patients recommendations regarding the choice of drug and administration timeframe.&#x0D; Conclusion: pilot study of FRAX introduction into undergraduate medical education helped to ascertain several gaps in teaching of osteoporosis diagnosis, prevention and treatment to be covered during undergraduate medical education

The clinical epidemiology of male osteoporosis: a review of the recent literature.

Osteoporosis, a musculoskeletal disease characterized by decreased bone mineral density (BMD) and an increased risk of fragility fractures, is now recognized as an important public health problem in men. Osteoporotic fractures, particularly of the hip, result in significant morbidity and mortality in men and lead to considerable societal costs. Many national and international organizations now address screening and treatment for men in their osteoporosis clinical guidelines. However, male osteoporosis remains largely underdiagnosed and undertreated. The objective of this paper is to provide an overview of recent findings in male osteoporosis, including pathophysiology, epidemiology, and incidence and burden of fracture, and discuss current knowledge about the evaluation and treatment of osteoporosis in males. In particular, clinical practice guidelines, fracture risk assessment, and evidence of treatment effectiveness in men are addressed.

Adherence to osteoporosis guideline: survey among Czech general practitioners

Abstract

The impact of an osteoporosis clinical guideline on rates of referral to an osteoporosis clinic

ing to the superoxide group. Our own previous studies have shown that P. sarmentosum has the ability to inhibit the 11-β-hydroxysteroid dehydrogenase (11-βHSD) enzyme, an enzyme important in the synthesis of cortisol. Based on this and also its antioxidant property, we hypothesize that P. sarmentosum will be able to prevent osteoporosis in a rat model of excess glucocorticoids. Forty male Sprague–Dawley rats, aged 3 months and weighing between 200 and 250 g were used. Twenty-four animals were adrenalectomized and replaced with intramuscular dexamethasone 120 μg/kg/day. They were simultaneously given either P. sarmentosum 0.125 g/kg/day, glycyrrhizic acid (GCA) 240 μg/kg/day or vehicle distilled water (adrx-control group) daily by oral gavage. A group of eight animals were sham-operated and given vehicle daily, i.e. intramuscular olive and oral distilled water. The treatment was given for 8 weeks. The group given GCA was used as a comparison since GCA had been proven to inhibit 11-βHSD enzyme, therefore reducing serum cortisol levels. A baseline control group was used to determine whether any significant stress was induced in the sham-control group. The results after eight weeks showed increased serum cortisol levels in the adrx-control group compared to the sham-control group. However, in the groups treated with P. sarmentosum and GCA, the serum cortisol levels were maintained at sham-control levels. Plasma pyridinoline (bone resorption marker) levels were lower in the P. sarmentosum and GCA groups compared to the adrx-control group. No difference in serum osteocalcin levels were detected between all the groups. In conclusion, the results showed that P. sarmentosum was as effective as GCA in preventing the increased cortisol levels seen in adrenalectomised rats treated with dexamethasone. This was associated with reduced bone resorption activity. Therefore, this suggests that P. sarmentosum is potentially useful in prevention of osteoporosis induced by long-term glucocorticoid therapy.

Osteoporosis: Evaluation of Screening Patterns in a Primary-Care Group Practice

An estimated half of all women aged older than 50 yr will have an osteoporosis-related fracture in their lifetime. National osteoporosis clinical guidelines for screening recommend measurement of bone mineral density in average risk women beginning at age 65 yr. Little data are available regarding compliance with this recommendation. The objective of this study was to evaluate osteoporosis screening rates in a random sample of women, aged 66 yr or older, in a large multisite primary-care group practice. The study was conducted in a primary-care group practice serving over 180,000 patients in the Denver metropolitan area. Medical records of a random sample of 833 female patients aged 66 yr or older were reviewed retrospectively. Patients were seen at 1 of 13 practice locations, by 1 of 34 physicians, who practiced either family medicine or internal medicine. The frequency of osteoporosis screening was calculated. Accepted methods of screening include peripheral bone density measurement by ultrasound or dual-energy X-ray absorptiometry (DXA), or central DXA. The physician-specific osteoporosis screening rates varied widely, ranging from 19% to 97%. The practice-specific osteoporosis screening rates ranged from 26% to 91%. Overall, the mean rate of osteoporosis screening among all physicians was 56%. Despite improvements in osteoporosis screening, there continues to be a gap in the quality of care provided compared to national recommended guidelines. Policy changes, performance improvement measures, and interventions are needed to improve screening rates in primary-care practices.

Awareness and perceptions of published osteoporosis clinical guidelines—a survey of primary care practitioners in the Cape Town metropolitan area

AbstractBackground: Despite the widespread production and dissemination of clinical practice guidelines, both worldwide and in South Africa, they have not resulted in the expected improvements in quality of care and patient outcomes. There are limited studies concerning the impact of South African-developed guidelines on local physician behaviour and knowledge. Awareness of a guideline is a necessary prerequisite for its successful implementation. This study aimed to survey primary care practitioners in Cape Town employed in both the private and state sectors on their awareness and perceptions of the Osteoporosis Clinical Guidelines, published in the South African Medical Journal in September 2000.Methods: A descriptive, cross-sectional survey design was used. A telephonic survey of 150 randomised Cape Town primary care practitioners was conducted (100 private general practitioners and 50 public sector primary care practitioners). A survey instrument developed for the study was applied in a standardised m...

Evaluation of current practice: compliance with osteoporosis clinical guidelines in an outpatient fracture clinic

Better detection and management of osteoporosis will reduce unnecessary health expenditure. A number of high quality guidelines are available to support early detection and best practice management of osteoporosis in hospital settings. However, sustainable implementation of guidelines poses practical issues in terms of structure and processes in hospitals. This paper describes an investigation into guideline compliance in one large tertiary metropolitan hospital and discusses practical elements of guideline implementation. Given the evidence of poor practice across the two audit periods, we recommend that a coordinated clinical pathway be implemented in the fracture clinic, supported by a targeted and discipline-specific training program. Small steps towards improving awareness and management of osteoporosis in patients presenting for the first time with non-trauma wrist fracture may well produce large cost savings by future fracture prevention.

Prevalencia de los criterios de indicación de densitometría ósea y de los factores de riesgo de baja masa ósea y fractura en unidades extrahospitalarias de reumatología

Many organisms have proposed criteria to identify individuals with low bone mass or increased risk for osteoporotic fracture in order to provide them with the available diagnostic and therapeutic resources. Among these organisms are the WHO, the Catalan Agency for Health Technology Assessment (CAHTA) and the International Committee for Osteoporosis Clinical Guidelines (ICOCG). We designed a prospective multicenter study to determine the prevalence of indications for bone densitometry in rheumatology outpatient clinics by applying the criteria of these three organisms. Two hundred sixty-two women and 98 men aged 18 years or older who attended five rheumatology outpatient clinics were interviewed and their medical records were reviewed. The mean age was 58.3±13.4 years. Bone densitometry was indicated in 45% of the patients interviewed according to the CAHTA criteria, in 77% according to the WHO criteria and in 62% according to the ICOCG criteria (applicable only to women). The proportion of patients with indications for bone densitometry increased with age, and was higher in women. The concordance among criteria was low.