Barriers to Osteoporosis Identification and Treatment Among Primary Care Physicians and Orthopedic Surgeons

Transcription

1 334 Original Article Barriers to Osteoporosis Identification and Treatment Among Primary Care Physicians and Orthopedic Surgeons CHRISTINE SIMONELLI, MD; KATHLEEN KILLEEN, MOT; SUSAN MEHLE, BS; AND LEAH SWANSON, RN, GNP Objective: To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height. Methods: A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians. Results: Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the From Osteoporosis Service, HealthEast Clinics, Woodbury, Minn (C.S.); HealthEast Orthopaedic Services, St Paul, Minn (K.K., L.S.); and Department of Research, HealthEast Medical Research Institute, St Paul, Minn (S.M.). This project was funded by the HealthEast Clinics and Orthopaedic Collaborative Practice, HealthEast Medical Research Institute, St Paul, Minn. Dr Simonelli is a recipient of research grant funds from Merck & Co. Address reprint requests and correspondence to Christine Simonelli, MD, Osteoporosis Service, HealthEast Clinics, Woodwinds Birch Center, 1875 Woodwinds Dr, Woodbury, MN ( msciao@attbi.com). single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twentyone primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture. Conclusions: Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture. Mayo Clin Proc. 2002;77: BMD = bone mineral density; DXA = dual energy x-ray absorptiometry A pilot study conducted to examine the frequency of identification and treatment of osteoporosis among 301 postmenopausal women hospitalized with low-impact fractures 1 indicated that only 48 patients (16%) had calcium and vitamin D needs assessed during hospitalization despite the high risk for nutritional deficiency. 2 Only 30 (10%) of the 301 patients had bone mineral density (BMD) testing, with 78 patients (26%) receiving osteoporosis medication at 1 year postfracture. The pilot study also indicated that nonorthopedic follow-up after fracture was poor and that often the patient s medical record did not include a diagnosis of osteoporosis. Similarly, in a cohort of 108 patients with a history of fragility fracture treated in an Ontario fracture clinic, Hajcsar et al 3 reported that less than 20% of patients were diagnosed with osteoporosis; fewer received appropriate therapy. Many potential barriers exist for addressing the possibility of osteoporosis in this high-risk population, including blurred lines of responsibility between the orthopedist and the primary care physician, concerns regarding the cost of evaluation with BMD Mayo Clin Proc. 2002;77: Mayo Foundation for Medical Education and Research

2 Mayo Clin Proc, April 2002, Vol 77 Barriers to Osteoporosis Identification and Treatment 335 testing and use of medications, and knowledge about efficacy and safety of existing therapies. Limited supplementation with calcium and vitamin D after fragility fracture suggests that attention to osteoporosis may be limited by ill-defined factors other than cost and safety. METHODS In an effort to understand better the existing barriers to identification and treatment of osteoporosis among hospitalized patients with fracture, a survey was mailed to 35 admitting orthopedic surgeons and 75 primary care clinic physicians in a midwestern managed care organization in March A total of 31 surveys (28%) were returned over the next month, 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. The 1-page survey consisted of 7 questions regarding perceptions of barriers to postfracture medical attention to osteoporosis. RESULTS Overall, 100% of orthopedic surgeons (n=8) and 70% (n=16) of primary care physicians thought it exclusively the responsibility of the primary care physician to address the fracture patient s nutritional need for calcium and vitamin D. Of the primary care physicians, 30% (n=7) thought it was a shared responsibility with the orthopedic surgeons (Table 1). When asked about limiting factors in scheduling followup BMD testing in hospitalized patients with low-impact fractures, 9 primary care physicians (39%) answered they could treat without BMD testing. Four primary care physicians (17%) thought the patients were too old or too frail to warrant BMD testing. One respondent did not believe in the merits of BMD testing, and one said that testing was too expensive. Seven of the orthopedic surgeons (88%) thought there were no limiting factors in ordering followup BMD testing. The most frequently indicated factors limiting treatment of presumed osteoporosis in postfracture patients were concerns about medication adverse effects (n=14 [61%]) and cost (n=13 [57%]), according to the primary care physician respondents. One physician cited his/her belief that osteoporosis medication has not been proved to prolong life. Four orthopedic surgeons (50%) reiterated it was not their responsibility, while 3 (38%) cited medication adverse effects as a variable limiting treatment. Four (50%) of the orthopedic surgeons were more likely to treat patients younger than 65 years, 3 orthopedic surgeons (38%) were more likely to treat women vs men, and 3 (38%) were more likely to treat independently living adults compared with those in long-term care facilities. Primary care physicians were more likely to treat women than men (n=15 [65%]) and those in whom a secondary cause was known (n=14 [61%]). Twelve primary care respondents (52%) would be more inclined to treat independently living patients, and 9 (39%) would be more likely to treat patients younger than 65 years than older adults. Eight orthopedic surgeons (100%) and 21 primary care physicians (91%) said they would be more likely to treat elderly patients with a fracture if they had a safe medication shown to reduce patients risk of a recurrent fracture by 50% in less than 2 years. Four orthopedic surgeons (50%) and 14 primary care physicians (61%) who said they would be more likely to treat if they had a safe and effective medication indicated that medication was the limiting variable in treatment. When asked to rate the single most important barrier to treating patients for osteoporosis postfracture, primary care physicians rated cost of treatment (n=14 [61%]); managed care restraints (n=5 [22%]) was the next most cited factor. Seven orthopedic surgeons (88%) indicated it was not their responsibility, although time constraints (n=2 [25%]), cost (n=1 [13%]), and managed care restraints (n=1 [13%]) were also noted. To increase the attention to possible osteoporosis in adults admitted to the hospital with a fragility fracture, all the orthopedic surgeons supported the idea of having an orthopedic or geriatric nurse practitioner see their patients for osteoporosis management. Fifty percent (n=4) also believed it was important to increase primary care provider awareness of osteoporosis in hospitalized patients. Primary care physicians agreed that there was a need to increase their awareness of osteoporosis in hospitalized patients (n=16 [70%]), but only 5 (22%) favored routine evaluation by a nurse practitioner specialist. DISCUSSION Conclusive evidence shows that a history of a low-impact fracture significantly increases the risk for a subsequent fracture in both men and women. 4-8 In fact, even wrist fractures can foretell a future increased risk for hip fracture We also know that patients at highest risk for fracture, those with a prior fracture and lowest BMD values, are most responsive to current US Food and Drug Administration approved therapies. 12,13 Surprisingly both primary care physicians and orthopedic surgeons indicated that they are more likely to treat the female patient with fracture. Although osteoporosis and related fractures are more common in women and men tend to experience fracture at an older age than women, men are more likely to have a secondary contributing factor that may be treatable. 14,15 For the primary care physician, male sex was a stronger limiting factor than age older than 65 years. It is not known if this is in part related to the paucity

3 336 Table 1. Survey Questions and Response Rates No. (%) of primary care No. (%) of physicians orthopedists Question Response (n=23) (n=8) When you see patients hospitalized for Primary care physician 16 (70) 8 (100) management of an acute fracture by the Orthopedist 0 (0) 0 (0) orthopedic service, whose responsibility is it to Both 7 (30) 0 (0) address the patient s nutritional needs, including calcium and vitamin D? What are the limiting factors in scheduling Patients old/frail 4 (17) 0 (0) follow-up bone mineral density testing in Can treat without 9 (39) 1 (13) hospitalized patients with low-impact fractures? Don t believe in testing 1 (4) 0 (0) (Check all that apply) Too expensive 1 (4) 0 (0) No limiting factors 9 (39) 7 (88) No response 3 (13) 0 (0) What are the factors limiting treatment of Life expectancy/comorbidity 6 (26) 0 (0) presumed osteoporosis in patients following Meds not shown to prolong quality-adjusted 1 (4) 1 (13) low-impact fracture requiring hospitalization? years (Check all that apply) Meds too expensive 13 (57) 1 (13) Side effects 14 (61) 3 (38) Not my responsibility 0 (0) 4 (50) Other 3 (13) 0 (0) No response 5 (22) 1 (13) Are you more likely to treat Younger (<65 y) than older patients 9 (39) 4 (50) (Check all that apply) Independent living vs nursing home residents 12 (52) 3 (38) Those in whom secondary cause is obvious 14 (61) 3 (38) Women than men 15 (65) 3 (38) No response 4 (17) 1 (13) Would you be more likely to treat elderly patients Yes 21 (91) 8 (100) with a fracture if you had a safe medication No 1 (4) 0 (0) shown to reduce their risk of a recurrent fracture No response 1 (4) 0 (0) by 50% in less than 2 years? If you had to choose the single most important Cost 14 (61) 1 (13) barrier to treating patients hospitalized with a Managed care restraints 5 (22) 1 (13) low-impact fracture, would it be Time 2 (9) 2 (25) Not my responsibility 0 (0) 7 (88) Don t believe it is important 0 (0) 0 (0) None 1 (4) 0 (0) Other 3 (13) 0 (0) No response 6 (26) 0 (0) If we wanted to increase the treatment of older Orthopedist should include management of 5 (22) 1 (13) patients admitted to the hospital with fracture, osteoporosis in orders should we (Check all that apply) Have orthopedic nurse/practitioner see all 5 (22) 8 (100) patients for osteoporosis Refer patients for evaluation 0 (0) 1 (13) Increase primary care awareness of 16 (70) 4 (50) osteoporosis in hospitalized patients No response 5 (22) 0 (0) of controlled trials of osteoporosis therapies for men or the lack of clear guidelines for BMD testing and treatment thresholds in men. 16 For postmenopausal women National Osteoporosis Foundation guidelines indicate that all postmenopausal women who experience a low-impact fracture deserve attention to osteoporosis, and therapy may be offered without BMD testing if necessary. 17 Bone mineral density testing is ideal if available and if the patient is a candidate for active therapy. Bone mineral density testing with dual energy x- ray absorptiometry (DXA) of the spine and hip is a useful measurement tool for monitoring response to therapy and

4 Mayo Clin Proc, April 2002, Vol 77 Barriers to Osteoporosis Identification and Treatment 337 quantifying current BMD If a patient is not considered a candidate for an osteoporosis prescription medication, nutritional and safety issues may still need to be addressed. Both calcium deficiency and vitamin D deficiency are common in elderly persons, and nearly half of postmenopausal women hospitalized with a hip fracture are reported to have subclinical vitamin D deficiency. 2,21,22 Clearly, most physicians responding to our survey believe that a safe, effective medication for osteoporosis does not exist despite Food and Drug Administration approval of 2 bisphosphonates, alendronate and risedronate 26,27 ; nasal salmon calcitonin 28 ; and raloxifene 29,30 for treatment of osteoporosis in women and alendronate 15 for treatment in men. Testosterone is also approved for use in hypogonadal men. 31 Hormonal supplementation with estrogen may be an important adjunct to consider for bone health in postmenopausal women. Although prospective fracture data with estrogen are limited, epidemiological studies suggest estrogen may afford some fracture protection in older women. 32 Prospective data from the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial show significant BMD gains in younger postmenopausal women given various regimens of conjugated estrogen as monotherapy or with a progestin or micronized progesterone. 33 Estrogen is not considered adequate monotherapy for the postmenopausal woman with osteoporosis if she is a suitable candidate for more potent therapy. There is a strong expression of concern regarding the cost of medication to treat osteoporosis despite the high cost of hospitalization and treatment for fracture, postfracture care, and compromised quality of life Studies such as the Fracture Intervention Trial with alendronate 24,25 and the vertebral and hip fracture trials with risedronate 26,27,37 have shown both vertebral and hip fracture reductions of 30% to 50% in a high-risk population. The safety profile of these medications is favorable compared with placebo, particularly the once-weekly administration of alendronate therapy. 38,39 Non-BMD directed interventions are of increased importance for fracture prevention in elderly persons. These include exercise for muscle strengthening and balance, home safety measures, and other fall prevention strategies. 40,41 A review of medications that may affect alertness or reflex responses may contribute to prevention of falls. Screening for fall risk may select a subpopulation of patients with fracture who may benefit from hip pads. A large randomized trial of elderly nursing home residents showed hip pads reduced fall-related hip fractures from 46 per 1000 person-years to 21 per 1000 person-years. 42 The physicians who responded to the survey agree that osteoporosis is important and deserves attention in the patient with fragility fracture. The issue remains about the most efficient and acceptable way to have this issue addressed to ensure that all patients are offered the best care to reduce their risk for subsequent fracture. This includes attention to nutritional requirements, specifically calcium and vitamin D, appropriate metabolic evaluation, BMD testing, and treatment. The orthopedic surgeons who responded to this survey favor addressing osteoporosis with these patients as long as the responsibility does not rest directly on them. They support a nurse practitioner intervention to address their concerns and promote additional physician education. In contrast, the primary care physicians want to claim the treatment of these patients for themselves; however, some discrepancies remain between the survey results and what the pilot data showed 1 and others have reported. 3 Further strategies need to be developed to ensure that the postfracture patient is receiving appropriate evaluation and treatment for osteoporosis. The small sample size and overall response rate of 28% is a limitation to interpretation of our survey data. There may also have been a natural selection for physicians with a greater than average interest in osteoporosis to respond to the survey rather than a random sampling of physicians. Some physicians may have been hesitant to respond with negative comments because the survey came from their organization. Despite these limitations, the responsibility for attention to osteoporosis and bone health is currently not well defined in the postfracture setting. We thank Mark Laliberte of the Department of Research, HealthEast Medical Research Institute, for his assistance in preparing the data and reviewing the submitted manuscript. REFERENCES 1. Simonelli C. Longitudinal analysis of diagnosis and treatment of osteoporosis in fracture patients [abstract]. Osteoporos Int. 2000; 11(suppl 2):S144-S145. Abstract 329 (305). 2. LeBoff MS, Kohlmeier L, Hurwitz S, Franklin J, Wright J, Glowacki J. Occult vitamin D deficiency in postmenopausal US women with acute hip fracture. JAMA. 1999;281: Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ. 2000;163: Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M. 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