Outcome of osteoporosis evaluation, treatment, and follow-up in patients referred to a specialized outpatient clinic compared to patients in care of general practitioners

Abstract

Summary

In Denmark, osteoporosis treatment is either handled by general practitioners or at more resource demanding specialist clinics. We evaluated the treatment adherence and persistence in the two settings, which were overall similar. The type of medical support did, however, differ and was provided to two very different patient populations.

Purpose

The study aimed to investigate the effect of patient care by general practitioners (GPs) or specialists on treatment adherence among osteoporosis patients initiating treatment with oral bisphosphonates (OB).

Methods

Dual-energy X-ray absorption (DXA)-scanning data from 2005 to 2013 were extracted. Treatment naïve patients with a T-score ≤ − 2.5 (spine or hip) were included. Information on medical treatment, comorbidities, and socio-economic status was extracted from Danish registries. Scanning results were evaluated by a specialist. Subsequent treatment initiation and follow-up was either handled by GPs or specialists: GP population (GPP) vs. specialist population (SP). Primary adherence was defined as treatment initiating within 12 months from diagnosis and secondary adherence as days with medicine possession rates (MPR) > 80%.

Results

Of 11,201 DXA-scanned patients, 3685 met the inclusion criteria (GPP = 2177, SP = 1508). The GPP consisted of relatively more men, was older, had shorter education, lower income, and more comorbidities. There was no difference in baseline T-score or prior incidence of major osteoporotic fractures (MOFs). The GPP was primarily treated with OB and had better primary adherence (adjusted ORGPP/SP = 1.52 [1.31–1.75], p < 0.0001) than the SP that to a higher degree received another treatment. Secondary adherence was similar (adjusted ORGPP/SP: OR12 months = 1.02 [0.83–1.26]; OR24 months = 0.90 [0.73–1.10]; OR4 years = 0.88 [0.71–1.07]; OR5 years = 0.91 [0.74–1.13].

Conclusion

Patients in care of specialists were most likely to receive a treatment other than OB. Primary adherence was highest in the GPP, whereas short- and long-term persistence was similar for up to 5 years whether treated by a specialist or a GP.

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References

  1. 1.

    Yeam CT, Chia S, Tan HCC, Kwan YH, Fong W, Seng JJB (2018) A systematic review of factors affecting medication adherence among patients with osteoporosis. Osteoporos Int 12:2623–2637

    Article  Google Scholar 

  2. 2.

    Osterberg L, Blaschke T (2005) Adherence to medication. NEJM 353:487–497

    CAS  Article  Google Scholar 

  3. 3.

    Maraka S, Kenrel KA (2015) Bisphosphonates for prevention and treatment of osteoporosis. BMJ 351:h3783

    Article  Google Scholar 

  4. 4.

    Cramer JA, Silverman S (2006) Persistence with bisphosphonate treatment for osteoporosis: finding the root of the problem. Am J Med 119(4A):12S–17S

    CAS  Article  Google Scholar 

  5. 5.

    Cheen MHH, Tan YZ, Oh LF, Wee HL, Thumboo J (2019) Prevalence of and factors associated with primary medication non-adherence in chronic disease: a systematic review and meta-analysis. Int J Clin Pract 73(6):e13350

    Article  Google Scholar 

  6. 6.

    Reynolds K, Muntner P, Cheetham TC (2013) Primary non-adherence to bisphosphonates in an integrated healthcare setting. Osteoporos Int 24(9):2509–2517

    CAS  Article  Google Scholar 

  7. 7.

    Chiu CK, Kuo MC, Yu SF, Su BY, Cheng TT (2013) Adherence to osteoporosis regimens among men and analysis of risk factors of poor compliance: a 2-year analytical review. BMC Musculoskelet Disord 14:276

    Article  Google Scholar 

  8. 8.

    Lee S, Glendenning P, Inderjeeth CA (2011) Efficacy, side effects and route of administration are more important than frequency of dosing of anti-osteoporotic treatment in determining patient adherence: a critical review of published articles from 1970-2009. Osteoporos Int 22:741–753

    CAS  Article  Google Scholar 

  9. 9.

    Lemstra M, Nwankwo C, Bird Y, Moraros J (2018) Primary nonadherence to chronic disease medications: a meta-analysis. Patient Prefer Adherence 12:721–731

    Article  Google Scholar 

  10. 10.

    World Health Organization (2003) Adherence to long-term therapies—evidence for action https://apps.who.int/medicinedocs/en/d/Js4883e/6.html

  11. 11.

    Rolnick SJ, Pawloski RA, Hedblom BD, Asche SE, Bruzek RJ (2012) Patient characteristics associated with medication adherence. Clin Med Res 11(2):54–65

    Article  Google Scholar 

  12. 12.

    Adachi J, Lynch N, Middelhoven H, Hunjan M, Cowell W (2007) The association between compliance and persistence with bisphosphonate therapy and fracture risk: a review. BMC Musculoskelet Disord 8:97

    Article  Google Scholar 

  13. 13.

    Kelly TL (1990) Bone mineral density databases for American men and women. J Bone Miner Res 5(suppl 2):S249

    Google Scholar 

  14. 14.

    Kanis JA, Adachi JD, Cooper C, Clark P, Cummings SR, Diaz-Curiel M, Harvey N, Hiligsmann M, Papaioannou A, Pierroz DD, Silverman SL, Szulc P (2013) Standardising the descriptive epidemiology of osteoporosis: recommendations from the epidemiology and quality of life working group of IOF. Osteoporos Int 24(11):2763–2764

    CAS  Article  Google Scholar 

  15. 15.

    Kildemoes HW, Sørensen HT, Hallas J (2011) The Danish National Prescription Registry. Scand J Public Health 39:38–41

    Article  Google Scholar 

  16. 16.

    Lynge E, Sandegaard JL, Rebolj M (2011) The Danish National Patient Register. Scand J Public Health 39:30–33

    Article  Google Scholar 

  17. 17.

    Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sørensen HT (2011) The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med Res Methodol 11. https://doi.org/10.1186/1471-2288-11-83

  18. 18.

    R Core Team (2018) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/

  19. 19.

    Rossini ML, Bianchi G, Di Munno O, Giannini S, Minisola S, Sinigaglia L, Adami S (2006) Determinants of adherence to osteoporosis treatment in clinical practice. Osteoporos Int 17(6):914–921

    CAS  Article  Google Scholar 

  20. 20.

    Penning-van Beest FJ, Erkens JA, Olson M, Herings RM (2008) Determinants of non-compliance with bisphosphonates in women with postmenopausal osteoporosis. Curr Med Res Opin 24(5):1337–1344

    CAS  Article  Google Scholar 

  21. 21.

    Jones TJ, Petrella RJ, Crilly R (2008) Determinants of persistence with weekly bisphosphonates in patients with osteoporosis. J Rheumatol 35(9):1865–1873

    CAS  PubMed  Google Scholar 

  22. 22.

    Ideguchi H, Ohno S, Hattori H, Ishigatsubo Y (2007) Persistence with bisphosphonate therapy including treatment courses with multiple sequential bisphosphonates in the real world. Osteoporos Int 18(10):1421–1427

    CAS  Article  Google Scholar 

  23. 23.

    Iversen MD, Vora RR, Servi A, Solomon DH (2011) Factors affecting adherence to osteoporosis medications: a focus group approach examining viewpoints of patients and providers. J Geriatr Phys Ther 34(2):72–81

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    van der Zwaard BC, van der Horst HE, Hugtenburg JG (2017) Adherence and persistence of patients using oral bone sparing drugs in primary care. Fam Pract 34(5):525–531

    Article  Google Scholar 

  25. 25.

    Black DM, Rosen CJ (2016) Clinical Practice. Postmenopausal Osteoporosis. N Engl J Med 374(3):254–262

    CAS  Article  Google Scholar 

  26. 26.

    Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J-Y (2013) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24:23–57

    CAS  Article  Google Scholar 

  27. 27.

    Hall SF, Edmonds SW, Lou Y, Cram P, Roblin DW, Saag KG, Wright NC, Jones MP, Wolinsky FD (2017) Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy. J Am Pharm Assoc (2003) 57(4):503–509

  28. 28.

    Fardellone P, Lello S, Cano A, de Sá ME, Watanabe de Oliveira R, Julian GS, Tang B (2019) Real-world adherence and persistence with bisphosphonate therapy in postmenopausal women:a systematic review. Clin Ther 41(8):1576–1588

    CAS  Article  Google Scholar 

  29. 29.

    Pepe J, Cipriani C, Cecchetti V, Ferrara C, Della Grotta G, Danese V, Colangelo L, Minisola S (2019) Patients' reasons for adhering to long-term alendronate therapy. Osteoporos Int 30(8):1627–1634

    CAS  Article  Google Scholar 

  30. 30.

    Alswat K, Adler SM (2012) Gender differences in osteoporosis screening: retrospective analysis. Arch Osteoporos 7:311–313

    Article  Google Scholar 

  31. 31.

    Sawka AM, Adachi JD, Papaioannou A, Thabane L, Ioannidis G, Davison KS, Olszynski WP, Brown JP, Hanley DA, Murray TM, Josse RG, Sebaldt RJ, Petrie A, Tenenhouse A, Goldsmith CH (2004) Are there differences between men and women prescribed bisphosphonate therapy in Canadian subspecialty osteoporosis practices? J Rheumatol 31:1993–1995

    PubMed  Google Scholar 

  32. 32.

    Schneider DL, Bettencourt R, Barrett-Connor E (2006) Clinical utility of spine bone density in elderly women. J Clin Densitom 3:255–260

    Article  Google Scholar 

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Acknowledgements

The authors thank Amgen AB, Hellerup, Denmark, for an unrestricted grant. The authors also thank Katrine Ross-Hansen from MediKat, Copenhagen, Denmark, for providing medical writing support including developing the tables, drafting the results section, and reviewing/revising the final manuscript.

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Correspondence to Mette Friberg Hitz.

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Conflict of interests

Mette Friberg Hitz has received grants from Orkla Care, UCB, Ellab fond, and Amgen and received personal payment in relation to lectures and advisory board meetings. Jakob Praest Holm has participated as a subinvesigator in studies by Amgen and MSD and received payment for lectures sponsored by Amgen and LEO Pharma. Jens-Erik Beck Jensen reports grants and personal fees from Amgen during the conduct of this study, grants and personal fees from Eli Lilly, and personal fees from UCB, Giliad, and Astra Zeneca outside the submitted work. Sofie Arup, Anne Lyngholm Soerensen, and Thomas Alexander Gerds declare that they have no conflict of interests.

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Hitz, M.F., Arup, S., Holm, J.P. et al. Outcome of osteoporosis evaluation, treatment, and follow-up in patients referred to a specialized outpatient clinic compared to patients in care of general practitioners. Arch Osteoporos 15, 97 (2020). https://doi.org/10.1007/s11657-020-00774-9

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Keywords

  • Osteoporosis
  • Bisphosphonates
  • Adherence
  • Registry
  • Healthcare organization