Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice

Abstract

Background Among Australians aged 50 and over, an estimated 1 in 4 men and 2 in 5 women will experience a minimal trauma fracture during their remaining lifetime. Effective fracture prevention is hindered by substantial undertreatment, even of patients who clearly warrant pharmacological therapy. Poor adherence to osteoporosis treatment is also a leading cause of repeat fractures and hospitalisation. The aim of this study was to identify current osteoporosis treatment patterns and gaps in practice in Australia, using general practice data, and to explore general practitioners’ (GPs’) attitudes to osteoporosis treatment and their views on patient factors affecting osteoporosis management. Methods The study was conducted in two phases. Phase 1 was a longitudinal retrospective cohort study which utilised data from MedicineInsight – a national general practice data program that extracts longitudinal, de-identified patient data from clinical information systems (CISs) of participating general practices. Phase 2 included semi-structured, in-depth telephone interviews with a sample of MedicineInsight practice GPs. Data were analysed using an inductive thematic analysis method informed by the theory of planned behaviour. Results A diagnosis of osteoporosis was recorded in 12.4% of patients over the age of 50 years seen in general practice. Of those diagnosed with osteoporosis, almost a quarter were not prescribed osteoporosis medicines. From 2012 to 17, there was a progressive increase in the number of denosumab prescriptions, while prescriptions for bisphosphonates and other osteoporosis medicines decreased. More than 80% of patients who ceased denosumab treatment had no subsequent bisphosphonate prescription recorded. Interviews with GPs revealed beliefs and attitudes that may have influenced their intentions towards prescribing and osteoporosis management. Conclusions This study suggests that within the Australian general practice setting, osteoporosis is underdiagnosed and undertreated. In addition, it appears that most patients who ceased denosumab treatment had no record of subsequent antiresorptive therapy, which would place them at risk of further fractures. The study supports the need for the development of clinical education programs addressing GP knowledge gaps and attitudes, and the implementation of specific interventions such as good reminder/recall systems to avoid delays in reviewing and treating patients with osteoporosis.

Persistence with oral bisphosphonates and denosumab among older adults in primary care in Ireland

“…This recommendation is due in part to the cost of the medication but also due to the need to pre-screen for hypocalcaemia and co-morbidities and due to complications that arise with cessation of the drug [7, 21, 28]. This pattern of prescribing reflects findings from a large primary care study in Australia where denosumab went from making up a small percentage of bone-health prescriptions in 2012 to being the most frequently prescribed in 2017 [23]. The denosumab cohort in this study included a higher proportion of female patients and more patients with a diagnosis of osteoporosis in comparison to the bisphosphonate cohort.…”

“…In five studies from the USA, Canada, Hungary and Sweden that were included in a recent systematic review and that measured two-year persistence using similar treatment gaps as the current analysis, estimates ranged from 19% to 46% [13, 29-33]. While there is some clinical uncertainty about whether particular patients should be given a break or “bisphosphonate holiday” after 3-5 years to avoid increasing the risk of adverse events, this should not influence persistence after only two years on medication [15-17, 23]. Furthermore, this cohort would be considered at relatively higher risk of fragility fracture as they have an average age of 77, a fracture history prevalence of 10% and a diagnosis of osteoporosis in 30% of the group.…”

The assessment and pharmacological management of osteoporosis after admission for minimal‐trauma fracture at a major metropolitan centre

“…17 Even in general practice settings confusion exists about responsibility for managing osteoporosis, with osteoporosis considered a low-priority issue, resulting in community patients being undertreated. [25][26][27] There remains a need for therapeutic guidelines to suggest the commencement of osteoporosis management in acute settings, with consensus provided from surgical and other acute clinical groups.…”

“…The development of the national osteoporosis guidelines in collaboration with the Royal Australian College of General Practitioners may contribute to the notion that osteoporosis should be treated by GPs, however the intent was for hospital and community practitioners to work in unison 17 . Even in general practice settings confusion exists about responsibility for managing osteoporosis, with osteoporosis considered a low‐priority issue, resulting in community patients being undertreated 25–27 . There remains a need for therapeutic guidelines to suggest the commencement of osteoporosis management in acute settings, with consensus provided from surgical and other acute clinical groups.…”

Health Literacy of Osteoporosis Risks among Caregivers Serving in Disability Care Facilities

“…Osteoporosis is characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and a risk of fracture, disability, and even death [2,3]. Osteoporosis has been highly prevalent but often underdiagnosed and undertreated, to the extent that it has become a silent disease [4]. Enforcing routine health screenings in primary healthcare settings could be an effective strategy to increase osteoporosis awareness and medication use [5].…”