Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial

Merle, Blandine; Chapurlat, Roland; Vignot, Emmanuelle; Thomas, Thierry; Haesebaert, Julie; Schott, Anne-Marie

doi:10.1007/s00198-017-3953-z

Cited by 22 publications

(17 citation statements)

References 40 publications

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“…A total of 4199 unique records (citations) were identified with the literature search strategies, of which 43 met inclusion criteria . A flow diagram of the literature search and inclusion/exclusion process is shown in Fig.…”

Section: Resultsmentioning

confidence: 99%

“… e Significance of meta‐analysis findings sensitive to removal of Gardner et al, Kessous et al, or Merle et al studies in influence analysis.…”

Section: Resultsmentioning

confidence: 99%

“…d Significance of meta-analysis findings robust to removal of individual studies in influence analysis. e Significance of meta-analysis findings sensitive to removal of Gardner et al, (37) Kessous et al, (41) or Merle et al (51) studies in influence analysis. f Lafata et al study (43) could not be included due to lack of clarity on 2Â2 table values from reporting in paper.…”

Section: Meta-analyses Findings For Osteoporosis Quality Improvement mentioning

confidence: 99%

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How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Nayak

Greenspan

2018

Journal of Bone and Mineral Research

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Although osteoporosis affects 10 million people in the United States, screening and treatment rates remain low. We performed a systematic review and meta-analysis of the efficacy of quality improvement strategies to improve osteoporosis screening (bone mineral density [BMD]/dual-energy X-ray absorptiometry [DXA] testing) and/or treatment (pharmacotherapy) initiation rates. We developed broad literature search strategies for PubMed, Embase, and Cochrane Library databases, and applied inclusion/exclusion criteria to select relevant studies. Random-effects meta-analyses were performed for outcomes of BMD/DXA testing and/or osteoporosis treatment. Forty-three randomized clinical studies met inclusion criteria. For increasing BMD/DXA testing in patients with recent or prior fracture, meta-analyses demonstrated several efficacious strategies, including orthopedic surgeon or fracture clinic initiation of osteoporosis evaluation or management (risk difference 44%, 95% confidence interval [CI] 26%-63%), fracture liaison service/case management (risk difference 43%, 95% CI 23%-64%), multifaceted interventions targeting providers and patients (risk difference 24%, 95% CI 15%-32%), and patient education and/or activation (risk difference 16%, 95% CI 6%-26%). For increasing osteoporosis treatment in patients with recent or prior fracture, meta-analyses demonstrated significant efficacy for interventions of fracture liaison service/case management (risk difference 20%, 95% CI 1%-40%) and multifaceted interventions targeting providers and patients (risk difference 12%, 95% CI 6%-17%). The only quality improvement strategy for which meta-analysis findings demonstrated significant improvement of osteoporosis care for patient populations including individuals without prior fracture was patient self-scheduling of DXA plus education, for increasing the outcome of BMD testing (risk difference 13%, 95% CI 7%-18%). The meta-analyses findings were limited by small number of studies in each analysis; high between-study heterogeneity; sensitivity to removal of individual studies; and unclear risk of bias of included studies. Despite the limitations of the current body of evidence, our findings indicate there are several strategies that appear worthwhile to enact to try to improve osteoporosis screening and/or treatment rates. © 2018 American Society for Bone and Mineral Research.

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Section: Resultsmentioning

confidence: 99%

“… e Significance of meta‐analysis findings sensitive to removal of Gardner et al, Kessous et al, or Merle et al studies in influence analysis.…”

Section: Resultsmentioning

confidence: 99%

Section: Meta-analyses Findings For Osteoporosis Quality Improvement mentioning

confidence: 99%

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How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Nayak

Greenspan

2018

Journal of Bone and Mineral Research

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“…There has been increasing recognition of the need for patient education regarding secondary prevention following a fracture . Langer and colleagues recently surveyed more than 1000 patients and even among patients rated high risk for secondary fracture using the Fracture Risk Assessment Tool (FRAX) tool, most perceived their future fracture risk as low.…”

Section: Discussionmentioning

confidence: 99%

Comparing Strategies Targeting Osteoporosis to Prevent Fractures After an Upper Extremity Fracture (C-STOP Trial): A Randomized Controlled Trial

Majumdar

McAlister

Johnson

et al. 2018

Journal of Bone and Mineral Research

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We compared osteoporosis care after upper extremity fragility fracture using a low-intensity Fracture Liaison Service (FLS) versus a high-intensity FLS in a pragmatic patient-level parallel-arm comparative effectiveness trial undertaken at a Canadian academic hospital. A low-intensity FLS (active-control) that identified patients and notified primary care providers was compared to a high-intensity FLS (case manager) where a specially-trained nurse identified patients, investigated bone health, and initiated appropriate treatment. A total of 361 community-dwelling participants 50 years or older with upper extremity fractures who were not on bisphosphonate treatment were included; 350 (97%) participants completed 6-month follow-up undertaken by assessors blinded to group allocation. The primary outcome was difference in bisphosphonate treatment between groups 6 months postfracture; secondary outcomes included differences in bone mineral density (BMD) testing and a predefined composite measure termed "appropriate care" (taking or making an informed decision to decline medication for those with low BMD; not taking bisphosphonate treatment for those with normal BMD). Absolute differences (%), relative risks (RR with 95% confidence intervals [CIs]), number-needed-to-treat (NNT), and direct costs were compared. A total of 181 participants were randomized to active-control and 180 to case-manager using computer-generated randomization; the groups were similar on study entry. At 6 months, 51 (28%) active-control versus 86 (48%) case-manager participants started bisphosphonate treatment (20% absolute difference; RR 1.70; 95% CI, 1.28 to 2.24; p < 0.0001; NNT = 5). Of active-controls, 108 (62%) underwent BMD testing compared to 128 (73%) case-managed patients (11% absolute difference; RR 1.17; 95% CI, 1.01 to 1.36; p = 0.03). Appropriate care was received by 76 (44%) active-controls and 133 (76%) case-managed participants (32% absolute difference; RR 1.73; 95% CI, 1.43 to 2.09; p < 0.0001). The direct cost per participant was $18 Canadian (CDN) for the active-control intervention compared to $66 CDN for the case-manager intervention. In summary, case-management led to substantially greater improvements in bisphosphonate treatment and appropriate care within 6 months of fracture than the active control. © 2018 American Society for Bone and Mineral Research.

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“…Patient education and counselling were shown to improve post-fracture care and treatment initiation, with more controversial results on medication adherence. As a prominent example for post-fracture care, the PREVOST trial suggested that repeated oral and written information about fragility fractures and osteoporosis management by a case manager increased treatment initiation (53% initiated post-fracture care in the intervention compared to 33% in the control) [66]. In another study [67], patient education and referral to endocrinologist by a nurse was shown to improve the initiation of calcium and vitamin D, although up to 50% of patients with osteoporosis did not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.…”

Section: Recommendations For Practicementioning

confidence: 99%

Determinants, consequences and potential solutions to poor adherence to anti-osteoporosis treatment: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Osteoporosis Foundation (IOF)

et al. 2019

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Many patients at increased risk of fractures do not take their medication appropriately, resulting in a substantial decrease in the benefits of drug therapy. Improving medication adherence is urgently needed but remains laborious, given the numerous and multidimensional reasons for non-adherence, suggesting the need for measurement-guided, multifactorial and individualized solutions. Introduction Poor adherence to medications is a major challenge in the treatment of osteoporosis. This paper aimed to provide an overview of the consequences, determinants and potential solutions to poor adherence and persistence to osteoporosis medication. Methods A working group was organized by the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) to review consequences, determinants and potential solutions to adherence and to make recommendations for practice and further research. A systematic literature review and a face-to-face experts meeting were undertaken. Results Medication non-adherence is associated with increased risk of fractures, leading to a substantial decrease in the clinical and economic benefits of drug therapy. Reasons for non-adherence are numerous and multidimensional for each patient, depending on the interplay of multiple factors, suggesting the need for multifactorial and individualized solutions. Few interventions have been shown to improve adherence or persistence to osteoporosis treatment. Promising actions include patient education with counselling, adherence monitoring with feedback and dose simplification including flexible dosing regimen. Recommendations for practice and further research were also provided. To adequately manage adherence, it is important to (1) understand the problem (initiation, implementation and/or persistence), (2) to measure adherence and (3) to identify the reason of non-adherence and fix it. Conclusion These recommendations are intended for clinicians to manage adherence of their patients and to researchers and policy makers to design, facilitate and appropriately use adherence interventions.

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Post-fracture care: do we need to educate patients rather than doctors? The PREVOST randomized controlled trial

Abstract: A patient-centered care program with a dedicated case manager can significantly improve post-fracture BMD investigation.

Cited by 22 publications

References 40 publications

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

How Can We Improve Osteoporosis Care? A Systematic Review and Meta-Analysis of the Efficacy of Quality Improvement Strategies for Osteoporosis

Comparing Strategies Targeting Osteoporosis to Prevent Fractures After an Upper Extremity Fracture (C-STOP Trial): A Randomized Controlled Trial

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