Osteoporosis as a Focus for Practice Improvement

Transcription

1 Osteoporosis as a Focus for Practice Improvement Karen E. Hansen, M.D. Assistant Professor of Medicine Rheumatology and Endocrine Sections University of Wisconsin Madison, WI

2 Postmenopausal Osteoporosis

3 Postmenopausal Osteoporosis One in two women will experience a fragility fracture after age 50 Fragility fractures have medical consequences Pharmacotherapy can prevent osteoporotic fracture and subsequent declines in function and quality of life

4 USPTF Guidelines for Screening of Postmenopausal Osteoporosis Screen all women at age > 65 with central DXA Screen women ages with risk factors for bone loss Low body weight (<154 pounds) No estrogen therapy There is insufficient evidence for or against screening in women < age 60

5 Do Physicians Screen for PMO? Study Subjects Results Daly, women >64 years Solomon, women > 64 years 55 % screened for OP 46% screened for OP

6 about 1% of adult Americans take steroids Corticosteroid Induced Osteoporosis (CIO)

7 Prevalence of CIO Most common form of drug-related osteoporosis Most common form of secondary osteoporosis in both men and women Between 30-50% of people taking steroids > 3 months experience fragility fractures Vertebrae or ribs Pelvis Other sites Caplan, J R Soc Med 1994;87: Tannenbaum, J Clin Endocrinol Metab 2002;87: Johnson, Arch Int Med 1989;149:

8 Fracture Risk During Steroid Therapy Relative Risk < 2.5 mg mg > 7.5 mg 0 Hip Vertebral Fractures Van Staa TP, JBMR 2000;15:

9 ACR Task Force on Osteoporosis: Initiating Long-Term (>6 months) Corticosteroid Therapy Baseline BMD Calcium, vitamin D supplementation Patient education T score < -1 Modify other risk factors Initiate bisphosphonates 2 nd line- consider calcitonin T score > -1 If Hypogonadal, Consider HRT 6-12 months follow-up: Repeat BMD Decrease >5%: change/add medication Stable or increased: no change in therapy Calcium and Vitamin D Consider bisphosphonate to prevent OP Repeat DXA in 6-12 months American College of Rheumatology Task Force on Osteoporosis Guidelines, 2001

10 Do Physicians Recognize and Manage CIO? P E R C E N T Receiving Treatment 0 Harrington Walsh Peat

11 Potential Practice Improvement Projects for UW Fellows Postmenopausal women Increase screening for osteoporosis among women >65 years old Increase osteoporosis therapy for women who merit same Patients taking steroids >6 months Increase rate of DXA testing Increase rate of prescribing calcium and vitamin D Increase use of bisphosphonates

12 Teaching Strategies Didactic lectures Necessary to understand prevalence, importance of disease process Form a basis for knowledge, but by themselves do not alter physician behavior Strategies to enhance physician learning Two or more lectures separated in time Patient handouts coupled with a lecture

13 Teaching Strategies Bone Densitometry Interpretation Basic understanding of test limits for both diagnosis and monitoring therapy Half day DXA course already created Fellows could chose to analyze DXA with medicine faculty member (n=100 over one week) ISCD certification course enhances CV when seeking jobs

14 Teaching Strategies Patient interaction- case based learning Created cases from a web site Patient-provider seminar Attend osteoporosis clinic Come to Osteoporosis Support Group meeting Interact with own patients

15 Testing Strategies Pre-tests and post-tests Interpret bone density reports Recall screening guidelines Implement therapy as appropriate to the patient Chart audits Meet screening guidelines Utilize treatments based on current guidelines Patient satisfaction questionnaires

16 ABIM Practice Improvement 25 patient surveys 25 chart reviews Osteoporosis practice module will be available this fall