Results of Patient Education about Osteoporosis after Fragility Fracture: DISCUSSION
Even though osteoporosis is a condition with significant implications, it often goes undiagnosed because it is not associated with obvious symptoms until a fragility fracture occurs. Even then, many patients with fragility fractures are not investigated for osteoporosis.
This study has demonstrated that pharmacists can have a positive impact in educating patients about osteoporosis and can prompt or encourage them to speak to their physicians about it.
In 2001, Smith and others reported that 39% of patients with fragility fractures of the hip and wrist were receiving osteoporosis treatment; in 60% of these cases, the treatment was calcium alone. Khan and others reported that only 38% of patients were taking either calcium or antiresorptive medication after fragility fractures of the wrist. In the current pilot study at KGH, 52% of patients were receiving antiresorptive medications at follow-up, an increase of 13 percentage points from baseline. Raising patients’ awareness of osteoporosis may motivate them to ask their physicians about the need for treatment, leading to a higher proportion of patients being treated.
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Although the pharmacist intervention in this study had a positive impact on the proportion of patients using antiresorptive medication, there were no statistically significant changes in modifiable risk factors. Dietary and total calcium intake trended upward at follow-up, but the proportion of patients actually attaining the required daily intake for calcium decreased. There was an increase in mean daily vitamin D intake after the intervention, but this was not significant. Perhaps patients need more than 12 to 14 weeks to modify their risk factors. However, these results may also indicate an ongoing need for reinforcement by all health care professionals to encourage adequate calcium and vitamin D intake. When a patient presents with a fragility fracture, the orthopedic surgeon, hospital pharmacist, nurse, and other members of the health care team should collaborate to promote bone health. Primary care physicians and community pharmacists are well positioned to continually emphasize the importance of calcium and vitamin D and to follow up on recommendations made to patients.
The educational intervention in this study did not have a statistically significant impact on caffeine consumption or smoking cessation. Again, it is imperative that health care workers act as a team to provide ongoing encouragement to reduce these risk factors. Weight-bearing exercise, another modifiable risk factor, was not assessed in this study because of the long recovery time for fractures and the short follow-up period of the study.
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During the study, orthopedic surgeons at KGH were made aware of the study but no measures were taken to inform them of which patients were involved. Awareness of the study might have influenced the assessment rates for osteoporosis; however, it was determined that patients with fragility fracture were not being assessed for osteoporosis at KGH, nor were they being referred to their family physicians for such assessment. This lack of assessment suggests that general awareness of the study did not influence behaviour; it also highlights the large gap in care between acute and community care settings. When a patient presents with a fragility fracture, it is important to take the opportunity to discuss risk factors for osteoporosis. This study has shown that educating patients alone is insufficient to significantly increase the proportion of patients being assessed for osteoporosis. Only 30% of the patients in this study went on to have a BMD scan within 3 months of their fracture. This demonstrates a need for greater physician education about the criteria for osteoporosis assessment. Action should be initiated while the patient is in hospital. A request from the orthopedic surgeon to the family physician for an osteoporosis assessment or an order for BMD scanning in hospital ensures some degree of patient follow-up. At the very least, all patients should be assessed for adequate calcium and vitamin D intake. Calcium and vitamin D initiated in the hospital may be more likely to be continued at home.
Because of limited resources and time constraints, this study was conducted as a pilot. The limitations of this study are the lack of a control arm, potential bias among subjects and investigators, the short follow-up period, and the small sample size. In addition, those who declined to participate (38% of those who were approached) may have different characteristics from those who did participate. Definitive statements about the influence of the pharmacist intervention cannot be made because of the lack of a control arm and potential subject and investigator bias. The accuracy of the results is limited by the subjective nature of self-reported data. In addition, investigator bias may have limited the accuracy of the study because the same investigator was responsible for conducting interviews, providing the educational sessions, and interpreting the follow-up data. If the study had been extended for a longer follow- up time, higher numbers of patients might have been assessed for osteoporosis by their family physicians and antiresorptive therapy might have been initiated for more patients. However, a longer follow-up time might also have negatively affected the number of patients taking antiresorptive therapy because of discontinuation due to intolerance or side effects. Follow-up to at least 6 months or 1 year would allow a clearer assessment of modifiable risk factors, osteoporosis screening, and initiation of appropriate therapy. It would also be worthwhile to conduct a similar trial on a larger scale. A larger sample size would allow randomization to control (standard care) and experimental (educational intervention) arms. This would allow the true effects of the educational intervention to be discerned. To eliminate investigator bias in future studies, the tasks should be divided up, such that one investigator collects the data, another conducts the educational session, and another inputs data for statistical analysis. Given the current pharmacist shortage, group educational sessions instead of individual sessions may be more practical. This trial suggests that knowledge alone may not be enough to influence a person’s decision to modify risk factors. Future trials should also examine how ongoing reinforcement by health care providers may influence patients’ decisions to modify osteoporosis risk factors through the transtheoretical model of behaviour change: pre-contemplation, contemplation, preparation, action, and maintenance.
It is recommended that a BMD scan and calcium supplementation for patients with inadequate calcium intake (about 70% of patients) become the minimum standard of care at KGH after a fragility fracture. Vitamin D supplementation should also be encouraged since this population is often vitamin D deficient.
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CONCLUSIONS
Pharmacists have an important role in educating patients about the risk factors and treatment options for osteoporosis. This study demonstrated that pharmacists can increase patients’ knowledge about osteoporosis and encourage them to speak to their family physician about the need for treatment and prevention. However, a single teaching session was not enough to motivate patients to decrease modifiable risk factors. Continual encouragement to modify these risk factors is needed from all health care professionals, especially pharmacists, who are well positioned to intervene and provide follow-up. This study confirmed the results of previous studies in other institutions showing that patients with fragility fracture are not being assessed for osteoporosis, nor are they being referred for assessment after discharge. It is recommended that a BMD scan and an assessment for osteoporosis therapy become the standard of care after a fragility fracture.
