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The prevalence of overtreatment of osteoporosis: results from the PAADRN trial

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Abstract

Summary

Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication.

Purpose

There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs.

Methods

One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables—sex, race/ethnicity, educational attainment, and differences across health systems—and overtreatment using a series of multivariable logistic regression models.

Results

Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers.

Conclusion

In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized.

Trial registration

clinicaltrials.gov identifier: NCT01507662

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References

  1. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R, National Osteoporosis Foundation (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25(10):2359–2381

    Article  CAS  Google Scholar 

  2. Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B (2014) The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res 29(11):2520–2526

    Article  Google Scholar 

  3. Looker AC, Borrud LG, Dawson-Hughes B, Shepherd JA, Wright NC Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, 2005–2008. NCHS Data Brief 2012(93):1–8

  4. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22(3):465–475

    Article  Google Scholar 

  5. Pfister AK, Welch CW, Emmett M. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011;155(4):275–276; author reply 6–7

    Article  Google Scholar 

  6. Dawson-Hughes B, Looker AC, Tosteson AN, Johansson H, Kanis JA, Melton LJ (2010) The potential impact of new National Osteoporosis Foundation guidance on treatment patterns. Osteoporos Int 21(1):41–52

    Article  CAS  Google Scholar 

  7. Amarnath AL, Franks P, Robbins JA, Xing G, Fenton JJ (2015) Underuse and overuse of osteoporosis screening in a regional health system: a retrospective cohort study. J Gen Intern Med 30(12):1733–1740

    Article  Google Scholar 

  8. Liu Z, Weaver J, de Papp A, Li Z, Martin J, Allen K, Hui S, Imel EA (2016) Disparities in osteoporosis treatments. Osteoporos Int 27(2):509–519

    Article  CAS  Google Scholar 

  9. Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17(12):1726–1733

    Article  CAS  Google Scholar 

  10. Herndon MB, Schwartz LM, Woloshin S, Welch HG (2007) Implications of expanding disease definitions: the case of osteoporosis. Health Aff (Millwood) 26(6):1702–1711

    Article  Google Scholar 

  11. Welch SS (2011) A call to action: changing definitions of “quality” in health care. J Med Assoc Ga 100(1):28 38

    PubMed  Google Scholar 

  12. Moynihan R, Doust J, Henry D (2012) Preventing overdiagnosis: how to stop harming the healthy. BMJ 344:e3502

    Article  Google Scholar 

  13. Schnatz PF, Marakovits KA, Dubois M, O'Sullivan DM (2011) Osteoporosis screening and treatment guidelines: are they being followed? Menopause 18(10):1072–1078

    Article  Google Scholar 

  14. Fenton JJ, Robbins JA, Amarnath AL, Franks P (2016) Osteoporosis overtreatment in a regional health care system. JAMA Intern Med:1–3

  15. Edmonds SW, Wolinsky FD, Christensen AJ, Lu X, Jones MP, Roblin DW, Saag KG, Cram P, PAADRN Investigators (2012) The PAADRN study: a design for a randomized controlled practical clinical trial to improve bone health. Contemp Clin Trials 34(1):90–100

    Article  Google Scholar 

  16. Cram P, Wolinsky FD, Lou Y, Edmonds SW, Hall SF, Roblin DW et al (2016) Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial. Osteoporos Int 27:3513–3524

    Article  CAS  Google Scholar 

  17. Wolinsky FD, Lou Y, Edmonds SW, Hall SF, Jones MP, Wright NC et al (2016) Activating patients with a tailored bone density test results letter and educational brochure: the PAADRN randomized controlled trial. J Clin Densitom

  18. Edmonds SW, Cram P, Lou Y, Jones MP, Roblin DW, Saag KG et al (2016) Effects of a DXA result letter on satisfaction, quality of life, and osteoporosis knowledge: a randomized controlled trial. BMC Musculoskelet Disord 17(1):369

    Article  Google Scholar 

  19. Edmonds SW, Cram P, Lu X, Roblin DW, Wright NC, Saag KG, Solimeo SL, PAADRN Investigators (2014) Improving bone mineral density reporting to patients with an illustration of personal fracture risk. BMC Med Inform Decis Mak 14:101

    Article  Google Scholar 

  20. Tunis SR, Stryer DB, Clancy CM (2003) Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA 290(12):1624–1632

    Article  CAS  Google Scholar 

  21. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381

    Article  Google Scholar 

  22. Feasby TE, Quan H, Tubman M, Pi D, Tinmouth A, So L, Ghali WA (2012) Appropriateness of the use of intravenous immune globulin before and after the introduction of a utilization control program. Open Med 6(1):e28–e34

    PubMed  PubMed Central  Google Scholar 

  23. Hibbard JH, Stockard J, Mahoney ER, Tusler M (2004) Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 39(4 Pt 1):1005–1026

    Article  Google Scholar 

  24. Sanfelix-Gimeno G, Hurtado I, Sanfelix-Genoves J, Baixauli-Perez C, Rodriguez-Bernal CL, Peiro S (2015) Overuse and underuse of antiosteoporotic treatments according to highly influential osteoporosis guidelines: a population-based cross-sectional study in Spain. PLoS One 10(8):e0135475

    Article  Google Scholar 

  25. Hamrick I, Whetstone LM, Cummings DM (2006) Racial disparity in treatment of osteoporosis after diagnosis. Osteoporos Int 17(11):1653–1658

    Article  CAS  Google Scholar 

  26. Mudano AS, Casebeer L, Patino F, Allison JJ, Weissman NW, Kiefe CI, Person S, Gilbert D, Saag KG (2003) Racial disparities in osteoporosis prevention in a managed care population. South Med J 96(5):445–451

    Article  Google Scholar 

  27. Cadarette SM, Beaton DE, Gignac MA, Jaglal SB, Dickson L, Hawker GA (2007) Minimal error in self-report of having had DXA, but self-report of its results was poor. J Clin Epidemiol 60(12):1306–1311

    Article  Google Scholar 

  28. Peeters GM, Tett SE, Dobson AJ, Mishra GD (2013) Validity of self-reported osteoporosis in mid-age and older women. Osteoporos Int 24(3):917–927

    Article  CAS  Google Scholar 

  29. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn't. BMJ 312(7023):71–72

    Article  CAS  Google Scholar 

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Funding/support

This work was supported by R01 AG033035 (Cram/Wolinsky) from the NIA at NIH. Dr. Cram is supported by a K24 AR062133 award from NIAMS at the NIH. Dr. Wright is supported by a K12 HS023009 award from AHRQ. Dr. Saag is supported by a K24 AR052361 award from the NIAMS at the NIH.

Role of the sponsor

The NIA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Author information

Authors and Affiliations

  1. Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave JJN1-200, Cleveland, OH, 44195, USA

    Sylvie F. Hall

  2. Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA

    Nicole C. Wright

  3. Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA

    Nicole C. Wright & Kenneth Saag

  4. Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, University of Iowa Carver, Iowa City, IA, USA

    Fredric D. Wolinsky & Stephanie Edmonds

  5. Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA

    Fredric D. Wolinsky

  6. College of Nursing, University of Iowa, Iowa City, IA, USA

    Fredric D. Wolinsky & Stephanie Edmonds

  7. Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA

    Yiyue Lou & Michael Jones

  8. Kaiser Permanente, Atlanta, GA, USA

    Douglas Roblin

  9. School of Public Health, Georgia State University, Atlanta, GA, USA

    Douglas Roblin

  10. Faculty of Medicine, University of Toronto, Toronto, Canada

    Peter Cram

  11. Division of General Internal Medicine and Geriatrics, Mt. Sinai and UHN Hospitals, Toronto, Canada

    Peter Cram

Authors
  1. Sylvie F. Hall
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  2. Nicole C. Wright
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  3. Fredric D. Wolinsky
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  4. Yiyue Lou
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  5. Stephanie Edmonds
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  6. Douglas Roblin
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  7. Michael Jones
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  8. Kenneth Saag
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  9. Peter Cram
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Contributions

Study concept and design: Cram, Edmonds, Jones, Roblin, Saag, Wolinsky

Acquisition of data: Edmonds, Hall

Analysis and interpretation of data: Jones, Lou, Wolinsky

Drafting of the manuscript: Cram, Hall, Lou, Wolinsky, Wright

Critical revision of the manuscript: Cram, Edmonds, Hall, Jones, Lou, Roblin, Saag, Wolinsky, Wright

Statistical analysis: Jones, Lou

Obtained funding: Cram, Roblin, Saag

Administrative, technical, or material support: Edmonds, Hall, Wolinsky

Study supervision: Cram, Edmonds, Hall, Wolinsky

Corresponding author

Correspondence to Sylvie F. Hall.

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Disclaimer

Cram, Jones, Lou, and Wolinsky had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of interest

P Cram, M Jones, F Wolinsky, S Edmonds, S Hall, Y Lou, and D. Roblin have no conflicts of interest. NC Wright has received unrestricted grant support from Amgen for work unrelated to this project, and is a consultant to Pfizer. KG Saag has received grants from Amgen, Eli Lilly, and Merck and has served as a paid consultant to Amgen, Eli Lilly, and Merck.

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Hall, S.F., Wright, N.C., Wolinsky, F.D. et al. The prevalence of overtreatment of osteoporosis: results from the PAADRN trial. Arch Osteoporos 13, 103 (2018). https://doi.org/10.1007/s11657-018-0517-6

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