We performed this survey on osteoporosis care during the COVID-19 pandemic among Dutch healthcare professionals to map the problems encountered during this period. To date, this is the first national multidisciplinary survey covering this topic. The number of respondents was relatively high (n = 77), given the fact that the Netherlands harbours approximately 70 FLS-es. Another strength of the current study is the fact that the data are derived from practitioners with various professional backgrounds providing osteoporosis care and prevention.
In the Netherlands, prevention and treatment for osteoporosis in new patient arrested and 57.1% of the respondents felt that they were providing care of insufficient quality during the COVID-19 pandemic. Especially, the unavailability of DXA-scans resulted in a delay of treatment and screening as well as the closing of the outpatient clinics. Overall, osteoporosis care for follow-up patients could often, with delay and altered consultation hours often, be continued. For new patients who presented with a fracture, however, screening and therapy were delayed and sometimes not performed at all. This is unfavourable, because in the early phase after initial fracture, there is a high risk for new fracture [6].
For known patients with osteoporosis, discontinuation or significant delay of treatment was only seen in patients using intravenous bisphosphonates as they depend on hospital administration. This will, in most patients, not result in any harm if part of regular treatment. However, when given for prevention of rebound after treatment with denosumab this might be the case [7]. This was not specifically addressed in the questionnaire although many respondents indicated continuation of care as usual. Discontinuation or delay was reported for Denosumab-treated patients by 6 (6.3%) respondents, whereas 1 (1.0%) respondent indicated that patients were transferred to bisphosphonates. More precise data on this topic such as rebound fractures or time between injections are lacking as the questionnaire was not designed to address these in detail. Also, we did not cover Romosozumab as this particular agent is not yet approved for reimbursement in the Netherlands.
Until the COVID-19 pandemic, no guideline issuing organization or professional society prepared recommendations on how such a crisis should be handled in terms of ensuring deliverance of osteoporosis care. To date, several position papers have been issued but no real-life data have been presented [8,9,10].
This study did not observe major problems in continuing drug treatment but did demonstrate major issues regarding fracture prevention and osteoporosis treatment during the COVID-19 pandemic, as reflected by more untreated patients despite high FRAX® or Garvan score, the absence of DXA measurements and cancelled appointments. It seems unlikely that all these patients can be captured after a reboot of the FLS-es although the majority of respondents were rather optimistic about this. Since fragility fracture rates have not dropped during the COVID pandemic, it remains unclear if the suboptimal delivery of osteoporosis care during this substantial period of time will lead to more fractures in the future [11]. We should focus on the follow-up of new and known patients with an indication for treatment, and in general on the incidence rates of fractures in the coming years. For the Netherlands, it might be of use to explore the recently proposed addition to the FRAX® algorithm in the revision of the current guideline for Osteoporosis and fracture prevention in order to get treatment ongoing during a crisis in patients with the highest risk, as the current guideline holds a prominent place for DXA and as such many healthcare providers will not easily go pass this advice [12].
Alternative modes for care delivery were employed by respondents, such as telephone contacts and video consultations. In addition, some interventions, like subcutaneous injections were transferred to the GP. From the results of the current questionnaire, it remains unclear how large the proportion of patients is that did not receive denosumab, since no information was gathered on injections given by GPs. In order to evaluate whether the transfer of care was successful, it is important that patients should be registered appropriately so that they can be contacted after the crisis. Furthermore, it points out that a good communication system with the GP is an overlooked problem, at least in the Netherlands. With telemedicine being introduced in many more patients than before the COVID-19 pandemic, more studies on the quality of alternatives methods of provision of osteoporosis care should be performed, since the literature on the effectiveness of innovative modes of delivery is scarce [13]. Moreover, we observed differences between professions, as nonphysicians less frequently reported continuation of consultation hours via (video) call for new patients than physicians (n = 21, 47.7% vs n = 27, 81.8%, respectively) and more often reported cancellation of appointments with new patients (n = 15, 34.1% versus n = 3, 9.1%, respectively). As for control patients, the same trend was observed.
Unlike we expected, no striking differences in survey answers were observed between respondents from the southern provinces of the Netherlands, where COVID-19 incidence rates were higher, when compared to the other provinces.
This study has a number of limitations. As it was designed to address a multidisciplinary group in a rapid way, we restricted the questions to 17 so that the survey would take 5–6 min maximum to complete as we wanted to get as many responses as possible. The current number of respondents is sufficient to get an overview of changes of osteoporosis care in the Netherlands during the COVID-19 pandemic.
Second, there might be selection bias, such as health professionals experiencing problems in care or professionals more dedicated to osteoporosis care being more likely to fill in the questionnaire. However, due to the high number of respondents and the variation in answers, we consider responses truly reflecting the situation with osteoporosis care.
The COVID-19 pandemic has initiated changes in our management of chronic, not acute care, which includes osteoporosis. Not only in the Netherlands but also globally, this is observed; the online FRAX tool has been accessed 58% less when compared to the previous year [14]. During the acute phase of the pandemic, we have postponed non-urgent elective consultations, tests and even therapeutic interventions. As we now enter the chronic phase of COVID-19, we need to make plans to mitigate the potential adverse effects and prepare a solid plan for future COVID-19 or other outbreaks locally or nationally. This can be done in many ways but starts by making plans for continuing outpatient clinics physically or remotely and ensuring basic screening and treatments. Furthermore, we should focus on better communication about treatments (starting and continuing) with patients, caregivers and GPs in order to enable them to take control in their (remote) treatments, especially as recent reports show worsened outcomes of patients with hip fractures and COVID-19 infections [15, 16]. Without active planning of this chronic but important care, we might face an increase in fracture rates and a decrease in patient compliance and satisfaction in the near future.