Remote bone health service increased osteoporosis screening in high-risk men
A centralized screening program in Veterans Affairs primary care practices used an electronic tool to identify patients at risk for osteoporosis and a nurse case manager to coordinate screening and encourage initiation of treatment and adherence to therapy.
A remote bone health service significantly improved osteoporosis screening and treatment among men, a study found.
The cluster-randomized clinical trial included 3,112 men ages 65 to 85 years who had at least one fracture risk factor but no prior fractures and were treated by 39 primary care teams in two Veterans Affairs (VA) facilities. The primary care teams were randomized to either usual care or the involvement of the remote bone health service, a centralized team that used an electronic health record case-finding tool and a nurse care manager to coordinate dual-energy X-ray absorptiometry (DXA) scanning, followed by an electronic consult with patients' primary care clinicians that included additional recommendations for treatment as needed. To promote adherence to treatment, the nurse called patients at one, six, and 12 months. Results were published by JAMA Internal Medicine on Aug. 25.
Overall, 49.2% (830 of 1,688) of the intervention group was screened for osteoporosis versus 2.3% (33 of 1,424) of the usual care group (P<0.001). More than half of those screened (51.1%) had osteopenia or osteoporosis. Of the patients found to have osteoporosis in the intervention group, 84.4% started osteoporosis treatment. They achieved high levels of adherence with a mean of 91.7% of subsequent days covered and a high persistence with a mean of 657 days over two years of follow-up. A random subset of patients in each group had a DXA scan performed 24 months after team enrollment, regardless of whether they had been screened, and the mean femoral neck T-score favored the intervention over usual care (−0.55 vs. −0.70; P=0.04).
The bone health service was associated with significantly improved osteoporosis screening, treatment, and adherence compared with usual care, with high patient and clinician acceptance, the study authors wrote. They observed that selecting men for osteoporosis screening based on clinical risk factors before a fracture occurred was high yield.
“Currently, Medicare covers DXA scans for men for only limited conditions (hyperparathyroidism, glucocorticoids, androgen deprivation, osteopenia on radiography),” the authors wrote. “The program achieved high rates of medication persistence and adherence, both of which were associated with decreased fracture rates.”
An accompanying commentary stated that while the prevalence of osteoporosis in men older than age 65 years is about fourfold lower than in women (6% vs. 27%), fractures in older men are associated with greater morbidity and mortality.
“These data strengthen the rational for a centralized approach to osteoporosis screening in men and are likely generalizable to other health systems where motivated clinicians can implement preventive treatment with the goal of reducing the morbidity and mortality associated with fractures,” the editorial stated. “In the meantime, a simple screening strategy for most older men based on previous fracture history and universal bone density screening at age 70 or 75 years is a reasonable option until additional evidence regarding more complicated risk prediction models and screening strategies becomes available.”