Menopause Live (11 October, 2010) from IMS 

The prevention of fractures caused by fragility associated with osteoporosis requires long-term treatment and, therefore, patients must adhere to their therapy. Many factors have an influence on the decision to initiate and adhere to osteoporosis treatment. In a recently published study, Brask-Lindemann and colleagues [1] evaluated patient understanding of the results of their diagnosis by dual-energy X-ray absorptiometry (DXA) and their beliefs in the effects of therapy, in order to measure what influence this understanding had on their decision to initiate and to persist with osteoporosis therapy.

The study included 1000 consecutive men and women who were referred for DXA scanning by their general practitioner (GP), according to local guidelines, over a period of 14 months. All referrals were reviewed by an endocrinologist to determine whether the patients met the referral criteria and no patients were excluded.

Risk factors, medical history, alcohol consumption and smoking history were assessed through a self-administered questionnaire at the time of the DXA examination. An osteoporosis specialist reviewed the DXA results and risk factor profile and entered these data into a database to diagnose patients, based on the lowest T-score of the femoral neck and the anterior/posterior lumbar spine, and the presence of low-energy fractures, as being: osteoporotic (T-score ≤ 2.5 and/or one or more low-energy fractures regardless of the T-score); osteopenic (T-scores between -2.5 and -1 SD; or normal (T-score values above -1 SD).

Standardized information letters were mailed to patients based on this diagnosis, and identical information was communicated electronically to the referring GP. The letters included the diagnosis as well as individual treatment and lifestyle recommendations. All patients were encouraged to discuss the results with their GP, and those who had been diagnosed with osteoporosis were encouraged to talk with their GP in order to initiate treatment. This process did not involve any personal contact between the patient and the osteoporosis specialist. One year after, a questionnaire was mailed to all patients with multiple-choice questions about the DXA test results, health status, follow-up with referring physicians, current and past osteoporosis treatment, and, if they had stopped pharmacotherapy, why they had stopped it. In addition, the perceptions of the patient were measured regarding osteoporosis pharmacotherapy.

Of the 1000 patients who had DXA scans, 717 (72%) responded to the questionnaire. The agreement between self-reported and actual DXA results was very good (κ = 0.83). Of the patients with osteoporosis and osteopenia, 80% correctly reported their diagnosis, and patients with a normal bone mineral density reported the correct diagnosis in 86% of all cases. Of the patients who answered the questionnaire and who reported the correct DXA diagnosis and to whom treatment was recommended, 83% initiated treatment. Of the patients who initiated therapy, 89% were still undergoing treatment 1 year later. The patients who had a better understanding of the benefits of therapy were more likely to initiate treatment (odds ratio (OR) 1.4; 95% confidence interval (CI) 1.1–1.9; p = 0.0006) and to persist with therapy after 1 year (OR 1.8; 95% CI 1.2–2.7; p = 0.006). The authors concluded that patient understanding of their diagnosis may be improved by communicating the results of their diagnosis in writing. This definitely improves osteoporosis management and prevention.

Comment
Persistence with osteoporosis therapy remains relatively low and decreases significantly during the first months after treatment initiation. The final decision to initiate and persist with treatment is primarily the patient’s decision and it has been suggested that this decision, in the case of osteoporosis, is significantly influenced by the accessibility of a diagnosis through bone densitometry [2,3] to the adequate interpretation of the results [4] and by the beliefs of the patient in the effectiveness of the treatment [5].

In this study, the absence of a control group did not allow us to assess the behavior of a similar group of patients, to whom an additional written report was not given. However, the results indicate that educational interventions, to increase patients’ understanding of their pathology and the interpretation of DXA results, increase the initiation and maintenance of treatment because the interventions allow a better perception of the benefits obtained from the therapy [1,6].

The impact of correct self-understanding of the DXA results on adherence to treatment will depend to a great extent on the patient’s degree of information and education [7]. In this study, the results could have been influenced by a selection bias since patients were referred to a specialized center for the diagnosis of osteoporosis. In addition, the patients were well educated, favoring a potential better perception of the results. However, this basic understanding may improve with a physician-patient dialogue and discussion of the results, and the need to initiate and adhere to therapy. Better self-interpretation should be expected if the written DXA reports include an explanation of the meaning of the individual results and suggested management when appropriate, based on the person’s fracture risk. 

Health-care systems should provide citizens with the possibility of an early DXA diagnosis and, according to its results, should offer individual therapeutic options to each person, according to her/his risk, on the one hand [1], and local health policies on the other hand. Patients’ lack of understanding of their illness may produce an erroneous perception that they do not need the treatment, especially if they are asymptomatic, and this may cause doubts as to the real need to initiate and maintain treatment in order to achieve the benefits expected from it. Other studies have also suggested that, in order to improve adherence to interventions, the interventions must be patient-oriented [8,9].

Carmen Troya
Department of Obstetrics & Gynecology, Hospital Punta Pacífica, Panama, Republic of Panama

References
1. Brask-Linderman D, Cadarette SM, Eskildsen P, Abrahamsen B. Osteoporosis pharmacotherapy following bone densitometry: importance of patient beliefs and understanding of DXA results. Osteoporos Int 2010 August 4. Epub ahead of print.
http://www.ncbi.nlm.nih.gov/pubmed/20683704
2. Cadarette SM, Gignac MA, Jaglal SB, Beaton DE, Hawker GA. Access to osteoporosis treatment is critically linked to access to dual-energy x-ray absorptiometry testing. Med Care 2007;45:896-901.
http://www.ncbi.nlm.nih.gov/pubmed/17712261
3. Pressman A, Forsyth B, Ettinger B, Tosteson AN. Initiation of osteoporosis treatment after bone mineral density testing. Osteoporos Int 2001;12:337-42.
http://www.ncbi.nlm.nih.gov/pubmed/11444079
4. Pickney CS, Arnason JA. Correlation between patient recall of bone densitometry results and subsequent treatment adherence. Osteoporos Int 2005;16:1156-60.
http://www.ncbi.nlm.nih.gov/pubmed/15744452
5. Yood R, Mazor K, Mazor K, et al. Patient decision to initiate therapy for osteoporosis: the influence of knowledge and beliefs. J Gen Intern Med 2008;23:1815-21.
http://www.ncbi.nlm.nih.gov/pubmed/18787907
6. Van Dulmen S, Sluijs E, Van Dijk L, et al. Patient adherence to medical treatment: a review of reviews. BMC Health Serv Res 2007;7:55.
http://www.ncbi.nlm.nih.gov/pubmed/17439645
7. Cadarette SM, Beaton DE, Gignac MA, et al. Minimal error in self-report of having had DXA, but self-report of its results was poor. J Clin Epidemiol 2007;60:1306-11.
http://www.ncbi.nlm.nih.gov/pubmed/17998086
8. Warriner AH, Curtis JR. Adherence to osteoporosis treatments: room for improvement. Curr Opin Rheumatol 2009;21:356-62.
http://www.ncbi.nlm.nih.gov/pubmed/19412103
9. Shu AD, Stedman MR, Polinski JM, et al. Adherence to osteoporosis medications after patient and physician brief education: post hoc analysis of a randomized controlled trial. Am J Manag Care 2009;15:417-24.
http://www.ncbi.nlm.nih.gov/pubmed/19589009