Multimodal Educational Program to Reduce Osteoporosis Risk

Jill Stein

May 13, 2011

May 13, 2011 (National Harbor, Maryland) — A multipronged educational intervention can help pulmonary specialists follow osteoporosis management guidelines in their older patients with chronic obstructive pulmonary disease (COPD) and asthma, investigators reported here at the American Geriatrics Society 2011 Annual Scientific Meeting.

Patients with COPD and asthma are at increased risk for osteoporosis because of their prolonged use of corticosteroid therapy.

The study found that academic pulmonary specialists at Beth Israel Deaconess Medical Center, in Boston, Massachusetts, had a 19% increase (P = .003) in their rate of adherence to osteoporosis screening, prevention, and treatment recommendations after the intervention.

Dr. Mark Simone

"Any provider who prescribes steroids to older patients could benefit from this intervention," Mark Simone, MD, a geriatrician and clinician educator at the Harvard-affiliated Mount Auburn Hospital in Cambridge, Massachusetts, told Medscape Medical News. "In addition to pulmonologists, other providers likely to prescribe oral steroids include primary care doctors, rheumatologists, orthopedic surgeons, and dermatologists."

The intervention included a virtual patient module as an interactive media tool, clinic posters to serve as visual reminders, pocket management cards to provide easy access to information, and individual report cards to record performance data.

Long-Term Corticosteroid Use

The use of glucocorticoids in patients with COPD and asthma increases the risk for osteoporosis, Dr. Simone explained. Systemic corticosteroids, even prescribed at a low dose for short-term use, are known to decrease bone formation and increase bone resorption and fracture risk. High-dose inhaled corticosteroids might also be deleterious.

However, several effective treatments are available; bisphosphonates, in particular, have been shown to benefit patients with glucocorticoid-induced osteoporosis and patients with chronic lung disease, he added. Unfortunately, research has shown that high-risk patients often do not receive appropriate screening, prevention, or treatment for osteoporosis. Pulmonologists frequently prescribe glucocorticoids for chronic lung disease, and the need for pulmonologists to be more aware of osteoporosis and to better use preventive strategies has previously been identified.

Dr. Simone and his coworkers reviewed the medical records of a random selection of 190 first-time or repeat COPD or asthma outpatients to determine the rates of adherence to bone health guidelines by the pulmonary specialists who treated them.

The pulmonary specialists were 19 physicians and 1 nurse practitioner from the division of pulmonary medicine, critical care, and sleep medicine at Beth Israel Deaconess Medical Center.

Overall, 78 patients (53 women and 25 men) 50 years or older were maintained on chronic oral or high-dose inhaled corticosteroid therapy and therefore satisfied the inclusion criteria.

Intervention Boosts Adherence

Before the intervention, 45% of pulmonary specialists adhered to the guidelines, which include medication for osteoporosis, calcium and vitamin D therapy, bone density screening, and estrogen replacement hormonal therapy. The adherence rate increased to 64% after the intervention (P = .003).

Notably, the study is the first to demonstrate that an educational intervention can produce significant and sustained improvement in provider adherence to osteoporosis management guidelines, Dr. Simone observed.

He cautioned that because the participants were a small group of academic pulmonary specialists, it might not be possible to extrapolate the results to clinicians who practice in other settings. He was quick to emphasize, however, that the findings are sufficiently robust to demonstrate convincingly the efficacy of the intervention.

Also, the lack of a control group raises the possibility that the pulmonary specialists might have been exposed to factors unrelated to the intervention that motivated them to adhere to the guidelines.

Finally, Dr. Simone noted that adherence rates might be even higher with the addition of patient-specific automated prompts in the electronic medical record system, or by creating incentives to perform better (such as compensation incentives or by encouraging competition among peers).

Amy R. Ehrlich, MD, interim chief of the division of geriatrics, and geriatrics fellowship program director at Montefiore Medical Center and Albert Einstein College of Medicine in Bronx, New York, told Medscape Medical News that "pulmonary specialists are definitely an interesting group to target for an educational intervention on osteoporosis. . . . While pulmonologists may prescribe steroids, bone health is not part of their main clinical arena."

She added that "it's not that the pulmonologist doesn't know that a patient on chronic prednisone needs bone healthcare, but rather that the pulmonologist may think that one of the patient's other physicians is managing his or her bone health. For example, the pulmonary specialist assumes that the primary care physician is doing it, and the primary care physician may not see the patient as often because the patient is primarily seeing his or her pulmonologist. Ultimately, things get lost in the healthcare maintenance of patients who are at risk."

The study was funded by the Donald W. Reynolds Foundation for the Advancement of Geriatrics Education at Harvard Medical School. Dr. Simone reports receiving an honorarium for developing an online educational module for the Fenway Community Health Center in Boston, Massachusetts. He and coauthor Zaldy Tan, MD, have been supported by the Health Resources and Service Administration Geriatric Academic Career Award. Dr. Ehrlich has disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2011 Annual Scientific Meeting: Abstract B67. Presented May 12, 2011.


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