Implementation of Pharmacy-Led Services to Identify and Treat Osteoporotic Fractures

Implementation of Pharmacy-Led Services to Identify and Treat Osteoporotic Fractures
Erica Hanson, PharmD, Cash Wise Clinic Pharmacy

Background: Osteoporosis is defined as a bone mineral density T-score of -2.5 or less, which can lead to an increased risk of fractures. Osteoporosis-related hip fractures can increase mortality by 36% within one year after the fracture occurs, and fractures increase healthcare costs and can lead to patients requiring hospitalization. Bone mineral density tests, often done with a dual-energy X-ray absorptiometry (DXA) scan, are recommended every two years for men 70 years old and older by the National Osteoporosis Foundation. However, many patients are not screened until after suffering a fracture. Patients in rural settings may have an added disadvantage obtaining DXA scans, as less services may be available and distance to see a physician may be an issue.

Purpose: This study aimed to develop and implement a service that is pharmacist and pharmacy student-led to increase DXA screening rates and treat those at high risk of fractures. It focused on education, initial assessment and plan, and coordination of follow-up care for rural veterans.

Study Design: A list of patients 70 years old and older, living in a rural or highly rural setting, and having received primary care from one Patient-Aligned Care Team at the Madison VA West Clinic was generated in January 2018. Patients were excluded if they had a prior DXA scan in the last two years, had changed providers, were residing in a hospice facility, or had died since the list was generated. Eligible patients were contacted via telephone from November 2018 to February 2020 and offered a DXA screening. The pharmacy was given results after a densitometrist reviewed completed scans. If the patient was diagnosed with osteoporosis or osteopenia, levels for serum creatinine, vitamin D, and serum calcium were also obtained. Patients diagnosed with osteoporosis and osteopenia then completed a fracture risk assessment tool (FRAX) to estimate the probability of a fracture over the next ten years to determine eligibility for medications. A flow chart was created to assist the decision-making of appropriate pharmacologic therapy with an oral bisphosphonate, vitamin D, and/or calcium. Patients with contraindications to oral bisphosphonates were referred to the specialty osteoporosis clinic.

Results: A total of 196 patients were eligible to be contacted for a DXA scan. Of those, 154 patients participated in the telephone encounter, and 115 patients completed the scan. Of the patients who completed a DXA scan, 57 (50%) were diagnosed with osteoporosis or osteopenia, and 33 (58%) were eligible for antiresorptive therapy based on their FRAX score. Of these 33 veterans, 12 (36%) were started on alendronate.

Conclusion: This study concluded that pharmacist-led osteoporosis services can help increase bone mineral density screening rates and increase the number of patients receiving pharmacologic therapy. The percentage of patients in this study who received a DXA scan increased three-fold compared to the pre-implementation DXA screening rate. Half of those screened in the study had a diagnosis of osteoporosis or osteopenia, and about a third of those patients were started on alendronate. Although a long-term endpoint of a bone fracture was not studied, initiating an osteoporosis program for rural veterans helped screen and treat patients who may not have had access to healthcare.

Key Point: Pharmacists involved with screening and initiating drug therapy for patients with osteoporosis have the potential to reduce fracture risk in older adultmale patients.

 

Reference:

  1. Wopat M, Breslow R, Chesney K, et al. Implementation of a pharmacist and pharmacy student-led primary care service to identify and treat rural veterans at risk for osteoporotic fracture]. J Am Pharm Assoc. 2021; doi:10.1016/j.japh.2021.07.011.