Factors affecting Patient Compliance in the Treatment of Osteoporosis.

Purpose/Aims

To evaluate the incidence of patients declining osteoporotic pharmacologic treatment and to identify factors affecting patient refusal or deferment of treatment options.

Rationale/Background

Patient consumption of recent literature on the side effects of osteoporosis treatment protocols has dropped the usage of medications such as bisphosphonates by as much as half. This has posed a considerable obstacle in the proactive treatment of osteoporosis and the prevention of fractures.

Methods

Researchers studied data from 412 patients from a community-based primary care clinic who had undergone screening for osteoporosis utilizing a bone density or DEXA scan. The criteria for identifying individuals as having osteoporosis was based on International Osteoporosis Foundation criteria, which states that the threshold for qualification is a T-Score of less than or equal to -2.5 in one or more regions or the occurrence of a fragility fracture of the hip or vertebra. Of the 412 patients, 134 patients were confirmed to have had osteoporosis based on this criteria. Patient consent to treatment, side effects, reasons for refusal, and incidence of fractures were recorded for those 134 patients.

Results

Of the 412 patients screened for osteoporosis, 83.9% were female (346/412), and 16% (66/412) were male. The average age for the sample group was 68.5 (68 for females and 73 for males), which is in line with expectations given that post-menopausal women are thought to be the population that requires the screening the most. There were 134 patients who were diagnosed with osteoporosis, and the average age of a person in that group was 71 (70 for females and 81 for males). The average T-Score on a bone density scan for those individuals was -2.8. There was no preference for which region (lumbar vs. hip) was most affected within the group studied. Of the 134 patients diagnosed with osteoporosis based on bone density scan results, 67.9% (91/134) agreed to start and continue a treatment plan for osteoporosis. While 28.4% (38/134) refused treatment for osteoporosis, 97% of that group(34/38) said the reason was lack of insurance or a high deductible on their plan. Only four people out of the group that refused treatment ended up stating that they preferred natural remedies for their condition. There was no evidence based on records that any of the patients experienced any side effects due to the treatment regimen. However, there were 5 cases where patients had fractures before the start of their respective treatments. Among the patients, there was a striking preference for Prolia (denosumab) as the treatment plan, with 68.1% (62/91) electing for that exclusively, whereas only 29.7% (27/91) elected to receive Reclast (zolendronate) exclusively. Only five people (5/91) elected for oral bisphosphonates.

Implications

A strong patient advocacy team appears to be the key to increasing patient compliance to osteoporotic treatment plans. This encompasses discussions between patient and provider, addressing the cost of drugs, and doing the due diligence necessary to acquire prior authorizations for medications. Treatments that are easier to administer are preferred by both patients and providers as seen by the high usage of Prolia (denosumab). However, oral bisphosphonates were generally declined based on the perceived potential for gastrointestinal side effects. Insurance coverage issues and cost to the patient remain the top reasons for refusing non-oral options. While patients did express a level of apprehension to begin the treatment because of the perceived side effects, they appeared to overcome these barriers more easily than the primary reasons for refusal. It should be noted that a very low number of patients actually ended up electing to go for the natural course of treatment within our study (just 4 patients). While incidence of side effects such as jaw necrosis and atypical fractures near the top of the femur seem rare, many people are hesitant about using bisphosphonates. These effects are possible, but are not generally observed, especially in the first five years of treatment.