Opportunities to Enhance Primary Care Management of Osteoporosis: A Mixed Methods Study




Hernandez, Christian
Camp, Kathlene E.
Gandy, Laura


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Purpose: The incidence of osteoporotic fractures is greater than that of heart attack, stroke, and breast cancer combined. However, healthcare providers often focus on other comorbidities at the expense of bone health management. Primary healthcare is poised to play a significant role in protecting bone health, yet osteoporosis (OP) care is often delayed until after the initial fracture. This research aimed to determine potential gaps in primary care management of osteoporosis and to attain insight from multiple stakeholders’ experiences to understand care expectations and opportunities to enhance services.

Methods: This research was performed within a geriatric practice setting using a convergent, mixed methods study design. This study included geriatric practice specialists from multiple disciplines (n=9) and patients selected to represent both male and female genders, diverse age groups, and varying bone health diagnoses (n=9). Quantitative data was attained through a 3-year (October 2018-2020) retrospective chart review to collect patient demographics, health-related measures, and outcomes. A physician survey provided further quantitative data on practice patterns and preferences. Qualitative data was attained through physician interviews and focus groups by engaging clinicians and patients on five key topics related to care decisions, screening, intervention, care expectations, and improvement opportunities. Quantitative descriptive data was used to attain varying distribution points on demographics and alignment with performance measures and clinical practice guidelines. Additional quantitative data was evaluated for consensus through responses from a Qualtrics physician survey regarding practice patterns and preferences. Qualitative data from focus groups and physician interviews were processed in distinct stages using Ritchie and Spencer’s framework analysis. Integration of quantitative and qualitative results was achieved during analysis and interpretation.

Results: The chart review consisted predominantly of female patients, 95.9% (375/391). A diagnosis of osteopenia with and without fracture was 7.4% (29/391) and 22.3% (87/391); osteoporosis was 23.5% (92/391) and 46.8% (183/391), respectively. In the presence of osteoporosis or fracture, 44.7% (123/275) and 38.8% (47/121) were prescribed OP medication, respectively. 39.9% (156/391) presented with health conditions that could attribute the bone loss to secondary osteoporosis. 69.2% (259/372) of women ≥ 65 y.o. age and 33.3% (5/15) of men ≥ 70 y.o age had a documented dual-energy X-ray absorptiometry (DXA). Per quality metrics, 73.8% (48/65) of women aged 67-85 received a DXA and/or 43.1% (28/65) received OP medications within 6 months of fracture. Physician surveys revealed consistent practice patterns between physicians except for drug monitoring practices and comfort with using anabolic therapies. The US Preventive Services Task Force guideline was the predominant resource for OP management guidance. The focus group and interviews yielded four main themes: 1) condition awareness and fracture risk; 2) pharmacotherapy hesitancy and intervention preferences; 3) expectations of care; and 4) opportunities to enhance care.

Conclusions: The findings identified gaps and opportunities to enhance primary care osteoporosis management, reflecting all stakeholder input. The data provides insight into pragmatic approaches for future quality improvement implementation to enhance primary care management of osteoporosis.