Academics and clinicians call for national osteoporosis strategy

University of Galway researchshows osteoporotic fractures are one of the main reasons for acute public hospital admissions

Researchers at University of Galway have revealed the scale of over-treatment of people at low risk of osteoporosis and under-treatment of those most in need of medication.

Analysis of findings from a study of more than 5,000 men and women referred to the Galway University Hospital Osteoporosis service showed this "treatment gap" is much larger than prior reports suggest.

The results show the majority of men (70%) and women (54%) who are at very high risk of fracture are not on treatment, while an even greater proportion of at-risk men (80%) and at-risk women (70%) are not taking appropriate treatment.

The research is being released to coincide with World Osteoporosis Day today, Sunday October 20^th.

The international research team said a national osteoporosis programme would help address these anomalies, reduce waste in the health service, prevent harm from over diagnosis and overprescribing and improve appropriate prescribing for those most likely to benefit.

The research project is led by Professor John Carey, Professor in Medicine at University of Galway and Consultant Physician in Medicine and Rheumatology and Clinical lead in DXA, Osteoporosis and Fracture Liaison Services, Galway University Hospitals, and Associate Professor Attracta Brennan, School of Computer Science at University of Galway.

Professor Carey said: "Over-prescribing in low risk people has led to a false impression - an ecologic fallacy - that the treatment gap that we have for osteoporosis patients in Ireland is actually quite small. When treatment indications are taken into account, the gap remains unacceptably large.

"A national osteoporosis programme would help address these anomalies, reduce waste and harm for the patient and improve treatment for those most likely to benefit.

"This would make a significant improvement in the quality of care and value for money."

Ireland does not have an osteoporosis programme, although the bone disease is one of the most prevalent and disabling diseases in Ireland and accounts for almost 10% of the healthcare budget.

Following an analysis of the 5,000-plus men and women who attended the clinic, the research showed:

• Calcium and Vitamin D is widely prescribed for people concerned about their bone health despite very strong evidence that while additional supplementation has a benefit for the majority of people, it has a significant cost and can cause harm including increasing the risk of fracture.
• Calcium and Vitamin D prescribing exceeds osteoporosis medication prescribing, and costs around the same amount as osteoporosis medications which have very strong evidence to support their use (between €100 - €300 per year).
• Many 'low risk' men and women are prescribed osteoporosis medication who do not need it.
• The majority of people who should be prescribed osteoporosis medication are not.

The research team estimate the true gap for patients not receiving appropriate treatment is in the region of 60-70%.

Clinicians, computer scientists and engineers at the University of Galway are using Dual-energy X-ray Absorptiometry (DXA) technology to measure bone density and develop new screening and testing strategies for early identification of osteoporosis. The modern scanning technology assesses a person's risk before a fracture occurs; assesses their prognosis; and monitors their treatment.

Professor Carey added: "We regularly see patients in clinic who had a DXA test they did not require, following which a poor quality report and interpretation led to overtreatment and sometimes significant harm to the patient and all of the associated costs.

"On the other hand, we regularly see patients who have had a fracture and sometimes low or very low bone mineral density (BMD) who are not treated, despite multiple recommendations and overwhelming evidence that this is the group of people mostly likely to benefit from treatment.

"Furthermore, Calcium and Vitamin D are widely prescribed and overused, in the mistaken belief that they are a treatment for osteoporosis, which they are not. They are essential for good bone health, but only a treatment for deficiency or frank osteomalacia.

"A national programme which collates and is led by national experts and harmonises care based on standards and best practice for clinical staff and patients would significantly reduce waste and provide better quality care and value for money. This is something the Government should be striving for."

The University of Galway research - comparing the number of people attending for a DXA scan and those who have a DXA diagnosis of osteoporosis or an osteoporotic fracture who are not on treatment, to people who are on treatment and have no obvious reason to be on treatment - is part of the work carried out by Dual-energy X-ray Absorptiometry Management Application Project (DXA MAP), funded by the Health Research Board.

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