September 2023,Volume 45 No.3 
Original Article

How well can family physicians manage osteoporosis? A retrospective case series in a local public clinic in Hong Kong

Pui-kwan Chan 陳佩君, Vincent WS Li 李穎信, Yim-chu Li 李艷珠, Catherine XR Chen 陳曉瑞

HK Pract 2023;45:70-78

Summary

Objective: To explore the clinical effectiveness among osteoporotic patients, in terms of DEXA T-score improvement, of Multidisciplinary Osteoporosis Clinic (MOC) which was organised by primary care physicians in a local primary care clinic.
Design: A Retrospective case series
Subjects: All osteoporotic patients who had attended MOC of Kowloon Central Cluster during the period 1 January 2015 to 31 December 2018.
Main outcome Measures:
Primary outcomes:
1. Changes in DEXA T-score after two years of management at MOC.
2. Subgroup analysis: 2-year interval DEXA T-score changes among patients with or without history of fragility fracture; and among patients with or without pharmacological treatment.
3. Serial interval DEXA T-score changes of recruited patients who had completed 5 years of bisphosphonate treatment.
Secondary outcome: The occurrence of new osteoporotic fracture during two years of management in MOC.
Results: A total of 186 osteoporotic patients were recruited in this study. After two years of management at the Multidisciplinary Osteoporosis Clinic (MOC), there was an improvement in the T-scores at the lumbar spine and femoral neck, from -2.71±0.76 to -2.35±0.83 and -2.40±0.75 to -2.10±0.76 respectively (P <0.001). For subgroup analysis on patients with or without a history of fragility fracture and patients with or without bisphosphonate treatment, improvement in T-scores of both lumbar and femoral neck were all significant at two years (P <0.05).
Among those who had completed 5 years of bisphosphonate therapy, progressive improvement in T-scores of both lumbar and femoral neck were observed (P <0.001).
One patient suffered from new fragility fracture during the two-year follow up period.
Conclusions: Multidisciplinary Osteoporosis Clinic (MOC) run by family physicians in the public primary care setting could effectively treat osteoporotic patients with significant improvement in DEXA T-scores.
Keywords: Family physician, osteoporosis, primary care, multidisciplinary

摘要

目的： 探討由初級保健醫師組織的多學科骨質疏鬆症診所(MOC)在當地初級保健診所的骨質疏鬆患者中的臨床效果。
設計： 回顧案例系列
對象： 所有在2015年1月1日至2018年12月31日期間參加九龍中聯網MOC的骨質疏鬆症患者。
主要觀察指標：
主要結果：
(1) 在MOC管理兩年後DEXA T-score的變化。
(2) 亞組分析：有或無脆性骨折病史的患者2年間隔DEXA T-score變化；以及在接受或未接受藥物治療的患者中。
(3) 已完成5年雙膦酸鹽治療的招募患者的連續間隔DEXA T評分變化。
次要結果： 在MOC的兩年管理期間發生新的骨質疏鬆性骨折。
結果： 共招募了186名骨質疏鬆症患者。MOC治療2年後，腰椎和股骨頸T值分別從-2.71±0.76提高到-2.35±0.83和-2.40±0.75到-2.10±0.76 (P<0.001)。對有無脆性骨折病史的患者和有無雙膦酸鹽治療的患者進行亞組分析，腰椎和股骨頸T值在兩年時均有顯著改善(P<0.05)。
在完成5年雙膦酸鹽治療的患者中，腰椎和股骨頸的T值均逐漸改善(P<0.001)。
一名患者在兩年的隨訪期間出現了新的脆性骨折。
結論： 由家庭醫生在公共初級保健環境中運行的MOC可以有效治療骨質疏鬆症患者，DEXA T評分顯著提高。
關鍵詞： 家庭醫生，骨質疏鬆症，基層醫療，多學科

Introduction

With the ever-ageing population and longer life expectancy, osteoporosis is increasingly becoming a global health concern.1 Currently it is estimated that more than 200 million people suffer from the disease worldwide.2 Approximately 30% of all postmenopausal women have osteoporosis in the United State and Europe.3 According to a meta-analysis published in 2016, there has been an obvious increase in the prevalence of osteoporosis in China over the past 12 years (prevalence of 14.94% before 2008 and 27.9% during the period spanning 2012-2015). The pooled prevalence of osteoporosis in people aged 50 and older was 34.7%.4 In another local study, the prevalence of osteoporosis in Hong Kong Chinese females increase with age dramatically. In women aged 70 or above, over half have osteoporosis at the hip.5

Despite the enormous social and economic impact of osteoporosis and its related complication, namely fracture, osteoporosis remains under-diagnosed and under-treated worldwide.6

According to the Osteoporosis Society of Hong Kong, much of the responsibility for delivering effective treatment to osteoporotic patients falls on endocrinologists and orthopaedic surgeons in Hong Kong. With the long waiting time in specialty clinics, many patients miss the golden time for treatment, i.e. before the happening of fragility fractures and its associated morbidity and mortality. Meanwhile, our counterparts in Australia play a major role in managing osteoporosis in the community.7 We believe family physicians in Hong Kong can also take on an active role in combating osteoporosis. Therefore, a dedicated Multidisciplinary Osteoporosis Clinic (MOC) was set up at Yau Ma Tei Family Medicine Specialist Clinic (FMSC), Department of Family Medicine & General Outpatient Clinic of Kowloon Centre Cluster (FM & GOPC, KCC) in 2010. The objective of setting up this clinic was to provide comprehensive management for osteoporotic patients within the primary care setting and to enhance community-based care. However, to date, studies are lacking in the evaluation of the clinical effectiveness, in terms of improvement in bone mineral density (BMD), of osteoporosis management by primary care physicians.

Objective

This study aims to evaluate the clinical effectiveness of MOC, in terms of DEXA T-score improvement of osteoporotic patients. Through MOC, we believe we could provide effective treatment to patients and fill the service gap in osteoporosis management in Hong Kong.

Methods
The multidisciplinary osteoporosis clinic (MOC)

Patients with confirmed osteoporosis or osteoporosis related conditions such as history of fragility fractures were referred to MOC for further management. The referring source was mainly from different GOPCs of KCC and other primary care providers in Hong Kong. This multidisciplinary clinic was specially designed to cater the needs of osteoporotic patients.

Patients referred to the clinic were invited to a Community Based Specialty Nursing Session which included a health talk on osteoporosis and an individual counselling session. Fracture risk assessment tool (FRAX), a scoring system assessing one’s 10-year osteoporotic fracture risk based on the individual’s clinical risk factors as well as BMD at the femoral neck8, was used and FRAX score was calculated during the session. Advice was given accordingly.

After the nursing educational session, a doctor consultation session was arranged in the following weeks. Doctors conducting the consultation acquired at least fellowship qualification of both Hong Kong College of Family Physicians (HKCFP) and Royal Australian College of General Practitioners RACGP (RACGP). In addition, they were trained and equipped with updated knowledge regarding osteoporosis management via a training session. The consultation time was on average 15 minutes per patient, which was longer than the 7-minute consultation time in GOPC. This was to ensure sufficient time had been given to attending doctors to formulate a comprehensive and whole-person management plan with patients.9 Exercise and nutrition are essential elements in combating osteoporosis. Therefore, allied health services such as dietitian counselling, physiotherapy and occupational therapy was included in the management plan as needed.

Bisphosphonates are recommended as first line treatment in most guidelines including the National Osteoporosis Foundation (NOF) guidelines and the American Association of Clinical Endocrinologists (AACE) guidelines.10,11 Oral alendronate is the only pharmacological agent that can be reimbursed via the Hong Kong Hospital Authority (HKHA) for patients with a history of osteoporotic fracture. Therefore, guideline directed medical therapy, namely alendronate was regularly prescribed in our clinic. Calcium and Vitamin D supplement were also regularly prescribed.

Dual X-ray absorptiometry (DEXA) scan was performed upon joining MOC, i.e. baseline DEXA scan. It was repeated after 1-2 years of initiating pharmacological treatment and every 2 years thereafter if BMD had been stabilised or improved, compatible with most guidelines’ recommendations.10-12 After 5 years of bisphosphonate therapy, patients were offered a drug holiday.

To ensure uniform data comparisons, patients were urged to have their DEXA scans repeated in the same diagnostic center, assuming the same DEXA machine was used. Doctor follow up appointment was arranged depending on clinical needs.

Study Design

Retrospective case series study conducted in a FM (Family Medicine) clinic in the public setting

Subject

Inclusion criteria
All osteoporotic patients, coded by International Classification of Primary Care (ICPC) L95 (osteoporosis) , who had a t tended MOC of the Department of FM & GOPC, KCC from 1 January 2015 to 31 December 2018.

Exclusion criteria
  1. Osteopenia patients
  2. Osteoporotic patients due to secondary causes such as osteoporosis due to endocrine diseases or corticosteroid use
  3. Osteoporosis patients who had been followed up by other specialists or private doctors
  4. Osteoporotic patients who had been treated with osteoporosis medication before joining MOC, Osteoporosis medication means any type of bone antiresorptive and anabolic drugs, not including vitamin D and calcium supplement
  5. Osteoporotic patients who had no baseline DEXA scan
  6. Osteoporotic patients who had no interval DEXA scan

Definition of Osteoporosis
Dual X-ray absorptiometry (DEXA) is the gold standard and most precise technique for BMD (Bone mineral density) measurement.13 Osteoporosis was defined as DEXA T-score of ≤ -2.5, according to the World Health Organization.14

Determination of variables
The recruited patients’ age, gender, ethnicity, smoking status, drinking status, body mass index (BMI), family history of fracture, past history of fracture, other past medical history or co-morbidities, menopausal status (for female), age of menopause, FRAX score were retrieved from nursing consultation notes of Clinical Management System (CMS) of HKHA. The BMI was calculated as body weight (kg)/body height2 (m2). The patient was considered a smoker if he/she was an active smoker or had quit smoking within 6 months. Baseline blood test including complete blood count, liver function test, calcium level, phosphate level and thyroid function test of patients were collected from the CMS (Clinical Management System) of HKHA (Hong Kong Hospital Authority).

Baseline and 2-year interval DEXA T-scores were collected. Baseline DEXA T-score was the T-score of DEXA scan performed upon joining MOC, within one year before or after first doctor consultation. The 2-year interval DEXA T-score was the T-score of the DEXA scan performed at or nearest to 2 years after joining MOC. The serial interval T-scores of those who had completed 5 years of bisphosphonate were collected. These data were retrieved from doctor consultation notes from CMS of HKHA. If in any doubt, the original copy of DEXA report was referred to. The occurrence of new osteoporotic fractures documented in the consultation notes was also recorded.

Study Design

Primary outcomes
  1. Changes in DEXA T-score of recruited osteoporotic patients after two years of management at MOC.
  2. Subgroup analysis: 2-year interval DEXA T-score changes among patients with or without history of fragility fracture; and among patients with or without pharmacological treatment
  3. Serial interval DEXA T-score changes of recruited patients who had completed 5 years of bisphosphonate

Secondary outcome
The occurrence of new osteoporotic fracture of recruited osteoporotic patients

Sample size calculation
From previous studies, the mean BMD difference between treatment and non-treatment group was 0.03 g/ cm2, with a SD of 0.13.15,16 At 95% confidence level and a power of 0.8, with the use of paired sample T test for sample size calculation, the sample size required is 147. To allow the room for data exclusion (~20%), totally 186 patients were included into the data analysis.

Statistical Methods
All data were entered and analysed using a computer software (SPSS version 23, Chicago, IL, US). Categorical variables were presented as frequencies and percentages. Continuous variables were presented as mean, plus standard deviation. Paired Student’s t test was used to analyse continuous variables. All statistical tests were two-sided, and a P value of <0.05 is considered significant.

Ethical approval
This study was approved by the Hong Kong Kowloon Center / Kowloon East Cluster Research Ethics Committee, with reference number: KC/KE-18- 0183/ER-1.

Results

A total of 507 patients with ICPC coding L95 (osteoporosis) attended MOC during the period 1/1/2015 to 31/12/2018. In the final data analysis, 186 patients were included. Among the 321 excluded patients, majority of them were excluded because they had been treated with osteoporosis medication by other doctors before joining MOC (N=160, 50%) or they had no interval DEXA scan performed during the study period (N=102, 32%). The flowchart of case recruitment is summarised in Figure 1.

Among the 186 recruited patients, majority of them are Chinese females, with a mean age 66.2 +/- 8.3 years old. The demographics of the patients are summarised in Table 1.

Furthermore, there were 39 patients who had a personal history of fragility fracture (21.0%). Among them, 15 suffered from spinal collapse (38.5%), 9 had history of distal radius fractures (23.1%), 4 had proximal humerus fractures (10.2%), 3 suffered from metatarsal fractures (7.7%), and 2 suffered from hip fractures (5.1%).

Baseline blood test showed 12 out of 186 patients had anaemia. Six patients were thalassemia carrier, 1 suffered from per rectal bleeding, and the remaining 5 had no identified cause for the anaemia. The baseline liver, calcium, phosphate and thyroid hormone levels were normal.

The mean baseline DEXA T-score of lumbar spine and femoral neck were -2.71±0.76 and -2.40±0.75 respectively. While the FRAX score was 10.3±8.0% for major osteoporotic fracture and 4.0±5.3% for hip fracture. The baseline T-score and FRAX score for different age groups of patients were summarised in Table 2.

After 2 years of management via the MOC, T-scores of recruited patients simproved from -2.71±0.76 to -2.35±0.83 at lumbar spine, and from -2.40±0.75 to -2.10±0.76 at femoral neck, which were both statistically significant (P<0.001).

Subgroup analysis of patients with a history of fragility fracture showed that the baseline T-scores were lower at both the lumbar and femoral neck region compared to those without any history of fragility f racture, which were -2.96±0.77 and -2.57±0.72 respectively. Improvement i n T-scores o f both lumbar (P<0.001) and femoral neck (P=0.0017) were significant at 2-year follow up. For those without a history of fragility fracture, improvement in T-score of both lumbar and femoral neck were also observed (P<0.001). Among the 186 patients, 153 of them (82.7%) received osteoporosis drug treatment, namely bisphosphonate via the MOC. While 33 of them (17.3%) had not received drug treatment and were on life style modifications. Subgroup analysis of those who received pharmacological treatment showed significant improvement in the T-scores of both lumbar and femoral neck (P<0.001). While those who were on lifestyle modifications without drug treatment also enjoyed T-scores improvement at both lumbar spine (P<0.001) and femoral neck (P=0.025).

The 2-year interval T-score changes of patients were summarised in Table 3.

During the follow up period, 46 patients received and completed 5 years of bisphosphonate therapy. Progressive improvement in T-scores of both lumbar and femoral neck were observed. The interval T-scores of lumbar spine and femoral neck during the 5 years of drug treatment were shown in Figure 2.

Regarding the secondary outcome, 1 out of the 186 osteoporotic patients suffered from a new osteoporotic fracture within the 2-year follow-up period. The incidence rate was 2.7 cases per 1000 person-years. This patient suffered from a left hip fragility fracture after two years of oral alendronate.

Discussion

To our knowledge, no similar team based management model in primary care for osteoporotic patients has been described. In this retrospective case series analysis, we demonstrated that a dedicated team led by primary care physicians could significantly improve the bone mineral density of osteoporotic patients. Our patient demographics are in line with that of other studies on osteoporotic patients conducted in china and Asia.17-19 The results of our study were very promising in that the DEXA T-scores of the recruited patients improved significantly in both lumbar and femoral neck (P<0.001). Over 80% of osteoporotic patients joining the MOC were started on osteoporosis drug treatment which was significantly higher than the treatment rate of previous studies.20 For patients with pharmacological treatment, predominately treated with alendronate, their 2-year interval T-score improved 0.38SD (from -2.76 to -2.38) at lumbar spine and 0.33 SD (from -2.45 to -2.12) at femoral neck, which were comparable with other published clinical studies.21-23 Furthermore, subgroup analysis of patients who were not on drug treatment also showed significant improvement in T-scores of both lumbar and femoral neck. This suggests that the T-score changes and BMD improvements could not be solely explained by the pharmacological effect of bisphosphonates but also by the comprehensive service provided by the MOC.

The reasons why this MOC is highly effective in improving BMD of patients is multi-factorial. First of all, the MOC is a well-designed clinic tailored to manage osteoporotic patients in the community. Comprehensive, continual and coordinated care plan could be delivered proficiently by the primary care team in the MOC. Secondly, management plan offered to each patient is very individualised in the MOC. Our nurse would meet every patient during the individual counselling session and give personalised advice. With a longer consultation time, doctors can also formulate a whole-person management plan with patients. Thirdly, doctors who have attended the MOC are relatively experienced family physicians and were equipped with updated knowledge on osteoporosis management.

Previous research on doctors’ barriers on osteoporosis treatment have revealed that a lack of knowledge on osteoporosis drug treatment and specifically its adverse effects may deter many doctors from treating the disease.24-25 By centralising this group of osteoporotic patients to the MOC with dedicated doctors and team players, many of these obstacles of care could be overcome, resulting in improvement in outcomes.

This study has several strengths. This is the first study ever in the primary care of Hong Kong to evaluate the effectiveness of a community based osteoporosis clinic, in terms of DEXA T-score changes in osteoporotic patients. Previous studies published mainly focused on the detection and treatment rate of osteoporosis6,20,26 or tried to explore factors preventing the delivery of effective osteoporosis treatment to osteoporotic patients.20,27 Our study is comprehensive and impactful in terms of the outcome measurements. It assessed not only the treatment rate of osteoporotic patients but also the changes in their BMD and the occurrence of fall during the follow up period, which are important parameters directly influencing the mortality and morbidity brought about by the disease. Another strength of the study is that the clinical data were precisely documented and complete, by using preset templates and the CMS of HKHA. Doctors would also document patients’ clinical condition, DEXA scan results and blood investigation reports in consultation notes of the CMS with a similar format. These measures minimised the possibility of missing data or recall bias.

There are some limitations in this study. Firstly, a large proportion of patients were excluded from the final data analysis, which might result in selection bias. The majority of the patients excluded had been treated with bone resorptive agents before joining MOC (N=160) or they had no interval DEXA scan within the follow up period (N=102). Bone resorptive agents could have lasting effects on residual BMD and fracture prevention despite stopping the drug.28-29 A patient’s DEXA T-score change after joining the MOC could be related to previous treatment instead of the true effect of the MOC, therefore were excluded. We believe this treatment naive group could provide a fair reflection of the effectiveness of the MOC. Secondly, this study was carried out in a single public primary care clinic in HA and therefore, the results of this study may not be generalised to all primary care clinics in HK or in the private setting. In addition, most patients followed up in the MOC had to pay for their own drugs and DEXA scans as they were not readily available from HKHA for free, except for osteoporotic patients with a past history of fragility fracture. Therefore, those who continued to attend follow-up in the MOC could well represent a group of patients who were more health conscious and financially capable. Thirdly, since this is a retrospective study without a control group, we should be cautious in attributing all the positive outcome to the effect of the MOC. However, available literature has reported that age-related T-score of Chinese women who are treatment naive deteriorates with age.30 Hence, despite the lack of a control group, in view of the significant improvements in the T-score of patients who joined the MOC, especially in the non-pharmacological group, it is justifiable to credit improved BMD of osteoporotic patients to the effective management at the MOC.

Conclusion

With its growing incidence and increasingly significant complications, osteoporosis represents a major burden to healthcare. This study provided invaluable evidence that a multidisciplinary osteoporosis clinic run by dedicated family physicians in a public primary care setting can effectively treat osteoporosis patients with significant improvement in T-scores. We believe that, based on the findings of this study, an integrated, comprehensive and multi-disciplinary service model could be developed in primary care to meet the service demand in managing osteoporosis patients in the community.

Acknowledgement

We would like to express our sincere gratitude to all medical staff and nursing staff for their professional service at MOC of YMT FMSC.

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Pui-kwan Chan, MBchB, FHKCFP, FRACGP, FHKAM (Family Medicine)
Resident Specialist,
Department of Family Medicine & General Outpatient Clinic, Kowloon Central Cluster,
Hospital Authority Hong Kong

Vincent WS Li, MBBS, FHKCFP, FRACGP, FHKAM (Family Medicine)
Consultant,
Department of Family Medicine & General Outpatient Clinic, Kowloon Central Cluster,
Hospital Authority Hong Kong

Yim-chu Li, MBBS, FHKCFP, FRACGP, FHKAM (Family Medicine)
Chief of Service and Consultant,
Department of Family Medicine & General Outpatient Clinic, Kowloon Central Cluster,
Hospital Authority Hong Kong

Catherine XR Chen, MRCP(UK), PhD(Med, HKU), FRACGP, FHKAM (Family Medicine)
Consultant,
Department of Family Medicine & General Outpatient Clinic, Kowloon Central Cluster,
Hospital Authority, Hong Kong.

Correspondence to: Dr. Pui-kwan Chan, Room 807, 8/F, S Block, Queen Elizabath Hospital,
Hong Kong SAR.
E-mail: cpk241@ha.org.hk