Dr. Daniel Ngui (biography and disclosures)
What I did before:
According to Osteoporosis Canada, as many as 2 million Canadians suffer from osteoporosis. We can share with our patients that one in four women over the age of 50 has osteoporosis and at least one in eight men over 50 also osteoporosis. Finally, less than 20% of patients with a fracture after the age of 50 are assessed and treated for osteoporosis!1 The biggest challenges are motivating our patients to prevent a fracture given it is a silent disease and even convincing those with a prior fragility fracture to initiate and continue with treatment. Given our aging population, more and more family physicians are being asked for advice about diagnosis and treatment on osteoporosis. With the time constraints of family practice, I often felt overwhelmed by identifying the right patient, pressured to give enough information, challenged to review the clinical trials and only having to rely on BMD results.
What changed my practice
These things changed my practice regarding osteoporosis management in primary care:
- 2010 Osteoporosis Canada Guidelines and free CAROC electronic mobile device 10 year risk calculator app2
- World Health Organization FRAX® website3, free online10 year risk calculator and paid app4
- 2011 BC Guidelines and Protocol Advisory Committee Osteoporosis Guidelines available for free on the web and free BC Guidelines App on iTunes5
What I do now
Facing a patient and/or their families in the examination room, the common themes family physicians face are:
- Motivating our patients by giving them an individual fracture risk assessment at the point of care
- Determining which investigations are appropriate
- Providing patients with education and resources on the disease
- Effectively counseling them on lifestyle/non-pharmacologic and pharmacologic options to treat their disease and develop a long term plan for reassessment.
By being aware and utilizing both of the BC and National Osteoporosis practice guidelines and a combination of the free and/or paid apps available, I’m able to offer my patients complementary and mostly concordant advice about identification of risk factors, their individual 10 year fracture risk and options for treatment and investigations. In fact, using either online FRAX® calculator or Osteoporosis Canada CAROC hand held device application from the point of care helps me provide my patients with an idea of their approximate 10 year absolute fracture risk if they are naïve to therapy based on Canadian data. As a family physician, you may choose one, two or all of the tools and online resources depending on your practice style and patients. Access to the guidelines from the point of care allows me to tackle the various patients concerns and questions with reference material. Also, depending on your style, you can choose to squeeze all of this into one 15 minute appointment or negotiate with our patient to come back to review separate components in manageable sections or chunks.
I like the free Osteoporosis Canada mobile app (CAROC) http://itunes.apple.com/ca/app/10-year-fracture-risk assessment/id434296900?mt=8 as it is quick and easy to use in real world practice.
Also, it is endorsed by the Canadian Radiology Association. The calculator requires the clinician enter risk factors of age, sex, history of fracture, BMD results and information on glucocorticoid use. As you enter values into the calculator, the slider on the bottom moves left and right to show you and the patient their 10 year risk for having a fracture, which helps me inform my patients about the rationale to either recommend or postpone therapy. One further button toggle and this app gives me the ability to explain the guideline recommended therapeutic options including exercise and prevention of falls, Calcium and Vitamin D recommendations and presents an easy to use table for first line recommendations for pharmacologic therapy. Finally, this IOs app gives me access to the full text guidelines, executive guideline summary, recommendations for lab investigations and factors modifying patients at moderate (10-20%) 10 year risk for fracture.
I like the free online World Health Organization FRAX® website calculator as it gives me the ability to give my treatment naïve patients their 10 year absolute risk probability of having a major osteoporotic or hip fracture. You can calculate the absolute risk with our without BMD measurement (although without a BMD value, the tool is unvalidated).
One must have access to the internet via a computer in the exam room, but you can print up the results for the patient to review. In addition, this model integrates other independent risk factors including past history of fracture, parental history of fracture, smoking, rheumatoid arthritis, and alcohol use as well as the other osteoporotic risk factors. A paid application is available, http://itunes.apple.com/ca/app/frax/id370146412?mt=8
I like the free online BC GPAC guidelines (GPAC = Guidelines and Protocols Advisory Committee) as it offers me the ability to review assessment of risk, risk stratification, lifestyle advice, therapy all in one place as well as give me access to printable patient education materials. The free mobile device osteoporosis app will be available in early April 2012.7
The bottom line is guidelines, websites and electronic apps are simply meant to support and to enhance, never replace the doctor patient relationship and communication. The information at the point of care can help me to justify my recommendations and they add some credibility. These resources can help to share the responsibility for managing this chronic disease with our patients by giving them the information for improved informed decision making.
7) http://www.sigmamenopause.com/: The Canadian Menopause society, SIGMA, is an independent, multidisciplinary group of family physicians and specialists interested in menopausal and postmenopausal health. The Sigma website has a series of FAQ documents directed to patients to answer questions about different treatments including HRT, various anti-resportive agents and bioidentical hormones.
Special thanks to Dr. David Kendler and Dr. A Papaioannou for reviewing and providing their comments and suggestions.