OSTEOPOROSIS CHOICE Decision Aid Spyridoula Maraka, MD Mayo Clinic

CLINICAL CASE 67 year-old Caucasian female comes for preventive medicine visit History significant for type 2 diabetes-well controlled on metformin No personal/family history of fracture No history of malabsorption or thyroid disease Menopause 15 years ago, no hormone replacement therapy Denies alcohol/smoking Two dairy servings/day, calcium carbonate 600 mg+vitamin D 1000 IU daily

CLINICAL CASE (con’t) 25-hydroxy Vitamin D level 35 ng/mL, normal CBC, calcium level, and electrolytes Bone density: Left femur neck T-score: -2.2 Right femur neck T-score: -2.6 Lumbar spine T-score: - 2.9

INTRODUCTION Bisphosphonates can reduce the risk of osteoporotic fracture in postmenopausal women Many women at high risk for fractures choose not to initiate treatment Up to 50% of women discontinue treatment in less than 1 year

INTRODUCTION Failure to reduce the risk of osteoporotic fractures can increase healthcare costs and decrease quality of life/life expectancy Poor adherence: due to unexplored patient values or lack of understanding of the efficacy and safety of treatment Decision aids: effective at improving knowledge acquisition and reducing so-called decisional conflict

Osteoporosis Choice Single-sheet printed decision aid Pictograph of patient’s estimated 10-year risk of a major fragility fracture (using FRAX) Pictograph of how this risk is reduced by bisphosphonates List of adverse effects Estimation of oral bisphosphonates out-of-pocket costs Designed for use between patients and their clinicians

Osteoporosis Choice Improved the quality of clinical decisions about bisphosphonate therapy in at-risk postmenopausal women Did not affect start rates May have improved adherence

CALCULATE RISK

Type 1 diabetes, premature menopause, chronic malabsorption, hyperthyroidism, hypogonadism

BACK TO OUR CASE..

Major Osteoporotic Fracture-10 year risk

Hip Fracture-10 year risk

Intervention

Intervention

Issues

Issues

Issues

Notes

Questions What is the potential value of shared decision making and the use of osteoporosis treatment decision aids in osteoporosis in the context of quality improvement strategies and pay for performance systems? http://osteoporosisdecisionaid.mayoclinic.org/