Introduction
Osteoporosis is one of the most common chronic diseases, afflicting over 200 million people worldwide [
1]. According to the International Osteoporosis Foundation, among those aged at least 50 years, 1 in 3 women and 1 in 5 men will experience an osteoporotic fracture in their lifetime [
2‐
5]. Worldwide, osteoporosis is estimated to cause 8.9 million fractures annually; of which, hip, forearm, and vertebral fractures are the most common fracture sites [
6]. In Canada, the prevalence of osteoporosis is projected to increase in the coming years with a growing and aging population [
7]. According to the Public Health Agency of Canada (PHAC), fractures associated with osteoporosis are a main public health concern causing significant morbidity, mortality, and costs [
7].
Although osteoporosis is a prevalent disease, there has been a substantial care and management disparity, which has been classified as a crisis [
8,
9]. The Fragility Fracture Network initiated a global call to action to improve care of people presenting with low-energy fractures [
10]. According to the PHAC 2020 report focusing on trends in incidence of osteoporosis diagnoses and fracture rates between 2000/01 and 2015/16, osteoporosis diagnoses decreased over time, while fracture rates remained stable [
7]. Furthermore, among those who had an osteoporosis-related fracture, less than 20% of individuals received an osteoporosis diagnosis, bone mineral density (BMD) test, or an osteoporosis-related medication prescription within 1 year, despite effective therapy being widely available [
7]. This evidence suggests that patients and care providers are not aware or taking appropriate action to deal with the disease underlying their fracture, i.e., osteoporosis, and this has the potential to lead to under management of patients with low-energy fractures.
Practitioners have been urged to focus on improving secondary fracture prevention, since these patients are at highest risk for a future fracture. In Canada, only the provinces of Alberta and Ontario have formal government-supported fracture prevention action plans and combined, contain 83% of Canada’s fracture liaison services despite only having 50% of the country’s population [
11,
12]. In a Canadian study from Ontario focusing on the primary versus secondary fracture prevention gap, among patients who were identified as potentially at elevated risk for fracture, 62% did not complete BMD testing. The most common reasons for not receiving a BMD test were that physicians intended to order a BMD test at a later date, physicians did not think BMD testing was necessary, or the patient refused [
13]. Furthermore, among those patients with BMD tests, only 29% had completed 10-year fracture risk scores, and for patients with high fracture risk scores, 37% did not receive clinical guideline recommended osteoporosis medications [
13]. Furthermore, a real-world evidence study conducted in five European countries prior to the coronavirus disease 2019 (COVID-19) pandemic examined osteoporosis medication patterns among new users [
14]. They observed oral bisphosphonates and denosumab as the most common treatments prescribed for patients with osteoporosis, and a large proportion of patients stop treatment without starting any other new treatment thereafter [
14], further providing evidence of insufficient ongoing osteoporosis care and management.
With significant strains to the healthcare system in 2020 due to the COVID-19 pandemic, it was anticipated that osteoporosis care would be deprioritized, thus creating an even wider gap in care and management. A retrospective analysis of global google analytics data conducted between February and April 2020 found that compared to February 2020 numbers, the number of daily sessions on the FRAX® website for online fracture risk assessments fell 23.1% on March 2020 and 58.3% on April 2020 [
15]. Furthermore, a global survey of healthcare workers from 53 countries focusing on the impacts of the COVID-19 pandemic on osteoporosis care reported an increase in telemedicine consultations, and delays or interruptions in care and management, including BMD testing, supply of osteoporosis medications, and parenteral medication delivery [
16]. Specifically, 43% of clinicians reported difficulty in administering appropriate medication and only 29% of patients were able to obtain a dual-energy x-ray absorptiometry (DXA) scan for BMD testing as recommended [
16]. Prior to the COVID-19 pandemic, alendronate, one of the most prescribed oral bisphosphonates for osteoporosis, reported increased prescription uptake by new users in 2019 in Europe. However, after the COVID-19 pandemic lockdowns started on March 2020, rates of new use of alendronate rapidly decreased, with only some recovery to pre-pandemic levels after the initial lockdown (June to September 2020) [
17]. Although limited, initial evidence has shown that osteoporosis care and management may have been deprioritized because of the COVID-19 pandemic priorities and response. Additional research, particularly from a Canadian population-based perspective, will help to understand the impact of the COVID-19 pandemic on osteoporosis care and management in a Canadian setting.
The objective of this study was to describe changes in osteoporosis-related care patterns including patients with an osteoporosis-related healthcare encounter, physician visits, diagnostic and laboratory test volumes, and treatment prescription dispense patterns during the COVID-19 pandemic in Alberta, Canada, relative to the three-years preceding.
Discussion
While patients with osteoporosis-related healthcare encounters have slightly increased in 3 years prior to the COVID-19 pandemic, this study observed notable reductions in the number of patients with osteoporosis-related healthcare encounters in the first 3-month period (March to June 2020) of the COVID-19 pandemic, when public health lockdowns were implemented. The COVID-19 pandemic also impacted the management of patients with osteoporosis as observed by reductions in HCRU including physician visits, hospital- and ambulatory care-based BMD tests, laboratory tests, and osteoporosis treatment initiations and disruptions.
The current study revealed a slight increasing pattern in the number of osteoporosis-related healthcare encounters reported in each period throughout the control years. While a low number of patients with osteoporosis-related healthcare encounters was observed during the March to June 2020 period of the COVID-19 pandemic when lockdown measures were implemented, this appear to rebound once lockdown measures were removed in the June to September 2020 COVID-19 period, with the inclusion of telehealth visits, accounting for 33–36% of healthcare visits. Similar patterns were observed across the study periods in the number of patients with osteoporosis-related healthcare encounters when stratified by rural versus urban region. Interestingly, this study reveals a higher number of patients with osteoporosis treatments dispenses than patients with osteoporosis-related healthcare encounters in each period. This pattern supports the evidence suggesting a lack of application to assess patients for a diagnosis of osteoporosis, which may result in the general undermanagement of the disease as a whole.
There was an overall trend observed during the study period of stable specialist visits and increasing general practitioner visits including telehealth visits, revealing a possible shift in the management of patients with osteoporosis in Alberta. As anticipated, large reductions were observed in the number of global physicians visits during the first COVID-19 pandemic period. This aligns with the changes in health care measures implemented in Alberta on March 2020 [
18‐
20,
22]. In addition to the lockdown measures, these reductions may also be due to lack of personal protective equipment (PPE) measures in place to enable in-person visits, hesitancy for patients to visit specialists practicing within hospitals, and the practical implementation of telehealth visits. Laboratory and diagnostic test utilization were also stable across the control period with major reductions in test volumes observed during the March to June 2020 COVID-19 period. The reduction in laboratory services can be attributed to public health guidance recommending cessation of routine testing for stable community patients [
18]. BMD testing remained at reduced volumes in the June to September 2020 COVID-19 period, relative to the control periods. As a note, the BMD test volumes are based on BMD tests captured in hospital and ambulatory care settings (including emergency care and outpatient visits) across the province; therefore, changes in the use of BMD testing in community-based and private clinic settings, which represents the majority of BMD testing, were not captured in this study.
The reduction in HCRU measures observed in this study aligns with reports from other regions. A survey of health care providers from 53 countries revealed numerous institutions/clinics had closures during the pandemic, or changed services to focus on emergency care only and relied on other modes of visits to facilitate care [
16]. A greater proportion of physicians in this survey report using telemedicine appointments for established patients (40%) then for new patients (19%). Telemedicine was introduced as a billing option in Alberta on March 2020, creating this as an option for physician visits [
22], likely diminishing the impact of the pandemic lockdowns on the levels of physician visits observed. In the first 6 months of the pandemic, telehealth accounted for 33–45% of general practitioner and 36–39% of specialist visits. The use of telemedicine may vary by physician and patient, based on comfort with technology, infrastructure, accessibility, and institutional mandates [
23].
Joint guidance was released by numerous societies and organizations on the management of patients with osteoporosis during the COVID-19 pandemic [
24]. These recommendations were to limit laboratory and BMD testing when possible and utilize telehealth and altered treatment approaches to reduce the need for in-person visits. These recommendations were made to facilitate social distancing practices and aligned with the Public Health measures implemented in Alberta on March 2020 [
18‐
20,
22]. Specifically, regarding treatment, the recommendation for patients initiating osteoporosis medication was to initiate on oral bisphosphate therapy via telehealth appointments [
24]. For patients currently on treatment, the recommendation was to continue their current medication. In some cases where it was not feasible to continue treatment with injectables, treatment switches were recommended. For example, patients on denosumab were recommended to switch to oral bisphosphonates if the treatment disruption would be greater than 30 days (7 months from last administration) [
24]. Alternatively, for patients on IV bisphosphonates, delays of several months would be acceptable. While the number of patients initiating an osteoporosis treatment in the current study decreased in the March to June 2020 COVID-19 period for all three drugs reported, likely due to the reduced number of physician visits during this time, initiations of IV bisphosphonates and denosumab were observed to be greater in the June to September 2020 COVID-19 period, relative to the weighted average of the same control periods. However, oral bisphosphonates initiations remained lower during the June to September 2020 COVID-19 period than the average of the control periods. These initiation patterns support European estimates of reduced initiation of oral bisphosphates that continued past the initial COVID-19 pandemic lockdown periods [
17], but are unexpected based on the recommendations. The proportion of patients with treatment disruptions in the first period of the COVID-19 pandemic (March to June 2020) was fairly stable relative to the weighted average from the control period. In some countries, self-administration of denosumab is not in the approved product label, likely contributing to the anticipation of disruptions, and thus motivating the treatment recommendations discussed above. However, in Canada, self-administration has been approved [
25] and many patients may have already been trained in self-administration, therefore, mitigating the impact of the pandemic restrictions/lockdowns. Continued use of self-administered injectable drugs may be a strategy to help reduce treatment disruptions moving forward, outside of the pandemic, to improve patient care. Additionally, denosumab can be administered by pharmactists in Alberta precluding the need for physician visits, which may also have impacted the treatment patterns observed in this study. Lastly, many of the treatments considered in this study have long days supply; therefore, further follow-up is likely required to better assess the impact of the pandemic on osteoporosis treatment disruptions.
While lockdown measures were implemented during the first three months of the COVID-19 pandemic in Alberta, the number of COVID-19 cases and hospitalizations during this time were low. Subsequent waves of the pandemic saw much higher cases within Alberta resulting in capacity issues within the health system, warranting further analyses. Additional analyses are underway with data extended up to March 2021 to explore how osteoporosis-related clinical outcomes are associated with treatment disruptions. Additionally, longer follow-up will enable greater exploration of the trends in telehealth for patint management. The impact of shifting to telehealth on patient management and outcomes will be an important area of research to guide policy and practice patterns. Future research could also explore other osteoporosis-related laboratory tests, including serum calcium and creatinine levels. Further research focusing on these laboratory test levels in patients with osteoporosis would be valuable to examine since practitioners request these test values before initiating treatment for osteoporosis to account for any contraindications for osteoporosis-related treatments. Lastly, other areas for future research could compare regional differences in care strategies for individuals with osteoporosis and their corresponding clinical outcomes to help assess the generalizability of these findings to other regions within Canada. Such research may help inform approaches to improve the care for patients with osteoporosis and osteoporosis-related outcomes, such as fractures.
Along with future research directions, several strengths of this study should be noted. First, we used comprehensive population-based datasets, representative of the entire population of Alberta, Canada. Particularly, treatment patterns were obtained from community-based pharmacy dispensation records, which include dispensations from public, private, and out of pocket plans. Second, the repeated cross-sectional design utilized control periods three years before the COVID-19 pandemic to identify trends in the outcomes of interest. Third, examining osteoporosis-related healthcare encounters by urban and rural residence helps highlight the care gap in individuals, regardless of residency and account for variation in changes in care during the pandemic that may have occurred due to differences in COVID-19 case counts.
Although this study provided a unique opportunity to examine osteoporosis care patterns before and during the COVID-19 pandemic, there are limitations to consider when interpreting these results. First, open year data was used; therefore, the administrative data for this study had not been cleaned and validated by Alberta Health prior to analysis. Some outcomes of interest demonstrated increasing trends over the control periods; therefore, the weighted average from the control period may underestimate the percent change during the COVID-19 periods. Due to this, outcomes were also presented per period in figure format to depict the trends over time and provide a more comprehensive perspective of the potential change during the COVID-19 period. On another note, BMD test volumes are likely underestimated since our study only included BMD captured in hospital, emergency department, and outpatient care facilities. Other community-based or specialized clinics that conduct BMD testing were not captured in the administrative data. While treatment disruptions were captured during the March to June 2020 COVID-19 3-month period, reasons for these treatment disruptions are not known and only based on the follow-up data available. Therefore, it is not possible to accurately determine if patients resumed treatments after a disruption or if a disruption occurred based on long dosing intervals for some treatments (e.g., denosumab and IV bisphosphonates). Furthermore, for the treatment disruption analysis, patients in the last study period (June to September 2020) had insufficient follow-up available to meet the threshold of 60 days required to identify treatment disruptions; therefore, this data was not reported. Further analysis with extended data will help address this limitation. Lastly, the data from this study is from the province of Alberta; therefore, may not be generalizable to the rest of Canada. However, many regions within Canada imposed similar lockdown measures so these results are anticipated to provide relevant insights for such regions as to the impact on patients with osteoporosis.
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