Email UpdatesThe ASPIRE osteoporosis management guidance will be accessed in the EHR in the context of existing primary care workflows. This will facilitate provider and patient review of risk factors and pharmacological interventions needed, provide talking points for patient education and engagement, and provide a platform for prioritizing interventions that the patient agrees to implement. The final osteoporosis management care plan is saved as a note in the EHR and provided to the patients as a printout or in the after-visit summary.
Artifact Creation and Usage
- Patricia Dykes
- Robert Lucero
- Nancy Latham
- Pam Neri
- Tien Thai
- Hannah Rice
- Denise Schentrup
- Ragnhildur I Bjarnadottir
- Kristen Shear
This CDS artifact and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH), University of Florida Research Foundation, Inc (UF), and Regents of University of California (UC). BWH/UF/UC are not responsible for any use of the CDS artifact. BWH/UF/UC make no representations, warranties, or endorsement about the quality of any organization or physician that uses this CDS artifact.
This is a CQL-Based CDS artifact and is executed by one of the components of the CDS Connect project (i.e. CDS-Connect-CQL-Services application). The CDS-Connect-CQL-Services application exposes this CQL_Based CDS artifact thru a web-based API so it can be consumed by other applications.
Executable code that is interpretable by a CDS system at a local level. This will vary for each particular site
Provide CDS for select prioritized recommendations in the USPSTF Fall Prevention Guidelines. The artifact provides CDS for recommendations on fall and fracture prevention in the 2018 Final Recommendation Statement, Falls Prevention in Community-Dwelling Older Adults: Interventions, and Screening for Osteoporosis to Prevent Fractures, and the 2017 ACP recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women.
Many guidelines, including the US Preventive Service Task Force (USPSTF) and the American College of Physicians (ACP), recommend the screening and treatment of osteoporosis and low bone density to prevent fractures. Nonetheless, recent studies have shown that a large group of patients at high risk of fractures are untreated. For example, a study of eight countries across Europe estimated that up to 85% of patients eligible for osteoporosis treatment were not receiving it. This large treatment gap is comprised of eligible patients who have not been prescribed osteoporosis medication, as well as patients not adhering to the treatment once it is prescribed to them. Therefore, there is a need for CDS that provides providers with a synthesis of the best available evidence and patient-centered rationale for considering treatment options, as well as persuasive talking points to facilitate patient engagement and shared decision-making related to osteoporosis treatment.
Bisphosphonate treatment is recommended as a first-line treatment for osteoporosis, and in some cases for osteoporosis prevention among osteopenic patients. Strong evidence supports the effectiveness of bisphosphonates at reducing fracture risk and increasing bone mineral density. However, uncertainty about the long-term risk-benefit ratio of bisphosphonates and concerns about rare side effects have contributed to undertreatment and reduced treatment adherence over time.
The challenge is to ensure that older adults at risk of falling receive appropriate treatment recommendations, education and support from their PCP. Many PCPs are unaware of their patients’ falls, as half of older adults do not discuss falls with their PCP. Further fall prevention disparities exist in rural areas where older adults are more likely to fall, but are less likely to participate in fall prevention programs. Advances in computing technology can help to identify older people at risk of falls and disseminate guidance about the most appropriate treatment for osteoporosis using CDS. Given the many decisions that must be made to identify the most appropriate osteoporosis treatment plan for individual patients, PCPs need CDS to guide them and to facilitate engaging patients in their decision-making process. CDS would ensure that the osteoporosis treatment recommendations are evidence-based and consistent with patients’ needs and preferences.
Primary care patients age 65+ who screen positive for fall risk (answer “yes” to one or more fall risk screening questions)
Older adults (age 65+ years) who fail their fall risk screening during a primary care, and have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture.
Not applicable
Many guidelines, including the US Preventive Service Task Force (USPSTF) and the American College of Physicians (ACP), recommend the screening and treatment of osteoporosis and low bone density to prevent fractures. Bisphosphonate treatment is recommended as a first-line treatment for osteoporosis, and in some cases for osteoporosis prevention among osteopenic patients. Strong evidence supports the effectiveness of bisphosphonates at reducing fracture risk and increasing bone mineral density.
- U.S. Preventive Services Task Force. Falls Prevention in Community-Dwelling Older Adults: Interventions. 2018; Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1.
- U.S. Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures. 2018; Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1.
- McCloskey E, Rathi J, Heijmans S, et al. The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study. Osteoporos Int. 2021;32(2):251-259. doi:10.1007/s00198-020-05557-z.
- Qaseem A, Forciea MA, McLean RM, Denberg TD. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med. 2017;166(11):818-839. doi:10.7326/M15-1361
- US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521. doi:10.1001/jama.2018.7498.
- Compston J. Reducing the treatment gap in osteoporosis. The Lancet Diabetes & Endocrinology. 2020;8(1):7-9. doi:10.1016/S2213-8587(19)30378-X.
- Iqbal SM, Qamar I, Zhi C, Nida A, Aslam HM. Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review. Cureus. 11(2):e4146. doi:10.7759/cureus.4146.
- Ayub N, Faraj M, Ghatan S, Reijers JAA, Napoli N, Oei L. The Treatment Gap in Osteoporosis. J Clin Med. 2021;10(13):3002. doi:10.3390/jcm10133002.
- Guirguis-Blake, J.M., et al., Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 2018. 319(16): p. 1705-1716.
- Lam HC, Thomas CM, Shaver JM. Duration of Bisphosphonate Therapy. afp. 2018;97(7):online-online.
Based on the evidence, this artifact recommends that PCPs consider bisphosphonate treatment for all patients age 65+ who are at risk for falls, have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture, and do not have a bisphosphonate prescription. In addition, this artifact recommends that PCPs consider discontinuing bisphosphonate treatment for all patients age 65+ who are at risk for falls, have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture, and have been taking bisphosphonates for five years or more.
The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls (Grade C evidence).Bisphosphonate treatment is recommended as a first-line treatment for osteoporosis, and in some cases for osteoporosis prevention among osteopenic patients. Strong evidence supports the effectiveness of bisphosphonates at reducing fracture risk and increasing bone mineral density. The evidence on optimal duration of bisphosphonate treatment is less robust, but best available evidence indicates that treatment beyond 5 years has limited benefits.
Strong to moderate, based on meta-analyses
Based on the evidence, this artifact recommends that PCPs consider bisphosphonate treatment for all patients age 65+ who are at risk for falls, have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture, and do not have a bisphosphonate prescription. In addition, this artifact recommends that PCPs consider discontinuing bisphosphonate treatment for all patients age 65+ who are at risk for falls, have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture, and have been taking bisphosphonates for five years or more.
The ASPIRE application recommends that PCPs consider bisphosphonate treatment for all patients age 65+ who are at risk for falls, have an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture, and do not have a bisphosphonate prescription. Since osteoporotic fractures are not always captured reliably in the EHR due to interoperability limitations, we include the capability to capture this information in the ASPIRE user interface.
This is a CQL-Based CDS artifact and is executed by one of the components of the CDS Connect project (i.e. CDS-Connect-CQL-Services application). The CDS-Connect-CQL-Services application exposes this CQL_Based CDS artifact thru a web-based API so it can be consumed by other applications.
Primary care patients age 65+ who screen positive for fall risk (answer “yes” to one or more fall risk screening questions), an active diagnosis of osteoporosis or osteopenia, or a prior osteoporotic fracture
Primary care patients age <65 and age 65+ who do not screen positive for fall risk (answer “no” to all more fall risk screening questions), do not have an active diagnosis of osteoporosis or osteopenia, and do not have a prior osteoporotic fracture
- General bone health education (all)
- Bisphosphonate medication order (no bisphosphonate prescribed)
- Bisphosphonate medication holiday (bisphosphonate treatment duration ≥5 years
We pilot tested this logic in one rural (Florida) and one urban (Boston) primary care practice. We found that providers appreciated access to evidence-based recommendations and that patients are receptive to these recommendations. Upon completion of the clinic visit, the trained research staff member met with the patient in a private setting to ask a small set of open-ended questions and administer a patient-provider communication (Health Care Relationship Trust Scale) and shared decision-making questionnaire (Shared Decision-Making Questionnaire-9). For the HCR Trust Scale, patients from both sites reported a mean score of 58 (median 60, SD 6.1) out of a possible score range of 0-60. For the SDM-Q9 survey, patients from both sites reported a mean score of 92 (median 100, SD 14.9) out of a possible score range of 0-100. Once the 40 observations were completed, a focus group was conducted with clinicians at each site to gather individual perceptions of their experience using ASPIRE. At the end of both focus groups, the Health-ITUES survey was administered to each participating clinician in order to help gauge clinical feasibility and acceptability of the software in the primary care environment.