Make no bones about it: Treatment adherence is a challenge in Osteoporosis
It has been estimated that over 200 million people worldwide have osteoporosis and the prevalence is expected to increase as the population continues to age. For this reason, patient adherence for Osteoporosis treatment is more important than ever.
Osteoporosis is a relatively common chronic condition affecting approximately 50% of women and 30% of men over 65 years of age, for this reason osteoporosis is a significant clinical and public health concern. Indeed, fractures are one of the most common causes of patient disability and a major contributor to medical costs worldwide (Cummings & Melton, 2002). Despite the existence of effective treatments to reduce the risk of osteoporotic fractures, patient adherence to osteoporosis treatments is poor and treatment discontinuation is common (e.g., Cramer et al., 2007). As with other chronic diseases, patient reasons for treatment non-adherence and discontinuation are multiple and varied.
But I don’t feel sick?
The asymptomatic nature of osteoporosis poses particular problems for treatment adherence and continuation as patients are neither feeling ill nor experiencing symptoms. It is widely understood that feeling ill and experiencing symptoms function as internal cues for patients to take treatment. When these cues are absent, however, the likelihood of treatment non-adherence or discontinuation is greater as patients are neither reminded to take their treatment, nor do they see the need for treatment. The asymptomatic nature of osteoporosis also means that patients do not receive any tangible ‘evidence’ that the treatment is working. That is to say, the benefits of taking treatment are not evident to the patient as they do not experience an observable reduction in symptoms.
But osteoporosis is not really a serious illness?
In addition to the issues arising as a result of the asymptomatic nature of osteoporosis, research demonstrates that many patients also fail to appreciate the risk and potential consequences of osteoporosis. For example, a number of studies have demonstrated that where personal risk and consequences are perceived by the patient to be low, treatment non-adherence is likely to result (e.g., Cline & Worley, 2003; McHorney et al., 2007). Moreover, it is likely that the asymptomatic nature of osteoporosis precludes patients from accurately assessing their personal risk and the potential consequences of not adhering to the treatment regimen.
But I’m worried about treatment side effects?
Troublesome side effects pose one of the biggest challenges to patient adherence across chronic diseases (e.g., Horne et al., 2005). In osteoporosis, the side effects of oral bisphosphonates are multiple and can significantly interfere with a patient’s day to day life. It is perhaps unsurprising, therefore, that side effects are frequently cited as the main reason for treatment non-adherence and discontinuation in osteoporosis (e.g., Lau et al., 2008; McHorney et al., 2007). For example, McHorney and colleagues (2007) reported that 67% of patients categorised as ‘non-adherers’ rated the presence of side effects as an ‘extremely important’ or ‘very important’ reason for non-adherence.
Interventions to improve treatment adherence and continuation
In a health economics analysis, Hiligsmann and colleagues (in press) estimate that poor adherence with osteoporosis treatments results in approximately a 50% reduction in the potential benefits observed in clinical trials and a doubling of the cost per quality-adjusted life-year (QALY) gained from these treatments. On the back of this data, the authors suggest that programmes to increase adherence have the potential to be an efficient use of healthcare resources. For example, the authors state that an intervention to improve adherence by 25% would result in an incremental cost-effectiveness ratio of €11,511 per QALY and €54,182 per QALY, compared with real-world adherence, if the intervention cost an additional €50 and €100 per year, respectively.
To date, few interventions have been conducted to promote treatment adherence and continuation in patients with osteoporosis. Indeed, a recent systematic review of existing literature identified only seven adherence intervention studies in osteoporosis (Gleeson et al., 2009). Even though the literature in this area is in its infancy, there is some evidence to suggest that interventions designed to change patient’s beliefs about their osteoporosis and treatment result in increased treatment adherence and continuation. For example, a recent intervention study (see Solomon et al., 2012) involving motivational interviewing techniques with osteoporosis patients demonstrated some success in improving treatment adherence and continuation. Although the study did not report a statistically significant result, the authors argue that the increase observed [8% difference in median medication possession ratio (MPR) between the intervention and control arms] was nonetheless clinically significant.
Cline, R. R., & Worley, M. M. (2003). Osteoporosis health beliefs and self-care behaviours: An exploratory investigation. Journal of the American Pharmacy Association, 46(3), 356-363.
Cooper, C. (1999). Epidemiology of osteoporosis. Osteoporosis International, 9(Suppl 2): S2–8.
Cramer, J. A., Gold, D. T., Silverman, S. L., & Lewiecki, E. M. (2007). A systematic review of persistence and compliance with bisphosphonates for osteoporosis. Osteoporosis International, 18, 1023-1031.
Cummings, S. R. & Melton, L. J. (2002). Epidemiology and outcomes of osteoporotic fractures. Lancet, 359; 1761-1767.
Gleeson, T., Iversen, M. D., Avorn, J., Brookhart, A. M., Katz, J. N., Losina, E., May, F., Patrick, A. R., Shrank W. H., & Solomon, D. H. (2009). Interventions to improve adherence and persistence with osteoporosis medications: A systematic literature review. Osteoporosis International, 20, 2127–2134.
Haynes R., Ackllo, E., Sahota, N.,McDonald, H. P., & Yao, X. (2008). Interventions for enhancing medication adherence. Cochrane Database Systematic Review (2):CD000011
Hiligsmann, M., McGowan, B., Bennett, K., Barry, M., & Reginster, J. (in press). The clinical and economic burden of poor adherence and persistence with osteoporosis medications in Ireland. Value in Health, published online 13 April 2012.
Horne, R., Weinman, J., Barber, N., Elliott, R., & Morgan, M. (2005). Concordance, adherence and compliance in medicine taking. Report for the National Co-Ordinating Centre for NHS Service Delivery and Organisation. London: R & D (NCCSDO).
Lau, E., Papaioannou, A., Dolovich, L., Adachi, J., Sawka, A. M., Burns, S., Nair, K., & Pathak, A. (2008). Patients’ adherence to osteoporosis therapy: Exploring the perceptions of postmenopausal women. Canadian Family Physician, 54(3), 394-402. McHorney, C. A., Schousboe, J. T., Cline, R. R., & Weiss, T. W. (2007). The impact of osteoporosis medication beliefs and side effects experiences on on-adherence to oral bisphosphonates. Current Medical Research and Opinions, 23(12), 3137-3152.
Solomon, D. H., M. D. Iversen, Avorn, J., Gleeson, T., Brookhart, M. A., Patrick, A. R., Rededal, L., Shrank, W. H., Lii, J., Losina, E., & Katz, J. N. (2012). Osteoporosis telephonic intervention to improve medication regimen adherence: A large, pragmatic, randomized controlled trial. Archives of Internal Medicine, 172(6), 477-483.
Wolf, R. L., Stone, K. L., & Cauley, J. A. (2000). Update on the epidemiology of osteoporosis. Medicine Current Rheumatology Reports, 2(1), 74-86.
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