Shifts in Diagnosing and Treating Osteoporosis


receptor modulators (SERMs; e.g. raloxifene) or calcitonin, which are specific to the reduction of vertebral fracture only. Physicians should also keep in mind the side effects associated with these medications.


Side effects also have an important role in treatment decisions and can be separated into short-term and potential long-term effects (summarized in Table 3). Short-term side effects occur shortly after administration and can include gastrointestinal (GI) problems or acute phase reactions (e.g. myalgia and fever). Potential long-term side effects can include GI problems and osteonecrosis of the jaw (ONJ). Whereas short-term side effects can be common, the long-term side effects are often rare.


Treatment decisions can be further complicated by the cost of medication, a patient’s insurance coverage, and their ability to pay. Taken together, side effects, efficacy, cost and convenience are factors that patients and physicians use to weight their options when choosing an osteoporosis treatment.


Parties Involved in Medical Decision-making Physicians and patients place different values on side effects, cost, convenience, and efficacy.17–19


of treatment when communicating medical decisions,20–24


Physicians generally focus on the benefits whereas


patient preferences are based on the weighting of attributes and are currently being brought to light through various studies. Making medical decisions is further complicated by the insurance companies, whose concentration is focused on cost.


Patient Preferences


In a study comparing the use of teriparatide and bisphosphonates, it was reported that efficacy is the most important determinant of preference.25


However, the risks of serious side effects have also been shown to be statistically significant attributes in persuading patient preferences.26


Other studies comparing modes of administration have demonstrated that patients have a strong preference for the route of administration of a drug over its possible benefits.27


As of yet, there is no


consensus as to which attribute patients believe is most important. Although efficacy is an important factor in choosing a medication, patients have been reported to have different views that must be taken into account if they are to be included as partners in making their medical decisions.


Patients often create their preferences for medications before meeting with their physician.28,29


Much of this is the result of a shift in the


traditional patient–physician relationship when choosing medical treatments. In effect, patients are gaining more self-confidence and are looking to become more active participants in the direction of their healthcare.30–33


As a consequence, patients might make their decisions based on inaccurate and often misleading information. In forming their medication preferences, patients often take into account perceived side effects rather than those that are associated with the medication. They might have negative experiences with past medications and/or rely on media, family, friends, or the Internet for sources of information about side effects. Physicians must correct these misconceptions through education and dialog so that the patient can make a truly informed decision about treatment that will increase compliance.


US MUSCULOSKELETAL REVIEW


In addition to risk factors, considerations need to be made in terms of differences in racial and ethnic preferences. Racial and ethnic differences in the administration of healthcare are documented in patients with various illnesses, not just osteoporosis.47–56


These


disparities occur even in patients with adequate access to healthcare information.57,58


Studies have found that, whereas Caucasian patients place greater emphasis on efficacy, African-American patients put greater importance on the safety of the drug.59


Adherence with Osteoporosis Treatments Adherence to a prescribed medication regimen is important for effective treatment. There are two distinctions to be made about non-adherence. The first occurs when a patient receives a prescription for a drug and does not fill it. The second, and one that is more relevant to osteoporosis, occurs after treatment has started and the patient fails to follow medication instructions or fails to refill the prescription.34–36 Osteoporosis is a chronic, silent disease, lacking visible symptoms and, as a consequence, adherence to medications for osteoporosis has been relatively poor. Approximately 50% of women discontinue prescription therapy for osteoporosis during the first 12 months.37


Both physicians


and patients contribute to non-adherence. Patients contribute to poor adherence owing to their misunderstanding of side effects, lack of belief in treatment efficacy, poor understanding of the seriousness of osteoporosis, and treatment cost.38–40


Physicians exacerbate the


problem with poor explanations of side effects and lack of consideration for patient lifestyle.41


It is imperative for physicians to educate their


patients and account for patient preferences. In this way, patients become informed partners in making decisions about their treatments.42 Non-adherence is a concern that physicians must address when prescribing osteoporosis medications. Patients who fail to follow the prescribed treatment options tend to increase their risk for fracture and fail to improve their T score measurements, thus undermining the efficacy of the treatment.43


It is imperative that patients follow their


treatment regimen as prescribed by their physician. Elucidating Patient Preferences


In the same way that consumers weigh factors to make decisions about choosing a product, patients make similar decisions when choosing a medication. Conjoint analysis takes into account the careful consideration of trade-offs involved in complex decisions.50


By


studying the trade-offs between specific drug characteristics (e.g. benefits, risk for side effects, and cost) involved when choosing an osteoporosis medication, conjoint analysis can ascertain individual patient preferences.51


Given that adherence to osteoporosis treatments has been relatively poor, it is necessary for healthcare professionals to consider patient preferences when deciding on treatment. Marketing research methods are becoming valuable tools for understanding and influencing patient preferences for medical decision-making. Conjoint analysis is a popular method used in research studies investigating patient preferences. It has a strong theoretical basis and obtains high levels of internal consistency.44–49


Currently, there is a lack


of data concerning the preferences of Hispanic and Asian communities. Studies are now trying to elucidate racial and ethnic preferences for osteoporosis medications. One such study is being performed by Duke University and our group in Los Angeles. This study is examining racial and ethnic preferences in deciding on osteoporosis treatments. These


23


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