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OSTEOPOROSIS CHOICE
Decision Aid
Spyridoula Maraka, MD
Mayo Clinic
CLINICAL CASE
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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-ofpocket 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?
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http://osteoporosisdecisionaid.mayoclinic.org/