How has COVID-19 affected the treatment of osteoporosis?

A global survey of healthcare providers by the International Osteoporosis Foundation (IOF), the National Osteoporosis Foundation (NOF) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) has revealed unprecedented effects of the Covid-19 pandemic on worldwide healthcare delivery for osteoporosis.

Osteoporosis is a chronic, age-related disease which is associated with life-changing fragility fractures. Approximately 740,000 people lose their lives following hip fractures every year.

The survey report is based on online questionnaires completed from April to June 2020 by 209 healthcare providers in 53 countries: 28% from Europe, 24% from North America, and 19%, 17% and 12% from the Asia-Pacific, Middle East and Latin America, respectively. The majority of the respondents (85%) were physicians, mainly representing the specialties of rheumatology (40%), endocrinology (22%), orthopedics (15%) and internal medicine (11%).

The report provides an insight into how healthcare delivery for osteoporosis has been affected by the pandemic:

• Clinic/hospital closures: 21% of institutions were only open for emergency visits; 23% for non-acute/routine visits; 57% for both emergency and routine appointments; and 7% closed for all visit types.
• Form of consultations: 33% performed telephone consultations; 21% video consultations; 26% face-to-face appointments; 18% urgent in-person visits; and 3% other modalities (including instant messaging).
• Telemedicine: Lock-downs and self-isolation saw a necessary move toward telemedicine, which was found very useful for 20% of the respondents, who scheduled approximately more than 20 online appointments per week. In contrast, 20% only scheduled 1-5 appointments per week and 20 % did not schedule any appointments at all. Issues included unavailability of telemedicine, its non-reimbursement, or uncertainties about reimbursement.
• Risk Assessment: 29% scheduled a Dual-energy X-ray Absorptiometry (DXA) scan as soon as possible in order to inform treatment decisions; 11% assessed patients based on a clinical risk calculator alone (for e.g. FRAX); 29% assessed patients based on a risk calculator with a planned DXA at a later date; 33% postponed a DXA; 5% indicated that their DXA unit was currently closed or that they were referring patients to a fracture clinic service.
• Delivery of medication: Almost half (43%) reported difficulty arranging osteoporosis medications, including limited supply or difficult in acquiring medications, delay in administration of infusions and injections, reluctance on the part of patients to attend, or travel restrictions/self-isolation resulting in patients being unable to attend office visits.
• Prescriptions: 28% prescribed refills only; 63% prescribed both refills and new prescriptions; 3% issued new prescriptions only; and 4% did not prescribe any medication unless for an acute indication.
• Professionally administered treatment: 60% of clinicians had systems in place to identify patients receiving parenteral medication so that plans of care could be arranged; 46% were able to administer injections or infusions with safeguards in place to minimize patient risk; 3% moved treatments to an alternate clinical location; 21% suggested delaying treatment until Covid-19 risk had abated; 13% recommended switch to an oral medication; and 8% considered arranging in-home administration of treatment.
• Time needed for patient charts/electronic health records: 93% of the respondents reported that it took as much or more time than prior to the pandemic to complete documentation. Reasons included technical and work-flow related issues, among others.
• Patient follow-up: The time taken to follow-up patients was reported as greater by 39% of respondents, less by 9%, no change by 45%, and 7% of respondents were unsure. More time was often required to provide explanations or results over the phone, among other reasons.

IOF President Professor Cyrus Cooper, corresponding author, noted: "The survey indicates that the identification and management of osteoporosis in patients has been profoundly affected by the pandemic, by delays in obtaining a DXA scan or in providing medication. There is a concern that the traditional gold standard assessment and management of osteoporosis patients was not performed in the majority of cases during the pandemic, leaving many patients without assessment and treatment."

Professor Susan L. Greenspan, President of NOF and senior author, stated: "There appears to be a substantial impact on reimbursement, which may have implications for the ability to sustain and offer various osteoporosis clinical services and tests such as DXA. In the USA, despite Medicare allowing greater flexibility for home administration of injectable medication, some 39% of survey respondents were either not sure about the new arrangement or would not consider using this option. This could potentially lead to a reduction in resources, and corresponding decrease in the assessment and treatment of patients with osteoporosis and related fracture."

On a positive note almost one in three healthcare providers performed telephone consultations and one in five performed video consultations. Telemedicine has potential benefits for patients and can result in savings and efficiencies for healthcare systems. In some countries, temporary adjustments made to telemedicine reimbursement rates during the pandemic are being evaluated for implications and opportunities in the future when societies return to the new 'normal.'