Table 1 Referral question categories with narrative examples
From: A retrospective review of the community medicine needs from osteoporosis services in Canada
REFERRAL QUESTION CATEGORY | NARRATIVE EXAMPLE | DIRECTLY STATED OR INFERRED ISSUE |
|---|---|---|
Recent fracture, no therapy started yet | “70 year old with 2 recent compression fractures” “50 year old man with incidental compression fracture found on x-ray” “53 year old woman with wrist fracture but normal bone density” | Uncertainty about whether fracture is “osteoporotic” Uncertainty about whether treatment indicated Implied that severity needs specialist care Referral from non-prescribing specialist (i.e. orthopedic surgery) |
Recent fracture despite therapy | “84 year old with vertebral fracture despite risedronate” “75 year old with 3 metatarsal fractures on denosumab” | Implied that fracture means therapy failure Implied that specialist investigation is needed Implied that fracture defines need to switch treatment drugs Implied that fracture on therapy is abnormal, requires specialist review |
Bone disease in context of CKD | “38 year old with type 1 diabetes on dialysis with hip fracture” “77 year old with low BMD and eGFR 27 ml/min/m2” | Recognition that CKD changes therapeutic approach Recognition that bisphosphonates are not recommended in CKD Not recognizing that nephrology is already managing renal osteodystrophy |
Bisphosphonate Holiday (occasionally denosumab as well) | “65 year old on alendronate for 14 years” “79 year old stopped IV zoledronic 2 years ago, BMD still low” “stopped risedronate 1 year ago, just fractured wrist” “77 year old BMD shows high risk but took alendronate for 15 years, 10 years ago. OK to re-start?” “60 year old with intermittent bisphosphonate use × 7 years, BMD says ‘high risk’” “72 year old on alendronate × 4 years but dentist says it must be stopped for 6 months to get implants but BMD T-score < -2.5” “how long is it safe to use denosumab?” | Duration of bisphosphonate therapy Monitoring of bisphosphonate holiday Duration of bisphosphonate holiday Response to monitoring change while on bisphosphonate holiday Fracture risk while on drug holiday Fracture occurrence while on drug holiday Medication re-start Over-use of bisphosphonates |
Routine Osteoporosis Assessment | “52 year old seeking information about treatment options” “64 year old woman with BMD showing moderate risk” “patient is high risk but does not want to be treated; please see and advise” “patient requests referral for specialist opinion and education” | Uncertainty about intervention threshold Patient needs extra time/education Patient asking many questions Concern about non-treatment of low T-score BMD decreasing in postmenopausal woman Knowledge deficit for routine OP care Reassurance from specialist Making use of local expert resources/education Patient request to see specialist Doctor/patient disagreement on plan |
Medication Options beyond oral bisphosphonate | “67 year old with gastrointestinal side effects from alendronate” “83 year old with muscle twitching after each risedronate dose” “55 year old with cirrhosis and varices, can’t risk oral bisphosphonate” “60 year old who refuses bisphosphonate because she already has jaw pain” | Typical adverse effects Atypical adverse effects True contradindications Educational deficit around potential risks for adverse effects |
Adverse DXA change on therapy | “decrease in BMD despite alendronate” “2 years on IV zoledronic acide and BMD still shows osteoporosis” “BMD not getting better on therapy” “on therapy 4 years and BMD still shows ‘high risk’” | Knowledge deficit on clinical interpretation of small decreases in BMD Uncertainty about role of serial BMD testing Uncertainty about role of re-calculation of risk scores while on therapy Radiology narrative reports about failing therapy |
Metabolic bone diseases | “low bone density in 29 year old man” “family history of metabolic bone disease” “Rheumatoid arthritis on long-term prednisone” | Osteogenesis imperfecta, Paget disease, parathyroid disorders, phosphate disorders, osteopetrosis Drug-induced – glucocorticoids, heparin, anti-epileptics Complex chronic disease – iron storage disorders, short gut syndrome, gastric bypass, transplantation, alcoholic bone, chronic liver disease Work-up for unexpected low BMD in young person Idiopathic male osteoporosis |
Request for assessment and access to IV zoledronic | “patient interested in IV bisphosphonate” | Comparative efficacy of oral vs IV bisphosphonates Practical access to outpatient IV therapy |
Specific request for anabolic therapy | “3 vertebral fractures, please assess for teriparatide treatment” | Access to drugs rarely used in primary care |
Premature low estrogen state | “30 year old woman with premature menopause” “22 year old with severe endometriosis, requires ovarian suppression” | Role of BMD testing Options for bone mass maintenance outside of menopause |
Serious adverse effect | Suspected osteonecrosis of jaw Completed or impending atypical femur fracture | |
Malnutrition related osteoporosis | “26 year old with severe anorexia nervosa and hip fracture” | No guidelines for management |
Cancer therapy effect on bone | “54 year old woman with breast cancer starting aromatase inhibitor” “79 year old man with prostate cancer taking GnRH agonist” “32 year old with vertebral fracture 1 year post stem cell transplant” | Uncertainty from either primary care or oncology about bone management with cancer care |
Immobilization | “38 year old with quadriplegia and 2 lower limb fractures in past year” | Not addressed in guidelines |
Pain management | “77 year old with 2 vertebral fractures, please assist with pain management” | Limited access to acute pain management services |