Bisphosphonates and DEXA scans: how do you prescribe and order?

28 Feb 2024 Bisphosphonates and DEXA scans: how do you prescribe and order?

The Therapeutics Initiative produced and distributed individual Portraits on prescribing and ordering of bisphosphonates and DEXA scans for patients over 50 years old to approximately 6000 clinicians (physicians and nurse practitioners) in BC. Of the eligible clinicians, primary care physicians were randomized to receive the Portrait in two groups: one group of physicians received a Portrait in February 2023 (with data on prescriptions in 2021); another group was randomized to receive their Portrait one year later, in February 2024. This Portrait is accompanied by the Therapeutics Letter, “Screening to reduce fragility fractures: new trials, still ineffective” (Jan-Feb); 147:1-2.

Who received this Portrait?

Clinicians meeting all of the following criteria received an individual prescribing Portrait:

Physicians in family practice (FP), emergency medicine physicians or nurse practitioners (NP) registered by the BC Medical Service Plan (MSP) as having an active practice; and,

• had ≥100 prescriptions (for any drug) filled at a community pharmacy in 2021, according to PharmaNet claims data; and,
• had ≥100 patients treated in 2021, according to MSP billing data; and,
• did not opt out of the Portrait program.

In addition, physicians who are eligible to receive Portrait by mail must have a valid mailing address in BC as registered with the College of Physicians and Surgeons of British Columbia.

How were patients assigned to this Portrait?

The portrait includes two parts: 1) prescribing of bisphosphonates, and 2) ordering of DEXA scans:

1) Patients were included in a clinicians Portrait for prescribing bisphosphonates if they met the following criteria:

• filled a first prescription for bisphosphonates in a community pharmacy during the Portrait period (2021); and,
• were age 50 years or older on the date of the first prescription for bisphosphonates in 2021; and,
• were BC residents based on continuous BC MSP enrollment in the year before prescription filled; and,
• had not previously filled a prescription for pamidronate; and,
• did not have a record of cancer (except non-melanoma skin cancer), Hypercalcemia, Paget disease of bone, or Osteitis deformans (Table 1); or,
• did not have a record of a record of chemotherapy or radiotherapy (Table 2); and,
• were not enrolled in PharmaCare plan P before or during 2021.

Table 1.

Table 2.

What prescriptions were included in this Portrait?

Bisphosphonates include the following oral preparations, as monotherapy or combination: alendronate and risedronate. The following bisphosphonates were excluded: pamidronate (used only in hypercalcemia), zoledronic acid (injectable), or clodronate (indicated for malignancy). Other oral bisphosphonates (etidronate, ibandronate, and tiludronate) registered in Canada were not used for primary prevention by BC Portrait clinicians in 2021.

Prescription data were extracted from PharmaNet claims data and included all prescriptions filled at a community pharmacy in BC with a clinician’s prescribing number. Reversed prescription claims, out-of-province prescriptions, or drugs dispensed in hospital were not included.

2) Patients were included in a clinicians Portrait for dual-energy X-ray absorptiometry (DEXA) scans if they met all of the following criteria:

• had at least one BMD test recorded in MSP in 2021 and referred by you, and
• were age 50 years or older on the date of the test.

What DEXA tests were included in this Portrait?

The following MSP fee items were included:

• 08688 Bone density – single area
• 08689 Bone density – second area
• 08696 Bone density – whole body

For both Bisphosphonate prescribing and DEXA tests:

Data for patients who are federally insured (e.g. Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) or First Nations Health Benefits (PharmaCare Plan W) were not available.

Clinicians may have received a Portrait with masked or missing elements. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the number of patients may be presented as a range (e.g., 1-5 patients). Clinicians with no prescriptions (“0 prescriptions”) have this element displayed.

How were primary and secondary prevention identified?
Secondary prevention was defined as treatment given to individuals that had at least one fragility fracture, anytime between age 50 and the day before first bisphosphonate filled in 2021.
Included are fractures of any bone, excluding the head, face, toes, fingers and ribs.

Fragility fractures have been defined as:

• Fractures diagnosed by a radiologist, OR
• Fractures diagnosed (primary diagnosis) on discharges from hospital or an emergency room, OR
• Fracture diagnosis with an imaging (x-ray or spinal CT) in the 10 days before and excluding the diagnosis date, OR
• Surgeries for fractures, OR
• A combination of a possible fracture surgery + a diagnosis by any physician in the 10 days before or after fracture procedures,
• 2 diagnosis of fractures by a physician in 20 days, in the same region.

Multiple fractures of different bones recorded within 20 days (=major trauma, such as MVA) were excluded.

Gender & sex terminology: We note the limitations of our use of the words “women” and “men” in this Portrait. In the randomized controlled trials reviewed and in MSP data, sex and gender are often conflated and codified as binary states. We acknowledge that sex and gender may influence health in different ways and that conflating these is problematic.

How was ‘Optimal’ determined?

Based on the best available evidence, bisphosphonates are not recommended as primary prevention for women without a prior fragility fracture, which is why we set the optimal target as 0.

Please refer to: Therapeutics Initiative. Screening to reduce fragility fractures: new trials, still ineffective. Therapeutics Letter. 2023 (February); Limited early release:1-2.

How was ‘Median BC prescriber with a similar practice’ calculated?

In calculating “median BC prescriber” patients were categorized into 4 groups: females between 50 and 70 years of age; females 71 years and older; males between 50 and 70 years of age; males 71 years and older. The median, was calculated based on Portrait clinician median frequency for prescribing/testing and the number of patients treated in your office. Therefore, the median varies for different clinicians. It was calculated from the median prescribing patterns of BC primary care clinicians included in Portrait, using the following formula:

References and additional information

1. Therapeutics Initiative. Screening to reduce fragility fractures: new trials, still ineffective. Therapeutics Letter. 2024 (Jan-Feb); 147:1-2.
2. Therapeutics Initiative. A Systematic Review of the Efficacy of Bisphosphonates. Therapeutics Letter. 2011 (Sept-Oct); 83:1-2.
3. Canadian Institute for Health Information. Canadian Classification of Health Interventions, 2012. Available at: http://assets.ibc.ca/Documents/Auto%20Insurance/CCI%202015.pdf
4. Statistics Canada. Canadian Classification of Diagnostic. Therapeutic and Surgical Procedures, 1993 Ministry of Industry; Catalogue No. 82-562E. Available at: https://publications.gc.ca/collections/collection_2017/statcan/CS82-562-1980-eng.pdf

Research component

The research objective is to determine the impact of the Portrait on clinician prescribing. This impact will be evaluated at an aggregated level over the coming year by comparing pooled prescribing data from clinicians in the early mailing group to pooled prescribing data from clinicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and clinician numbers. No clinician or patient will be identified in any reports or publications. Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. For each Portrait, we seek approval from the University of British Columbia Clinical Ethics Review Board. This evaluation is being led by Drs. Colin Dormuth and Greg Carney, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.

If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca

FAQ

Can I request the names of my patients included in this Portrait?

No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list.

However, other resources may be available for you. Contact your Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.

I have a unique/specialized practice and do not believe that my data should be compared to GPs. Shouldn’t my comparison cohort be other clinicians with practices similar to mine?

Our ability to accurately include clinicians depends on how each clinician is listed in the BC MSP data. For example, to be included in the program, a clinician must be defined as a Nurse Practitioner or a General Practitioner with a license status of Private Practice in the MSP data; beyond that, it is difficult to accurately identify any individual’s specific work environment, as many clinicians work in multiple locations. We try to keep Portraits relevant to recipients by having a minimum prescribing/testing criterion for each Portrait topic. Clinicians who did not prescribe the drug and did not use the test typically will not receive a Portrait.

Creating accurate comparison cohorts is difficult for the same reasons. We often include the BC median as a point of interest when it is feasible, but we know that many clinicians have unique or specialized practices and this comparator is not ideal. As we continue to build and refine the Portrait program, we will be able to provide comparisons that are more relevant to a variety of practices.

Portraits are intended to be a tool for you to reflect upon and consider your own prescribing. Rest assured that we are not directly comparing your prescribing to any particular cohort. You are the only one who ever sees your own Portrait data, and you can decide for yourself whether you think your prescribing is in line with the evidence given your unique clinical setting. You will only receive future Portraits for based on minimum inclusion criteria, so you shouldn’t receive anything that is irrelevant to your practice (i.e., for drugs you do not prescribe or tests you do not use).

Why does my Portrait show ranges of patients that I treated (1-20, 20-30, etc.), and not exact numbers?

Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. Therefore, numbers between 1 and 5 patients were masked, and the length of the bar chart was set to 2.5 patients.

I don’t see my question here. Where can I find more information?

Please check out our program FAQ section. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca.