Osteoporos Int DOI 10.1007/s00198-015-3086-1
ORIGINAL ARTICLE
District nurses’ perceptions of osteoporosis management: a qualitative study A. Claesson & E. Toth-Pal & P. Piispanen & H. Salminen
Received: 8 September 2014 / Accepted: 20 February 2015 # International Osteoporosis Foundation and National Osteoporosis Foundation 2015
Abstract Summary Underdiagnosis of osteoporosis is common. This study investigated Swedish district nurses’ perceptions of osteoporosis management. They perceived the condition as having low priority, and the consequences of this perception were insufficient awareness of the condition and perceptions of bone-specific medication as unsafe. They perceived, though, competency when working with fall prevention. Introduction Undertreatment of patients with osteoporosis is common. Sweden’s medical care strategy dictates prioritisation of various conditions; while guidelines exist, osteoporosis is not prioritised. The aim of this study was to investigate district nurses’ perceptions of osteoporosis management within Sweden’s primary health care system. Methods Four semi-structured focus group interviews were conducted with 13 female district nurses. The interviews were analysed using thematic analysis. Results The overall theme was perceiving osteoporosis management as ambiguous. The themes were perceiving barriers and perceiving opportunities. These subthemes were linked to perceiving barriers: (i) insufficient procedures, lack of time and not aware of the condition; (ii) insufficient knowledge about diagnosis and about fracture risk assessment tools; (iii) low priority condition and unclear responsibility for osteoporosis management; and (iv) bone-specific medication was sometimes perceived to be unsafe. These subthemes were linked to perceiving opportunities: (i) professional competency when discussing fall prevention in home visit programs, (ii) willingness to learn more about osteoporosis management, (iii) collaboration with other professionals and (iv) willingness to identify individuals at high risk of fracture. A. Claesson (*) : E. Toth-Pal : P. Piispanen : H. Salminen Unit of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden e-mail: [email protected]
Conclusions Osteoporosis was reported, by the district nurses, to be a low-priority condition with consequences being unawareness of the condition, insufficient knowledge about bone-specific medications, fracture risk assessment tools and procedures. These may be some of the explanations for the undertreatment of osteoporosis. At the same time, the district nurses described competency performing the home visits, which emerged as an optimal opportunity to discuss fall prevention and to introduce FRAX with the aim to identify individuals at high risk of fracture. Keywords District nurses . Fragility fractures . Management . Osteoporosis . Qualitative study . Undertreatment
Introduction In the EU, nearly 30 million persons are estimated to have osteoporosis that leads to elevated risk for fragility fractures [1]. Sweden has one of the highest incidences of fragility fractures (about 107,000 cases annually) [2], and these fractures lead to substantial suffering and high costs for society. Pharmacological treatment accounts for only 2 % of total costs for fragility fractures in Sweden. Currently, a small percentage of women at high risk of fracture receive treatment [2], although bone-specific osteoporosis treatment enables costeffective fracture prevention [3]. Health and medical care professionals might not know that their patients have osteoporosis. Within Sweden’s primary health care (PHC) system, osteoporosis management can include (i) identifying persons at high risk of fracture and (ii) diagnosing and treating osteoporosis. In the PHC system, district nurses (DNs) are often responsible for fall prevention.
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Sweden’s national PHC strategy contains health and medical care guidelines and financial-related specifications that specify how to prioritise various conditions. Despite national and regional guidelines, osteoporosis is undertreated in PHC [1]. One exception, related to the prevention of fragility fractures, is the home visit program to the 75-year-old individuals who are patients in the primary health care centres (PHCCs). The programs, performed by the district nurses, are encouraged and funded by the county council and are therefore considered a high-priority task. Low adherence to prescribed medication is an increasing public health problem, especially for chronic diseases such as osteoporosis. While best practice guidelines for diagnosis and treatment of osteoporosis are available, many patients are not tested or treated [4–6]. Multiple reasons explain why this care gap exists, but organisational factors probably play a crucial role. There is clear demand for improvements in osteoporosis management, which could be facilitated with better structural support, for example, by implementing clinical decision support systems such as fracture liaison services [7–9]. The World Health Organization (WHO) designed the webbased fracture risk assessment tool (FRAX®) that calculates the 10-year absolute risk of osteoporotic fractures for the individual patient by factoring in several risks [10–12]; FRAX was originally designed for primary health care. Sweden’s National Board of Health and Welfare recommends FRAX for (i) estimating need for measurement of bone mineral density and (ii) decision support regarding bone-specific medication. Knowledge gaps in osteoporosis management have been reported among health and medical care professionals worldwide concerning osteoporosis management. Vered et al. found, in surveys, that knowledge about osteoporosis among DNs was limited and that the only osteoporosis-related factor that respondents felt confident about was advising patients on fall prevention [13]. Several studies in other countries confirm these results [14–16]. Qualitative research is useful for closing the osteoporosis management knowledge gaps because it enables investigators to better understand (i) people’s beliefs, attitudes or behaviours and (ii) the finer nuances of osteoporosis management [17, 18]. There are qualitative studies done on patients and their attitudes toward osteoporosis [19–21]. Among general practitioners, several qualitative studies were done on osteoporosis management and fragility fractures [22–27]. For example, structural factors, insufficient personal knowledge and general practitioners’ beliefs about osteoporosis management are reported as barriers to caring for the condition [23]. To conclude, there is limited knowledge about DNs’ perceptions of osteoporosis management. Consequently, the aim of the present study was to investigate and describe DNs’ perceptions of osteoporosis management.
Methods This qualitative, descriptive study gathered data via semistructured focus group interviews with DNs and analysed it using the thematic analysis method [28]. Participants The greater Stockholm area has about 200 PHCCs with four to five DNs at each centre. Via email, DNs from all PHCCs in Stockholm were invited to participate in the present study. The invitation and information about the study were also published on the Centre for Family Medicine (CeFAM) website. The study intended to have four to eight participants in each focus group and intended to have four to five focus groups in total [29]. Those who responded to the recruitment drive could sign up for one of five different dates. One of the offered dates did not get any participants. Unfortunately, late withdrawals resulted in only two participants in one group and three to four participants in the other three groups. In total, 13 DNs from eight PHCCs agreed to participate in four focus group interviews that were carried out between December 2013 and March 2014. Before starting each interview, the participants responded to a background questionnaire. Six of the participants had worked for more than 10 years as a DN; most of them estimated that they met patients with osteoporosis one to three times a month. Some DNs worked with home health care, others exclusively at the PHCCs and some within both contexts. Nine of the DNs believed that they did not have sufficient knowledge about osteoporosis, and all of them expressed a need for continuing education about the condition. For logistic reasons, all interviews were done at the same PHCC. Just one participant came from that PHCC. All participants were female (mean age, 50; age range, 28–63). They were financially compensated because the interviews occurred after working hours. The compensation was a fix fee approximately corresponding to a salary for a couple of hours of work. Data collection Articles with these keywords were searched for in the CINA HL, Ovid, Web of Science and PubMed databases: osteoporosis, fragility fractures, nurses and qualitative study. Only a few articles were found, and just one [30] suited the present study’s target group, i.e. DNs in PHCCs. The purpose of the literature search was to investigate the field and to identify knowledge gaps regarding osteoporosis management. We chose qualitative research with focus group interviews with the aim to investigate and to better understand—in depth—the DNs’ perceptions of the osteoporosis management [17, 18]. Focus group interviews activate participants to
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express their perceptions of a specific topic by discussing with each other. When using focus groups to gather data, researchers must recruit persons who have something to say about the chosen topic. Group size may range from 4 to 12 participants; the groups often consist of five to eight persons [29]. The interviews for the present study took 60–90 min. One moderator and one observer attended each interview; the first author moderated each session. The two observers belonged to the research team. One observer was present at the first two interviews, and the other one was present at the last two [29]. The moderator role is important. As per Twohig and Putnam, moderators play a key role in successful group conduct [29], and they must involve all participants in the discussions. The moderator for the present study was a physiotherapist; the observers were general practitioners. If necessary, the observers supported the moderator and they observed an interaction among participants and among the moderator and participants [29]. The moderators and observers were skilled in focus group facilitation and took steps to avoid any inadvertent or undue influence on the study participants, such as avoiding discussion of their own views [17]. To facilitate the interviews, the moderator used an interview guide with open-ended questions that covered three to four subject areas (see Appendix). Interview questions dealt with (i) opportunities, barriers, collaboration and responsibility for osteoporosis management and (ii) the use of FRAX. A brief demonstration of FRAX was a part of each group session. The participants were shown the FRAX website and were introduced to the risk factors included in FRAX. The moderator and the observer reviewed field notes after each session. All sessions were recorded, transcribed verbatim and then anonymised.
4. Identified one key theme by answering this question: How did the participants perceive osteoporosis management? 5. Identified themes and subthemes. 6. Validated themes and subthemes by searching for and unearthing corresponding words and phrases that several of the participants repeated during the interviews. Here, triangulation of the observers was used to validate results, because all research team members participated in collecting the data [17]. We also used triangulation during the analysis as all researchers compared and discussed preliminary ideas until consensus was reached. 7. Selected quotes from all interviews to illustrate main findings that emerged from the analysis. All research members independently developed the thematic analysis themes and subthemes and then discussed them until consensus was reached. The ethical review board in Stockholm approved the study (2013-1782-31-4).
Results The analysis identified one overall theme—perceiving osteoporosis management as ambiguous. DNs described how they were striving to overcome existing barriers and how they could see opportunities to osteoporosis management. Thus, two themes emerged: perceiving barriers and perceiving opportunities. Each theme had four subthemes. Figure 1 describes a model of the overall theme, themes and subthemes. Perceiving barriers
Data analysis The present study applied the thematic analysis method. As per Braun and Clarke, thematic analysis is used to identify, analyse and subsequently report patterns or themes within data [28]. Data were analysed in these stages: 1. Became familiar with the data (e.g. audio recordings were reviewed as soon as possible to detect information that repeatedly emerged—for early stage analysis—before doing the next interview). Field notes were incorporated in the analysis. Minor adjustments of the interview guide were made after the first interview. 2. Transcribed the interviews. 3. Read the transcribed text and reread it to identify new information and to increase trustworthiness. The text was read independently first by all four members and then by the whole group.
The perceiving barriers theme was divided into four subthemes: 1. Insufficient procedures, lack of time and not aware of the condition 2. Insufficient knowledge about diagnosis and about fracture risk assessment tools 3. Low-priority condition and unclear responsibility for osteoporosis management 4. Bone-specific medication was sometimes perceived to be unsafe
Insufficient procedures, lack of time and not aware of the condition The DNs reported that they did not have procedures for finding these patients and that they were unaware of the
Osteoporos Int Fig. 1 A model of district nurses’ perceptions of osteoporosis management—the overall theme, themes and subthemes
Competency when discussing fall prevenon in home-visit programmes
Collaboraon with other professionals
Perceiving possibilies Willingness to learn more about osteoporosis management
Willingness to idenfy individuals at high risk of fracture
Perceiving management of osteoporosis as ambiguous
Bone-specific medicaon was somemes perceived to be unsafe
Low priority condion and unclear responsibility for osteoporosis management
Perceiving barriers
Insufficient procedures, lack of me and not aware of the condion e risk
= subtheme
condition. They expressed the importance of discussing osteoporosis with colleagues, which may be a first step toward spotlighting the condition. During the interviews, the DNs started to realise that their patients could have osteoporosis. They expressed insufficient personal awareness for identifying patients at high risk of fracture even if these patients frequently visited the PHCC; many of these patients were never identified or diagnosed: I really haven’t had so many patients with fractures who’ve come my way. Naturally there’s the little old ladies who need casts removed, and then we send them to occupational therapists. When you think about it, there’s certainly a reason for these fractures (3, 233–242).
Insufficient knowledge about diagnosis and about fracture risk-assessment tools
= themes
= overall theme
The DNs perceived insufficient procedures and insufficient awareness of the condition. This could be one explanation to the low number of identified individuals at high risk of fracture.
Insufficient knowledge about diagnosis and about fracture risk assessment tools The DNs were concerned about their insufficient knowledge regarding osteoporosis and fracture risk assessment tools. Several did not consider themselves updated on new research results or new medication for patients with osteoporosis. Knowledge about different treatments or knowledge about the disease—just knowledge in general. Seems
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like we need to know everything or at least I do (4, 444–445). The DNs reported insufficient knowledge about the condition, and they expressed a need for updated information. Low-priority condition and unclear responsibility for osteoporosis management When the DNs were asked: Who is responsible for these patients, no one could give a clear answer. Opinions varied, and this might reflect the complexity of the question. The DNs reported that the responsibility and mandate were unclear. They did not know what health-care unit was responsible for identifying patients for testing and who should treat diagnosed patients. The DNs expressed that they were not allowed to give attention to patients at high risk of fracture. Other conditions had priority—probably because of the way in which financial compensation was set up in the PHC system. Conditions with higher priority were, for example, diabetes, dementia or hypertension; in these instances, procedures and mandates for managing the conditions were clear. The DNs revealed that osteoporosis was seldom discussed among health and medical care professionals. …there’s always time attend to diabetes patients or run memory tests—but managers wouldn’t be too happy if we started booking in patients to inform them about osteoporosis and various treatments; they’d wonder what we’re booking (1, 117–120). Not much talk of osteoporosis, I think. It’s….Well, it’s not a hot topic among physicians. So it’s never discussed in the break room or for that matter, at all. On the rounds….Nah, it…in some way, it’s uninteresting (3, 92-129). The DNs indicated that there were hindering factors for them to work with osteoporosis management. Bone-specific medication was sometimes perceived as unsafe The DNs were concerned about risks for adverse effects from bone-specific medications, especially if patients were old, had cognitive impairment, were living alone or were not motivated to take the medication. The DNs described how they sometimes were worried when giving the weekly pill (bisphosphonates), and concerns especially emerged because the DNs did not have opportunities to watch patients taking the pill. They often worried when they left patients in such a situation.
The tablet must be taken on an empty stomach. And they can’t lie down because the substance can irritate the oesophagus… (1, 11–13). The DNs perceived the bone-specific medication as unsafe. They were frequently worried about their patients when they dispensed this medication. Perceiving opportunities The perceiving opportunities theme was divided into four subthemes: 1. Competency when discussing fall prevention in home visit programs 2. Willingness to learn more about osteoporosis management 3. Collaboration with other professionals 4. Willingness to identify individuals at high risk of fracture
Competency when discussing fall prevention in home visit programs Home visits were considered opportunities to prevent falls and fractures, using a holistic approach; as mentioned earlier, fall prevention initiatives are regional programs. During the focus group interviews, the DNs revealed their enthusiasm and fall prevention skills. They thought that home visits might enable optimal opportunities to identify individuals at high risk of fracture. They expressed that when they met patients at high risk of fracture, they used their skills by recommending patients to visit (i) dieticians to discuss healthy diet or (ii) physiotherapists for strength and balance training advice. They reported that they also recommended contact with occupational therapists. These could assess the home environment for obstacles that increase risk for falls. The age-75 discussion affords great opportunities. Then you really go through everything. What they eat and drink and how much or how little they exercise and everything (4, 295–296). The DNs perceived competency when discussing fall prevention in the home visit programs. They indicated that these visits could enable optimal opportunities to identify individuals at high risk of fracture. Willingness to learn more about osteoporosis management Most DNs expressed willingness to learn more about osteoporosis management—preferably with other professionals. They also desired more information about osteoporosis from media and authorities.
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Yes, we want to know. New things and new research come along all the time. And it’s good that we get to know—and everyone really, media as well—should know about such a widespread disease. It’s so important to get the word out (4, 679–683). So I would really like, I would definitely go on a course like that (2, 1112). Data gathered using the descriptive background questionnaire revealed that just one nurse had sufficient knowledge about osteoporosis. The DNs indicated that continuing education could increase knowledge and awareness of osteoporosis. Collaboration with other professionals The DNs reported that they had some kind of collaboration with colleagues in other health and medical care professions concerning patients with osteoporosis. They expressed that frequency of collaboration between them and other health and medical care professionals varied considerably. One important reason seemed to be geographic distance that diminished opportunities for collaboration, but geographic closeness was no guarantee for collaboration. They expressed a desire to develop collaboration and build bridges with other health and medical care professionals, because they perceived that it could benefit their patients. Greater cooperation with, there again, physiotherapists and occupational therapists. I think. Particularly for fall risk and fall prevention in the home, which of course is a very big cause of fractures. Yes, but it would certainly be even greater (3, 665–674). The DNs perceived that increased collaboration with colleagues could improve osteoporosis management and could benefit the patients. Willingness to identify individuals at high risk of fracture The DNs were convinced of the importance of finding individuals at high risk of fracture. Early in the interviews, they expressed frustration about insufficient fracture risk assessment tools. Only a few of them knew about FRAX before. After they were briefly introduced to it, they agreed that FRAX could be used, for example, during home visits or during PHCC visits—to motivate patients to carry out preventive measures and/or try bone-specific medication. At the end of the interviews, all DNs expressed enthusiasm for being introduced to a tool that was accessible and easy to use. They were all positive about using FRAX in the future. And it’s very tempting (FRAX), because it was simple. You can’t complain that it takes time (1, 300).
Maybe we could use it (FRAX) during the home visits. To see that the risk is something like this or like that… (2, 690). DNs’ willingness to use FRAX could increase the number of individuals identified at high risk of fracture and they perceived that it could be useful in their daily work.
Discussion In this qualitative study, the aim was to investigate and describe DNs’ perceptions of osteoporosis management within Sweden’s primary health care system. The DNs perceived osteoporosis management as ambiguous (key theme). They gave vivid descriptions of barriers and opportunities that they perceived in their daily work. Our results are aligned with Vered et al. [13] who reported that fall prevention was the only aspect of osteoporosis for which nurses perceived their knowledge as high. In the present study, most DNs reported that they would rather recommend preventive measures, such as fall prevention, than bonespecific medication treatment. The DNs expressed concerns about bone-specific medication to be unsafe. Studies in other countries have reported that nurses describe their knowledge about osteoporosis as limited and that they want to learn more about the condition [14, 15]. These findings are aligned with results from the present study; here, DNs expressed that they did not have enough knowledge about osteoporosis and bone-specific medications but that they wanted to learn more about the condition. Concerns about risk of adverse effects from bone-specific medications emerged in the present study—a finding rarely frequent in earlier studies. In the present study, the DNs spontaneously reported their concerns about possible adverse effects from medications. This may be related to limitations in the DNs’ knowledge about benefits and risks for adverse effects that are associated with those medications. They were unsure about when bone-specific medication should be used. Results from other studies have shown that health and medical care professionals sometimes do not notice that the patients they meet may have osteoporosis because of insufficient awareness [13–16]. The present study confirms these findings. The DNs emphasised their insufficient awareness of risk factors and expressed that this could contribute to underdiagnosis and undertreatment. A clear mandate could increase DNs’ awareness and knowledge of the condition which could increase the numbers of persons treated with bone-specific medications. In Sweden, DNs are primary care specialists. They meet patients with osteoporosis regularly; consequently, they are in an ideal position to identify and motivate patients who have suffered fragility fractures for further assessment and
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treatment. The home visit programs [31] emerged in the interviews as optimal opportunities for discussing fall prevention—for which the DNs perceived that their professional skills were useful. The present study’s analysis found that the programs are renowned and well implemented among DNs who participated in the study. According to the DNs, one common problem related to home visits was that they only reached individuals who were interested in their own health. The DNs described that they did not actively search for individuals at high risk of fracture nor had structured procedures for osteoporosis management. Only a few DNs knew about FRAX, but at the end of the interview, they agreed that the instrument could be useful in identifying individuals at high risk of fracture. Today FRAX is thought of as a tool for general practitioners [10, 11]. In the future, DNs might use FRAX during home visits to identify individuals at high risk of fracture and to motivate patients to comply with bone-specific medication. To conclude, low priority of the condition may be one explanation for the described findings. Higher priority within the health-care system and a clear mandate for the DNs about the condition could facilitate and improve the osteoporosis management. In the future, continuing education could also be of interest to improve the quality of osteoporosis management. Further research is needed to investigate and evaluate effects of such interventions. Strengths and limitations Strengths of the study were that all participants worked as DNs at the time of the interviews and were all experienced nurses within the PHC system. They all met patients with osteoporosis regularly. Trustworthiness was achieved in several ways. Concerning credibility, the most appropriate methods for data collection and analysis of the research question were chosen. We found that thematic analysis would be suitable to describe the patterns of how the district nurses perceived osteoporosis management. Investigator triangulation was used when analysing data. First, all four researchers selected the meaning units independently. Consensus was reached by comparing and discussing the meaning units in the research group. The same procedure was used when creating themes and subthemes [17, 28, 32]. One more way to increase credibility was by choosing to interview DNs as they regularly meet patients with osteoporosis. Another way to achieve trustworthiness was by including the question of dependability. The interviews took place in a relatively short time span from December 2013 to March 2014. After the first interview, we reviewed the transcript and added one question in order to open up the interview. We do not think that this minimal change in the interview guide influenced the results.
The moderator and observers were not DNs, but they were health and medical care professionals who have knowledge about DNs’ roles. The whole research group had personal experience from clinical work in PHC but were not colleagues to the participants. The participants came from eight different PHCCs, which injected diversity into the group of the participants, although they all worked in urban areas. Workplace might have influenced the results as some DNs worked in home health care and others at PHCCs; this increased credibility achieving trustworthiness. No data were gathered regarding perceptions of DNs who work in rural areas, which can be seen as a limitation. The participants were all women, and there was a risk that only those who were interested in the issue participated, which may have influenced the results. Another limitation was that we had only 13 participants in total, which makes it difficult to ensure saturation in the material. One of the interviews had only two participants due to late withdrawals. Despite this, we chose to perform the interview and found the resulting material rich enough to be included in the data analysis.
Conclusions Osteoporosis was reported, by the district nurses, to be a lowpriority condition resulting in insufficient procedures, unawareness of the condition, insufficient knowledge about bone-specific medications and fracture risk assessment tools. This may be one explanation to the low number of patients that are treated with bone-specific medications. At the same time, the DNs perceived competency when they worked with fall prevention performing the home visits. To conclude, a higher priority of the condition in the healthcare system, systematic continuing education of the DNs and more collaboration between health-care professionals would benefit the patients. Acknowledgments A research grant from Vinnova mainly financed this study. Conflicts of interest Anne Claesson, Eva Toth-Pal, Päivi Piispanen and Helena Salminen declare that they have no conflict of interest.
Interview guide Background and context What comes to mind when you hear the word osteoporosis? Please describe the situation at your workplace regarding osteoporosis? Do you meet patients with osteoporosis?
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Do you meet patients who have fragility fractures due to low bone density? Patients with osteoporosis and fragility fractures often go unnoticed in primary care; what is your experience of this? Opportunities and barriers What opportunities do you see, when working with this patient group, which has suffered fragility fractures—patients who need to be identified, examined and eventually treated? What barriers do you see when working with this patient group? What kind of support would you need in this work? Who is responsible for these patients? What kind of collaboration would be needed between primary care physicians, district nurses and perhaps physiotherapists? A brief description and demonstration of FRAX® What do you think about the FRAX tool? How might the FRAX tool be used in primary care? The future In an ideal world, what care and treatments do you envision for patients with osteoporosis and fragility fractures? Thank you for taking time to share your thoughts and ideas.
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9. Åkesson K et al (2013) Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int 24:2135–2152 10. Kanis JA et al (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19(4):385–397 11. Ström O et al. (2013) Intervention thresholds for denosumab in the UK using a FRAX-based cost-effectiveness analysis 12. Kanis JA et al (2010) Development and the use of FRAX® in osteoporosis. Osteoporos Int 21(suppl 2):S407–S413 13. Vered I et al (2008) Nurses’ knowledge and perceptions about osteoporosis: a questionnaire survey. Int J Nurs Stud 45:847–854 14. Berarducci A et al (2002) The impact of osteoporosis continuing education on nurses’ knowledge and attitudes. J Contin Educ Nurs 33(5):210–216, quiz 238-9 15. Hunt AH et al (1998) Assessment of learning needs of registered nurses for osteoporosis education. Orthop Nurs 17(6):55–60 16. Giangregorio L et al (2007) Osteoporosis knowledge and information needs in healthcare professionals caring for patients with fragility fractures. Orthop Nurs Issue 26(1):27–35 17. Malterud K (2001) Qualitative research: standards, challenges, and guidelines. Lancet 358(9280):483–488 18. Hoang-Kim A et al (2014) Understanding osteoporosis and fractures: an introduction to use of qualitative research. Arch Orthop Trauma Surg 134:207–217 19. Hjalmarson HV et al (2007) Healthy risk awareness motivates fracture prevention behaviour: a grounded theory study of women with osteoporosis. Int J Qual Stud Health Well-being 2(4):236–245. doi: 10.1080/17482620701436939 20. Hansen C et al (2014) Women’s experiences of their osteoporosis diagnosis at the time of the diagnosis and 6 months later: a phenomenological hermeneutic study. Int J Qual Stud Health Well-being 9: 22438. doi:10.3402/qhw.v9.22438 21. Unson CG et al (2003) Nonadherence and osteoporosis treatment preferences of older women: a qualitative study. J Womens Health 12(10):1037–1045 22. Iversen MD et al (2011) Factors affecting adherence to osteoporosis medications: a focus group approach examining viewpoints of patients and providers. J Geriatr Phys Ther 34(2):72–81 23. Otmar R et al (2012) General medical practitioners’ knowledge and belief about osteoporosis and its investigation and management. Arch Osteoporos 7:107–114 24. Allin S et al (2014) Fracture risk assessment after BMD examination: whose job is it, anyway? Osteoporos Int 25:1445–1453 25. Bayliss M et al (2013) A conceptual and disease model framework for osteoporotic kyphosis. Osteoporos Int 24:2423–2432 26. Jaakkola E (2007) Physicians’ views on the influence of patient participation on treatment decisions—an explorative study. Health Serv Manag Res 20(3):174–182 27. Richardson JC et al (2004) GPs’ perceptions of the role of DEXA scanning: an exploratory study. Fam Pract 21(1):51–53 28. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Research Psychol 3:77–101 29. Twohig PL, Putnam W (2002) Group interviews in primary care research: advancing the state of the art or ritualized research? Fam Pract 19(3):278–284 30. Gaboury I et al (2013) Partnership for fragility care provision and prevention program (P4Bones): study protocol for a secondary fracture prevention pragmatic controlled trial. Implement Sci 8:10 31. Huss A et al (2008) Multidimensional preventive home visit programs for community dwelling older adults: a systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 63(3):298–307 32. Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 24:105–112
ORIGINAL ARTICLE
District nurses’ perceptions of osteoporosis management: a qualitative study A. Claesson & E. Toth-Pal & P. Piispanen & H. Salminen
Received: 8 September 2014 / Accepted: 20 February 2015 # International Osteoporosis Foundation and National Osteoporosis Foundation 2015
Abstract Summary Underdiagnosis of osteoporosis is common. This study investigated Swedish district nurses’ perceptions of osteoporosis management. They perceived the condition as having low priority, and the consequences of this perception were insufficient awareness of the condition and perceptions of bone-specific medication as unsafe. They perceived, though, competency when working with fall prevention. Introduction Undertreatment of patients with osteoporosis is common. Sweden’s medical care strategy dictates prioritisation of various conditions; while guidelines exist, osteoporosis is not prioritised. The aim of this study was to investigate district nurses’ perceptions of osteoporosis management within Sweden’s primary health care system. Methods Four semi-structured focus group interviews were conducted with 13 female district nurses. The interviews were analysed using thematic analysis. Results The overall theme was perceiving osteoporosis management as ambiguous. The themes were perceiving barriers and perceiving opportunities. These subthemes were linked to perceiving barriers: (i) insufficient procedures, lack of time and not aware of the condition; (ii) insufficient knowledge about diagnosis and about fracture risk assessment tools; (iii) low priority condition and unclear responsibility for osteoporosis management; and (iv) bone-specific medication was sometimes perceived to be unsafe. These subthemes were linked to perceiving opportunities: (i) professional competency when discussing fall prevention in home visit programs, (ii) willingness to learn more about osteoporosis management, (iii) collaboration with other professionals and (iv) willingness to identify individuals at high risk of fracture. A. Claesson (*) : E. Toth-Pal : P. Piispanen : H. Salminen Unit of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden e-mail: [email protected]
Conclusions Osteoporosis was reported, by the district nurses, to be a low-priority condition with consequences being unawareness of the condition, insufficient knowledge about bone-specific medications, fracture risk assessment tools and procedures. These may be some of the explanations for the undertreatment of osteoporosis. At the same time, the district nurses described competency performing the home visits, which emerged as an optimal opportunity to discuss fall prevention and to introduce FRAX with the aim to identify individuals at high risk of fracture. Keywords District nurses . Fragility fractures . Management . Osteoporosis . Qualitative study . Undertreatment
Introduction In the EU, nearly 30 million persons are estimated to have osteoporosis that leads to elevated risk for fragility fractures [1]. Sweden has one of the highest incidences of fragility fractures (about 107,000 cases annually) [2], and these fractures lead to substantial suffering and high costs for society. Pharmacological treatment accounts for only 2 % of total costs for fragility fractures in Sweden. Currently, a small percentage of women at high risk of fracture receive treatment [2], although bone-specific osteoporosis treatment enables costeffective fracture prevention [3]. Health and medical care professionals might not know that their patients have osteoporosis. Within Sweden’s primary health care (PHC) system, osteoporosis management can include (i) identifying persons at high risk of fracture and (ii) diagnosing and treating osteoporosis. In the PHC system, district nurses (DNs) are often responsible for fall prevention.
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Sweden’s national PHC strategy contains health and medical care guidelines and financial-related specifications that specify how to prioritise various conditions. Despite national and regional guidelines, osteoporosis is undertreated in PHC [1]. One exception, related to the prevention of fragility fractures, is the home visit program to the 75-year-old individuals who are patients in the primary health care centres (PHCCs). The programs, performed by the district nurses, are encouraged and funded by the county council and are therefore considered a high-priority task. Low adherence to prescribed medication is an increasing public health problem, especially for chronic diseases such as osteoporosis. While best practice guidelines for diagnosis and treatment of osteoporosis are available, many patients are not tested or treated [4–6]. Multiple reasons explain why this care gap exists, but organisational factors probably play a crucial role. There is clear demand for improvements in osteoporosis management, which could be facilitated with better structural support, for example, by implementing clinical decision support systems such as fracture liaison services [7–9]. The World Health Organization (WHO) designed the webbased fracture risk assessment tool (FRAX®) that calculates the 10-year absolute risk of osteoporotic fractures for the individual patient by factoring in several risks [10–12]; FRAX was originally designed for primary health care. Sweden’s National Board of Health and Welfare recommends FRAX for (i) estimating need for measurement of bone mineral density and (ii) decision support regarding bone-specific medication. Knowledge gaps in osteoporosis management have been reported among health and medical care professionals worldwide concerning osteoporosis management. Vered et al. found, in surveys, that knowledge about osteoporosis among DNs was limited and that the only osteoporosis-related factor that respondents felt confident about was advising patients on fall prevention [13]. Several studies in other countries confirm these results [14–16]. Qualitative research is useful for closing the osteoporosis management knowledge gaps because it enables investigators to better understand (i) people’s beliefs, attitudes or behaviours and (ii) the finer nuances of osteoporosis management [17, 18]. There are qualitative studies done on patients and their attitudes toward osteoporosis [19–21]. Among general practitioners, several qualitative studies were done on osteoporosis management and fragility fractures [22–27]. For example, structural factors, insufficient personal knowledge and general practitioners’ beliefs about osteoporosis management are reported as barriers to caring for the condition [23]. To conclude, there is limited knowledge about DNs’ perceptions of osteoporosis management. Consequently, the aim of the present study was to investigate and describe DNs’ perceptions of osteoporosis management.
Methods This qualitative, descriptive study gathered data via semistructured focus group interviews with DNs and analysed it using the thematic analysis method [28]. Participants The greater Stockholm area has about 200 PHCCs with four to five DNs at each centre. Via email, DNs from all PHCCs in Stockholm were invited to participate in the present study. The invitation and information about the study were also published on the Centre for Family Medicine (CeFAM) website. The study intended to have four to eight participants in each focus group and intended to have four to five focus groups in total [29]. Those who responded to the recruitment drive could sign up for one of five different dates. One of the offered dates did not get any participants. Unfortunately, late withdrawals resulted in only two participants in one group and three to four participants in the other three groups. In total, 13 DNs from eight PHCCs agreed to participate in four focus group interviews that were carried out between December 2013 and March 2014. Before starting each interview, the participants responded to a background questionnaire. Six of the participants had worked for more than 10 years as a DN; most of them estimated that they met patients with osteoporosis one to three times a month. Some DNs worked with home health care, others exclusively at the PHCCs and some within both contexts. Nine of the DNs believed that they did not have sufficient knowledge about osteoporosis, and all of them expressed a need for continuing education about the condition. For logistic reasons, all interviews were done at the same PHCC. Just one participant came from that PHCC. All participants were female (mean age, 50; age range, 28–63). They were financially compensated because the interviews occurred after working hours. The compensation was a fix fee approximately corresponding to a salary for a couple of hours of work. Data collection Articles with these keywords were searched for in the CINA HL, Ovid, Web of Science and PubMed databases: osteoporosis, fragility fractures, nurses and qualitative study. Only a few articles were found, and just one [30] suited the present study’s target group, i.e. DNs in PHCCs. The purpose of the literature search was to investigate the field and to identify knowledge gaps regarding osteoporosis management. We chose qualitative research with focus group interviews with the aim to investigate and to better understand—in depth—the DNs’ perceptions of the osteoporosis management [17, 18]. Focus group interviews activate participants to
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express their perceptions of a specific topic by discussing with each other. When using focus groups to gather data, researchers must recruit persons who have something to say about the chosen topic. Group size may range from 4 to 12 participants; the groups often consist of five to eight persons [29]. The interviews for the present study took 60–90 min. One moderator and one observer attended each interview; the first author moderated each session. The two observers belonged to the research team. One observer was present at the first two interviews, and the other one was present at the last two [29]. The moderator role is important. As per Twohig and Putnam, moderators play a key role in successful group conduct [29], and they must involve all participants in the discussions. The moderator for the present study was a physiotherapist; the observers were general practitioners. If necessary, the observers supported the moderator and they observed an interaction among participants and among the moderator and participants [29]. The moderators and observers were skilled in focus group facilitation and took steps to avoid any inadvertent or undue influence on the study participants, such as avoiding discussion of their own views [17]. To facilitate the interviews, the moderator used an interview guide with open-ended questions that covered three to four subject areas (see Appendix). Interview questions dealt with (i) opportunities, barriers, collaboration and responsibility for osteoporosis management and (ii) the use of FRAX. A brief demonstration of FRAX was a part of each group session. The participants were shown the FRAX website and were introduced to the risk factors included in FRAX. The moderator and the observer reviewed field notes after each session. All sessions were recorded, transcribed verbatim and then anonymised.
4. Identified one key theme by answering this question: How did the participants perceive osteoporosis management? 5. Identified themes and subthemes. 6. Validated themes and subthemes by searching for and unearthing corresponding words and phrases that several of the participants repeated during the interviews. Here, triangulation of the observers was used to validate results, because all research team members participated in collecting the data [17]. We also used triangulation during the analysis as all researchers compared and discussed preliminary ideas until consensus was reached. 7. Selected quotes from all interviews to illustrate main findings that emerged from the analysis. All research members independently developed the thematic analysis themes and subthemes and then discussed them until consensus was reached. The ethical review board in Stockholm approved the study (2013-1782-31-4).
Results The analysis identified one overall theme—perceiving osteoporosis management as ambiguous. DNs described how they were striving to overcome existing barriers and how they could see opportunities to osteoporosis management. Thus, two themes emerged: perceiving barriers and perceiving opportunities. Each theme had four subthemes. Figure 1 describes a model of the overall theme, themes and subthemes. Perceiving barriers
Data analysis The present study applied the thematic analysis method. As per Braun and Clarke, thematic analysis is used to identify, analyse and subsequently report patterns or themes within data [28]. Data were analysed in these stages: 1. Became familiar with the data (e.g. audio recordings were reviewed as soon as possible to detect information that repeatedly emerged—for early stage analysis—before doing the next interview). Field notes were incorporated in the analysis. Minor adjustments of the interview guide were made after the first interview. 2. Transcribed the interviews. 3. Read the transcribed text and reread it to identify new information and to increase trustworthiness. The text was read independently first by all four members and then by the whole group.
The perceiving barriers theme was divided into four subthemes: 1. Insufficient procedures, lack of time and not aware of the condition 2. Insufficient knowledge about diagnosis and about fracture risk assessment tools 3. Low-priority condition and unclear responsibility for osteoporosis management 4. Bone-specific medication was sometimes perceived to be unsafe
Insufficient procedures, lack of time and not aware of the condition The DNs reported that they did not have procedures for finding these patients and that they were unaware of the
Osteoporos Int Fig. 1 A model of district nurses’ perceptions of osteoporosis management—the overall theme, themes and subthemes
Competency when discussing fall prevenon in home-visit programmes
Collaboraon with other professionals
Perceiving possibilies Willingness to learn more about osteoporosis management
Willingness to idenfy individuals at high risk of fracture
Perceiving management of osteoporosis as ambiguous
Bone-specific medicaon was somemes perceived to be unsafe
Low priority condion and unclear responsibility for osteoporosis management
Perceiving barriers
Insufficient procedures, lack of me and not aware of the condion e risk
= subtheme
condition. They expressed the importance of discussing osteoporosis with colleagues, which may be a first step toward spotlighting the condition. During the interviews, the DNs started to realise that their patients could have osteoporosis. They expressed insufficient personal awareness for identifying patients at high risk of fracture even if these patients frequently visited the PHCC; many of these patients were never identified or diagnosed: I really haven’t had so many patients with fractures who’ve come my way. Naturally there’s the little old ladies who need casts removed, and then we send them to occupational therapists. When you think about it, there’s certainly a reason for these fractures (3, 233–242).
Insufficient knowledge about diagnosis and about fracture risk-assessment tools
= themes
= overall theme
The DNs perceived insufficient procedures and insufficient awareness of the condition. This could be one explanation to the low number of identified individuals at high risk of fracture.
Insufficient knowledge about diagnosis and about fracture risk assessment tools The DNs were concerned about their insufficient knowledge regarding osteoporosis and fracture risk assessment tools. Several did not consider themselves updated on new research results or new medication for patients with osteoporosis. Knowledge about different treatments or knowledge about the disease—just knowledge in general. Seems
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like we need to know everything or at least I do (4, 444–445). The DNs reported insufficient knowledge about the condition, and they expressed a need for updated information. Low-priority condition and unclear responsibility for osteoporosis management When the DNs were asked: Who is responsible for these patients, no one could give a clear answer. Opinions varied, and this might reflect the complexity of the question. The DNs reported that the responsibility and mandate were unclear. They did not know what health-care unit was responsible for identifying patients for testing and who should treat diagnosed patients. The DNs expressed that they were not allowed to give attention to patients at high risk of fracture. Other conditions had priority—probably because of the way in which financial compensation was set up in the PHC system. Conditions with higher priority were, for example, diabetes, dementia or hypertension; in these instances, procedures and mandates for managing the conditions were clear. The DNs revealed that osteoporosis was seldom discussed among health and medical care professionals. …there’s always time attend to diabetes patients or run memory tests—but managers wouldn’t be too happy if we started booking in patients to inform them about osteoporosis and various treatments; they’d wonder what we’re booking (1, 117–120). Not much talk of osteoporosis, I think. It’s….Well, it’s not a hot topic among physicians. So it’s never discussed in the break room or for that matter, at all. On the rounds….Nah, it…in some way, it’s uninteresting (3, 92-129). The DNs indicated that there were hindering factors for them to work with osteoporosis management. Bone-specific medication was sometimes perceived as unsafe The DNs were concerned about risks for adverse effects from bone-specific medications, especially if patients were old, had cognitive impairment, were living alone or were not motivated to take the medication. The DNs described how they sometimes were worried when giving the weekly pill (bisphosphonates), and concerns especially emerged because the DNs did not have opportunities to watch patients taking the pill. They often worried when they left patients in such a situation.
The tablet must be taken on an empty stomach. And they can’t lie down because the substance can irritate the oesophagus… (1, 11–13). The DNs perceived the bone-specific medication as unsafe. They were frequently worried about their patients when they dispensed this medication. Perceiving opportunities The perceiving opportunities theme was divided into four subthemes: 1. Competency when discussing fall prevention in home visit programs 2. Willingness to learn more about osteoporosis management 3. Collaboration with other professionals 4. Willingness to identify individuals at high risk of fracture
Competency when discussing fall prevention in home visit programs Home visits were considered opportunities to prevent falls and fractures, using a holistic approach; as mentioned earlier, fall prevention initiatives are regional programs. During the focus group interviews, the DNs revealed their enthusiasm and fall prevention skills. They thought that home visits might enable optimal opportunities to identify individuals at high risk of fracture. They expressed that when they met patients at high risk of fracture, they used their skills by recommending patients to visit (i) dieticians to discuss healthy diet or (ii) physiotherapists for strength and balance training advice. They reported that they also recommended contact with occupational therapists. These could assess the home environment for obstacles that increase risk for falls. The age-75 discussion affords great opportunities. Then you really go through everything. What they eat and drink and how much or how little they exercise and everything (4, 295–296). The DNs perceived competency when discussing fall prevention in the home visit programs. They indicated that these visits could enable optimal opportunities to identify individuals at high risk of fracture. Willingness to learn more about osteoporosis management Most DNs expressed willingness to learn more about osteoporosis management—preferably with other professionals. They also desired more information about osteoporosis from media and authorities.
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Yes, we want to know. New things and new research come along all the time. And it’s good that we get to know—and everyone really, media as well—should know about such a widespread disease. It’s so important to get the word out (4, 679–683). So I would really like, I would definitely go on a course like that (2, 1112). Data gathered using the descriptive background questionnaire revealed that just one nurse had sufficient knowledge about osteoporosis. The DNs indicated that continuing education could increase knowledge and awareness of osteoporosis. Collaboration with other professionals The DNs reported that they had some kind of collaboration with colleagues in other health and medical care professions concerning patients with osteoporosis. They expressed that frequency of collaboration between them and other health and medical care professionals varied considerably. One important reason seemed to be geographic distance that diminished opportunities for collaboration, but geographic closeness was no guarantee for collaboration. They expressed a desire to develop collaboration and build bridges with other health and medical care professionals, because they perceived that it could benefit their patients. Greater cooperation with, there again, physiotherapists and occupational therapists. I think. Particularly for fall risk and fall prevention in the home, which of course is a very big cause of fractures. Yes, but it would certainly be even greater (3, 665–674). The DNs perceived that increased collaboration with colleagues could improve osteoporosis management and could benefit the patients. Willingness to identify individuals at high risk of fracture The DNs were convinced of the importance of finding individuals at high risk of fracture. Early in the interviews, they expressed frustration about insufficient fracture risk assessment tools. Only a few of them knew about FRAX before. After they were briefly introduced to it, they agreed that FRAX could be used, for example, during home visits or during PHCC visits—to motivate patients to carry out preventive measures and/or try bone-specific medication. At the end of the interviews, all DNs expressed enthusiasm for being introduced to a tool that was accessible and easy to use. They were all positive about using FRAX in the future. And it’s very tempting (FRAX), because it was simple. You can’t complain that it takes time (1, 300).
Maybe we could use it (FRAX) during the home visits. To see that the risk is something like this or like that… (2, 690). DNs’ willingness to use FRAX could increase the number of individuals identified at high risk of fracture and they perceived that it could be useful in their daily work.
Discussion In this qualitative study, the aim was to investigate and describe DNs’ perceptions of osteoporosis management within Sweden’s primary health care system. The DNs perceived osteoporosis management as ambiguous (key theme). They gave vivid descriptions of barriers and opportunities that they perceived in their daily work. Our results are aligned with Vered et al. [13] who reported that fall prevention was the only aspect of osteoporosis for which nurses perceived their knowledge as high. In the present study, most DNs reported that they would rather recommend preventive measures, such as fall prevention, than bonespecific medication treatment. The DNs expressed concerns about bone-specific medication to be unsafe. Studies in other countries have reported that nurses describe their knowledge about osteoporosis as limited and that they want to learn more about the condition [14, 15]. These findings are aligned with results from the present study; here, DNs expressed that they did not have enough knowledge about osteoporosis and bone-specific medications but that they wanted to learn more about the condition. Concerns about risk of adverse effects from bone-specific medications emerged in the present study—a finding rarely frequent in earlier studies. In the present study, the DNs spontaneously reported their concerns about possible adverse effects from medications. This may be related to limitations in the DNs’ knowledge about benefits and risks for adverse effects that are associated with those medications. They were unsure about when bone-specific medication should be used. Results from other studies have shown that health and medical care professionals sometimes do not notice that the patients they meet may have osteoporosis because of insufficient awareness [13–16]. The present study confirms these findings. The DNs emphasised their insufficient awareness of risk factors and expressed that this could contribute to underdiagnosis and undertreatment. A clear mandate could increase DNs’ awareness and knowledge of the condition which could increase the numbers of persons treated with bone-specific medications. In Sweden, DNs are primary care specialists. They meet patients with osteoporosis regularly; consequently, they are in an ideal position to identify and motivate patients who have suffered fragility fractures for further assessment and
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treatment. The home visit programs [31] emerged in the interviews as optimal opportunities for discussing fall prevention—for which the DNs perceived that their professional skills were useful. The present study’s analysis found that the programs are renowned and well implemented among DNs who participated in the study. According to the DNs, one common problem related to home visits was that they only reached individuals who were interested in their own health. The DNs described that they did not actively search for individuals at high risk of fracture nor had structured procedures for osteoporosis management. Only a few DNs knew about FRAX, but at the end of the interview, they agreed that the instrument could be useful in identifying individuals at high risk of fracture. Today FRAX is thought of as a tool for general practitioners [10, 11]. In the future, DNs might use FRAX during home visits to identify individuals at high risk of fracture and to motivate patients to comply with bone-specific medication. To conclude, low priority of the condition may be one explanation for the described findings. Higher priority within the health-care system and a clear mandate for the DNs about the condition could facilitate and improve the osteoporosis management. In the future, continuing education could also be of interest to improve the quality of osteoporosis management. Further research is needed to investigate and evaluate effects of such interventions. Strengths and limitations Strengths of the study were that all participants worked as DNs at the time of the interviews and were all experienced nurses within the PHC system. They all met patients with osteoporosis regularly. Trustworthiness was achieved in several ways. Concerning credibility, the most appropriate methods for data collection and analysis of the research question were chosen. We found that thematic analysis would be suitable to describe the patterns of how the district nurses perceived osteoporosis management. Investigator triangulation was used when analysing data. First, all four researchers selected the meaning units independently. Consensus was reached by comparing and discussing the meaning units in the research group. The same procedure was used when creating themes and subthemes [17, 28, 32]. One more way to increase credibility was by choosing to interview DNs as they regularly meet patients with osteoporosis. Another way to achieve trustworthiness was by including the question of dependability. The interviews took place in a relatively short time span from December 2013 to March 2014. After the first interview, we reviewed the transcript and added one question in order to open up the interview. We do not think that this minimal change in the interview guide influenced the results.
The moderator and observers were not DNs, but they were health and medical care professionals who have knowledge about DNs’ roles. The whole research group had personal experience from clinical work in PHC but were not colleagues to the participants. The participants came from eight different PHCCs, which injected diversity into the group of the participants, although they all worked in urban areas. Workplace might have influenced the results as some DNs worked in home health care and others at PHCCs; this increased credibility achieving trustworthiness. No data were gathered regarding perceptions of DNs who work in rural areas, which can be seen as a limitation. The participants were all women, and there was a risk that only those who were interested in the issue participated, which may have influenced the results. Another limitation was that we had only 13 participants in total, which makes it difficult to ensure saturation in the material. One of the interviews had only two participants due to late withdrawals. Despite this, we chose to perform the interview and found the resulting material rich enough to be included in the data analysis.
Conclusions Osteoporosis was reported, by the district nurses, to be a lowpriority condition resulting in insufficient procedures, unawareness of the condition, insufficient knowledge about bone-specific medications and fracture risk assessment tools. This may be one explanation to the low number of patients that are treated with bone-specific medications. At the same time, the DNs perceived competency when they worked with fall prevention performing the home visits. To conclude, a higher priority of the condition in the healthcare system, systematic continuing education of the DNs and more collaboration between health-care professionals would benefit the patients. Acknowledgments A research grant from Vinnova mainly financed this study. Conflicts of interest Anne Claesson, Eva Toth-Pal, Päivi Piispanen and Helena Salminen declare that they have no conflict of interest.
Interview guide Background and context What comes to mind when you hear the word osteoporosis? Please describe the situation at your workplace regarding osteoporosis? Do you meet patients with osteoporosis?
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Do you meet patients who have fragility fractures due to low bone density? Patients with osteoporosis and fragility fractures often go unnoticed in primary care; what is your experience of this? Opportunities and barriers What opportunities do you see, when working with this patient group, which has suffered fragility fractures—patients who need to be identified, examined and eventually treated? What barriers do you see when working with this patient group? What kind of support would you need in this work? Who is responsible for these patients? What kind of collaboration would be needed between primary care physicians, district nurses and perhaps physiotherapists? A brief description and demonstration of FRAX® What do you think about the FRAX tool? How might the FRAX tool be used in primary care? The future In an ideal world, what care and treatments do you envision for patients with osteoporosis and fragility fractures? Thank you for taking time to share your thoughts and ideas.
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