Defining the key clinician skills and attributes for competency in managing patients with osteoporosis and fragility fractures.

Osteoporosis and fragility fractures are managed by clinicians across many medical specialties. The key competencies of clinicians delivering bone health care have not been systematically established. We aimed to develop a decision rule to define the threshold of adequate skills and attributes associated with clinical competency in bone health for a clinician serving as a referral source for bone health care. Using a modified-Delphi method, we invited clinicians with expertise in treating osteoporosis and representatives of patient advocacy groups focused on bone health to create a list of desirable characteristics of a clinician with bone health competency. Characteristics were defined as "attributes" with "levels" within each attribute. Participants prioritized levels by perceived importance. To identify the cut points for defining adequate competency, participants next ranked 20 hypothetical clinicians defined by various levels of attributes from highest to lowest likelihood of having adequate bone health competency. Lastly, we conducted a discrete choice experiment (DCE) to generate a weighted score for each attribute/level. The threshold for competency was a priori determined as the total weighted score at which ≥70% of participants agreed a clinician had adequate bone health competency. Thirteen participants generated lists of desirable characteristics, and 30 participants ranked hypothetical scenarios and participated in the DCE. The modified-Delphi exercise generated 108 characteristics, which were reduced to 8 categories with 20 levels with associated points. The maximum possible score was 25 points. A summed threshold score of >12 points classified a clinician as having adequate bone health competency. We developed a numeric additive decision rule to define clinicians across multiple specialties as having adequate competency in managing bone health/osteoporosis. Our data provide a rigorously defined criteria for a clinician with competency in bone health and can be used to quantitate the skills of clinicians participating in bone health research and clinical care.

Osteoporosis and fragility fractures are managed by clinicians across many medical specialties. The key skills of clinicians delivering bone health care have not been systematically established. We invited clinicians with expertise in treating osteoporosis and representatives of patient advocacy groups focused on bone health to create a list of desirable characteristics of a clinician with bone health competency. Participants next ranked 20 hypothetical clinicians defined by various characteristics from highest to lowest likelihood of having adequate bone health competency. Lastly, we generated a weighted score for each characteristic. The threshold for competency was determined as the total weighted score at which ≥70% of participants agreed a clinician had adequate bone health competency. The maximum possible score was 25 points, and a summed threshold score of >12 points classified a clinician as having adequate bone health competency. Our data provide a rigorously defined criteria for a clinician with competency in bone health and can be used to quantitate the skills of clinicians participating in bone health research and clinical care.

An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture.

Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the Emergency Department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in 2 tertiary-care EDs and triggered by the term "fall" in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2,608 EMR alerts among 2,509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.

Long-Term Mortality Following SARS-CoV-2 Infection in Rural Versus Urban Dwellers with Autoimmune or Inflammatory Rheumatic Disease (AIRD): A Retrospective Cohort Analysis from the National COVID Cohort Collaborative (N3C).

OBJECTIVE: Autoimmune or inflammatory rheumatic diseases (AIRD) increase the risk for poor COVID-19 outcomes. While rurality is associated with higher post-COVID-19 mortality in the general population, whether rurality elevates this risk among people with AIRD is unknown. We assessed associations between rurality and post-COVID-19 all-cause mortality, up to 2 years post-infection, among people with AIRD using a large, nationally sampled U.S. METHODS: This retrospective study utilized the National COVID Cohort Collaborative, a medical-records repository containing COVID-19 patient data. We included adults with ≥2 AIRD diagnostic codes and a COVID-19 diagnosis documented between April 2020 and March 2023. Rural residency was categorized using patient residential ZIP Codes. We adjusted for AIRD medications and glucocorticoid usage, age, sex, race and ethnicity, tobacco/substance usage, comorbid burden, and SARS-CoV-2 variant-dominant periods. Multivariable Cox Proportional Hazards with inverse probability treatment weighting assessed associations between rurality and 2-year, all-cause mortality. RESULTS: Among the 86,467 SARS-CoV-2-infected persons with AIRD, we observed a higher risk for 2-year post-COVID-19 mortality in rural versus urban dwellers. Rural-residing persons with AIRD had higher 2-year, all-cause mortality risk (aHR 1.24, 95% CI 1.19-1.29). Use of glucocorticoids, immunosuppressives, and rituximab was associated with a higher risk for 2-year post-COVID-19 mortality, while risk with non-biologic or biologic DMARDs was lower. CONCLUSION: Rural residence in people with AIRD was independently associated with higher post-COVID-19 2-year mortality in a large U.S. cohort after adjusting for background risk factors. Policymakers and healthcare providers should consider these findings when designing interventions to improve outcomes in people with AIRD following SARS-CoV-2 infection, especially among higher-risk rural residents.