Background Osteoporosis involves thinning of the bones, making them more prone to break. The most common osteoporotic fracture is a vertebral fracture (OVF). People with OVFs are at high risk of further fractures. To reduce this risk, guidelines recommend prescription of bone protection therapies to people who have experienced a fracture. However, many patients do not receive diagnosis. Understanding patient pathways to treatment for OVFs will provide information to improve practice and aid in effective identification and management.
Objectives To understand and characterise patient pathways to treatment for OVFs.
Methods Twenty-three semi-structured qualitative interviews were conducted with patients aged ≥50 years with diagnosis of OVF. Patients were recruited through two hospitals in England and were purposively sampled to capture variation in pathways to diagnosis, sex, age, comorbidities and other relevant characteristics. Interviews were audio-recorded, transcribed and analysed thematically, with themes transposed onto key stages of the patient pathway.
Results Several factors influenced patient pathways to treatment:
Patient appraisal and self-management: Characteristics and attitudes towards back pain impacted treatment-seeking behaviour. Patients who appraised their pain as ‘different’, severe or disruptive, or associated with an injury such as a fall, were more likely to seek help. Limited availability of information about OVFs and risk factors meant most patients did not associate symptoms with a potential OVF. Factors contributing to delayed consultation included the normalisation of back pain and prioritisation of comorbid conditions. Several misappraised their symptoms as a “pulled muscle” or other minor injury. Many adopted strategies to manage pain, including use of painkillers, lying flat or resting. For some, a lack of improvement in symptoms over time, combined with worsening pain, created a ‘tipping point’ in seeking care. There was a moral dimension for some patients who did not want to “bother” healthcare professionals.
Healthcare professional appraisal: Differential diagnosis was a barrier to treatment and healthcare professionals interpreted OVF pain as broken ribs, muscular pain, kidney pain or sciatica. GPs tended to instigate watchful waiting, in which patients were asked to re-consult if pain did not improve. Feeling disbelieved caused some patients to become disillusioned and reluctant to re-consult and a small number of patients presented at Accident and Emergency. Those already having treatment for musculoskeletal conditions with access to specialist care, were more likely to receive timely diagnosis.
Communication of diagnosis: Patients discussed multiple methods of communication, including written communication and clinical conversations. Several expressed confusion around the use of unfamiliar medical terminology, the implications of OVFs, how many OVFs they had experienced and how they had been identified.
Treatment initiation: Bone protection therapies were not consistently prescribed after diagnosis. Patients who were familiar with these therapies were unsure whether treatment should be initiated in primary or secondary care. Patients described how they felt a need to be proactive by arranging appointments and asking for treatment.
Conclusion The study provides novel findings about patient pathways to treatment and will be used to identify targeted solutions to improve management of OVFs. This work addresses stages of the Model of Pathways to Treatment and provides detailed understanding of patients’ experiences of these stages. Further work with healthcare professionals in primary care is underway to identify additional system-level factors that may impact patients’ journeys to treatment.
References Scott, S.E., et al., The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol, 2013. 18(1): p. 45-65.
Acknowledgements This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) programme NIHR201523. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Disclosure of Interests None declared
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