Questionnaire survey of advice given to patients with fractures

Osteoporosis Assessment and Treatment in Older Patients who Have Sustained a Hip Fracture

Background and aims

Currently fracture sufferers are not being assessed or treated for osteoporosis. Osteoporosis guidelines differ in their secondary prevention recommendations, with the Scottish Intercollegiate Guideline Network (SIGN) advocating bone densitometry in all fracture patients and anti-resorptive treatment only if evidence-based criteria are confirmed, but the National Institute of Clinical Excellence (NICE) technology appraisal recommends treatment for all older females without this bone densitometry confirmation. We aimed to determine the rate of referral for bone densitometry, the numbers achieving SIGN criteria for anti-resorptive therapy, and the rate of osteoporosis treatment in patients with hip fracture

Methods

A retrospective review of all patients older than 65 years who had sustained a hip fracture in Tayside between April 2003 and July 2005 was performed

Results

Only 8.6% of hip fracture patients underwent bone densitometry, of which 90.6% of females older than 75 years met SIGN criteria for anti-resorptive treatment. 74.3% of all patients referred for bone densitometry were treated with an anti-resorptive agent, compared to only to 12.7% of the large majority group who were not assessed for osteoporosis

Conclusion

Osteoporosis investigation and therefore treatment remains sub-optimal in hip fracture patients. Almost all females, older than 75 years, with a hip fracture met evidence-based criteria for anti-resorptive treatment. NICE guidance, recommending anti-resorptive treatment without bone densitometry confirmation of reduced bone mineral density, should maybe be implemented for this specific group of patients in an attempt to increase osteoporosis treatment rates.

Perception of severe osteoporosis amongst medical doctors in South Korea: Awareness, impact, and treatment

OBJECTIVES

Little is currently known about the issues surrounding management and treatment of severe osteoporosis in South Korea. Our objective was to assess doctors' views on the perception, diagnosis, and treatment of severe osteoporosis.

METHODS

Face-to-face interviews were conducted (16 February-13 March 2015) with 100 doctors (specialists in orthopedic surgery, endocrinology, neurosurgery, family medicine, or rheumatology) who treated ≥5 severe osteoporosis (T-score ≤ -2.5, plus fracture) patients per month. Respondent demographic characteristics, their perception of severe osteoporosis, its impact and treatment, and their views on current practice and unmet needs were assessed.

RESULTS

Of 416 doctors approached, 100 completed the survey (24% response rate). Most doctors (90%) specialized in orthopedic surgery, endocrinology, or neurosurgery. When diagnosing severe osteoporosis, most doctors (79%) considered both bone mineral density and fracture. Almost all doctors (≥91%) ranked disease impact and seriousness highly, but much fewer (≤25%) doctors thought society agreed. Most doctors (89%) had concerns with current treatments, switching treatments because of the efficacy and safety of bisphosphonates (>89%), the efficacy of selective estrogen receptor modulators (>71%), and the high cost of parathyroid hormone (>73%). Parathyroid hormone was ranked highest for efficacy and was preferentially prescribed to severe osteoporosis patients (mean 32.2% of prescriptions) compared with osteoporosis patients overall (3.7%). "Limitations with reimbursement" was the most commonly cited (76%) unmet need.

CONCLUSIONS

There are concerns with the safety, efficacy, and affordability of current treatments for severe osteoporosis in South Korea, as well as a perceived lack of disease awareness amongst patients and doctors.

Fracture Liaison Services in the United Kingdom

Fracture Liaison Services (FLS) have been demonstrated to be a clinically and cost-effective means of providing secondary preventive care for patients presenting with new fragility fractures. This review summarizes the emergence and widespread adoption of the FLS model in the United Kingdom. Large scale national audits have clearly illustrated the need for FLS by revealing the care gap experienced by the majority of patients who suffer fragility fractures. Since 2003, FLS has featured increasingly more prominently in relevant national professional guidance. During the last 5 years that professional consensus has led to FLS being embedded in government policy on fracture prevention. Quality incentives have been created to encourage hospitals and primary care providers to pro-actively deliver best practice. The strategic approaches taken and lessons learned in the UK may have relevance to quality improvement efforts in other jurisdictions.

Do the hospitalized patients with osteoporotic fractures require endocrinologists' help?

AIM

Osteoporotic fractures are a crucial cause of morbidity and mortality in patients with fragility fractures and impose huge economic burden on health care services. Orthopedic surgeons are often the only clinicians seen by the patients with osteoporotic fractures. The improvement in osteoporosis management is an urgent require; therefore, the aim of this study was to determine the efficacy of consultation with an endocrinologist in osteoporosis management of patients with a fragility fracture.

METHODS

This survey was undertaken in three phases that focused on patients with osteoporotic fractures who were admitted to five tertiary care, level-I, trauma hospital. Patients were evaluated through a questionnaire which was designed to determine whether physicians manage underlying osteoporosis.

RESULTS

The number of patients who underwent a bone mineral density test increased from a rate of 3.6% to 91% after the intervention, as calcium and vitamin D supplementation from 18% to 92%, bisphosphonate prescription from 0.5% to 83%. Also, the overall medication usage increased from 9% to 87%. A small number of patients (3%) were followed up in contrast to a rate of 73% in the third phase.

CONCLUSION

Orthopedic surgeons are not completely engaged in osteoporosis care for patients with a fragility fracture; therefore, a consultation with an endocrinologist is required to enable orhopedic surgeons to provide an effective osteoporosis care for their patients with an osteoporotic fracture.

Secondary prevention program for osteoporotic fractures and long-term adherence to bisphosphonates

Our purpose was to assess the impact of a secondary prevention program for osteoporotic fractures in patients with fragility fracture and to determine its effect on long-term compliance with bisphosphonate treatment. Persistence with bisphosphonate use was 71%. Attending follow-up visits was the only variable significantly associated with adherence to bisphosphonates.

INTRODUCTION

The aim of this study is to assess the impact a secondary prevention program for osteoporotic fractures in a prospective cohort of patients with at least one fragility fracture and to determine the effect of this intervention on long-term compliance with bisphosphonate treatment.

METHODS

All patients older than 50 years with a fragility fracture attended at the emergency department over a 2-year period were appointed for a clinical visit through a telephone call. Two follow-up controls at 4 and 12 months were scheduled. After a mean of 4 years, a telephone survey was conducted to assess compliance with treatment.

RESULTS

Of 683 eligible patients, 380 (55.6%) were visited at the hospital. Previous treatment with bisphosphonates was recorded in 17.9% of patients. DXA scan was considered normal in 61 patients and revealed osteopenia in 184 and osteoporosis in 135. Pharmacological treatment was indicated in 90% of patients (alendronate in 76%). Among 241 patients who participated in the survey, eight patients had new fractures (four were on treatment with bisphosphonates and four had discontinued treatment). Of 187 patients in which bisphosphonates were prescribed at the initial visit, 133 (71.1%) continued using bisphosphonates. Attendance of scheduled visits was associated with adherence to bisphosphonates (odds ratio, 3.33; 95% confidence interval, 2.99-3.67).

CONCLUSIONS

The efficacy of the program to recruit patients was 55%. In patients visited at the hospital, treatment with bisphosphonates increased from 17.9% to 76%. Persistence with bisphosphonate use after a mean of 4 years was 71%. Attending follow-up visits was significantly associated with adherence to bisphosphonates.

Primary-care prescribing of anti-osteoporotic-type medications following hospitalisation for fractures

PURPOSE

We examined the prescribing of antiosteoporotic medications pre- and post hospital admission in patients with fragility fractures as well as factors associated with prescribing of these treatments following admission.

METHODS

We identified all patients aged ≥ 55 years at a large teaching hospital between 2005 and 2008 with a fracture using the Hospital In-Patient Enquiry (HIPE) system. These data were linked to prescribing data from the Health Service Executive Primary Care Reimbursement Services (HSE-PCRS) scheme before and after discharge (821 patients). Logistic regression analysis was used to examine the likelihood of prescription of antiosteoporotic medication pre- and post discharge in relation to year of discharge, age, gender, and type of fracture.

RESULTS

Prescribing of antiosteoporotic treatment before fracture increased from 2.6% [95% confidence interval (CI) 2.23-2.93%] in 2005 to 10.6% (95% CI 9.32-11.86) by 2008, whereas post fracture prescribing increased from 11% (95% CI 9.64-12.36) to 47% (95% CI 43.6-50.3). In patients discharged from hospital in 2007, postfracture prescribing was 31.8% (95% CI 28.66-35.02) at 12 months, increasing to 50.3% (95% CI 46.6-53.9) at 24 months. The highest rate of prescribing was in the 65- to 69-year age group [odds ratio (OR) 8.51, 95% CI 1.75-41.35]. Patients discharged in 2008 were eight times more likely to be treated than patients discharged in 2005 (OR 8.01, 95% CI 4.55-14.09).

CONCLUSION

The percentage of patients on antiosteoporotic treatment post fracture increased significantly from 2005 to 2008. This may be largely due to the introduction of the Osteoporosis Clinic to the hospital in 2005.

Recognizing osteoporosis and its consequences in Quebec (ROCQ): Background, rationale, and methods of an anti-fracture patient health-management programme

Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) is an ongoing patient health-management programme aimed at evaluating the diagnostic and treatment care gaps for osteoporosis following a fragility fracture, and subsequently initiating and measuring interventions to decrease these gaps in women 50 years of age and over. Hospitals servicing approximately half of the population of the Province of Quebec (Canada) are participating in the ROCQ programme. Women with fragility and traumatic fractures are approached during their visit to a cast or outpatient clinic and are subsequently contacted by telephone 0 to 16 weeks after their fracture (phase 1). During the first phone contact, they are invited to answer a questionnaire aimed at identifying the specific circumstances of their fracture and asked to participate in an observational study that could last up to 18 months. Based on this initial questionnaire, patients are classified as having either experienced a fragility or traumatic fracture. During the first phone contact, there is no reference about the possible association between the fracture and osteoporosis and no investigation or intervention is proposed. Six to eight months after the fracture event (phase 2), women are again contacted by phone to complete a questionnaire that evaluates the diagnostic and treatment rates for osteoporosis. At this phase of the programme, women with fragility fractures are randomized to one of the three following intervention groups: 1) Educational Video Group, 2) Documentation Group and 3) Control Group. Participants are contacted 12 to 14 months after the intervention (phase 3) to evaluate the efficacy of the interventions on the diagnosis and treatment rates of osteoporosis. All participants with fragility or traumatic fractures who consent will be followed for 20 years using data from the Québec Ministry of Health database to measure the association between the index fracture and future fracture risk.

Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention

BACKGROUND

Barriers prevent osteoporosis care in nursing homes. Successful interventions designed to circumvent these barriers benefit from target recipient input during development.

OBJECTIVE

To elicit suggestions for an osteoporosis quality improvement intervention designed for use by nursing home health care professionals.

DESIGN

Modified nominal group technique.

SETTING

Convenience sample of Alabama nursing home directors.

PARTICIPANTS

Fifteen Alabama nursing home directors of nursing were recruited by mailing. Sixty percent of respondents participated (n = 9).

MEASUREMENTS

In the first phase conducted via teleconference, an experienced moderator used a preformulated question and elicited 41 suggestions to improve osteoporosis care in nursing homes. Substantively similar suggestions were combined and idiosyncratic suggestions were discarded resulting in the retention of 20 suggestions. In the second phase conducted by mail, the same participants rated the 20 suggestions based on perceived practicality and helpfulness. Elements were grouped into tertiles based on the ranking of the mean ratings of the 2 attributes and then cross-tabulated.

RESULTS

All director of nursing (n = 9) participants completed both phases. The most practical, most helpful suggestions were information on fall prevention program implementation, osteoporosis treatment protocols, and osteoporosis medication information.

CONCLUSIONS

A modified nominal group technique provided useful information from nursing home directors of nursing for an osteoporosis intervention. The technique proved efficient and facile to perform.

Fragility Fractures and the Osteoporosis Care Gap: An International Phenomenon

OBJECTIVES

To describe practice patterns in the management of osteoporosis after fragility fracture.

METHODS

Systematic review of articles in MEDLINE, EMBASE, Cochrane, and CINAHL databases (1996 to February 2005). Diagnostic outcomes included clinical osteoporosis diagnoses, laboratory tests, and bone density scans. Treatment outcomes included initiation of calcium, vitamin D, hormone replacement therapy, bisphosphonates, calcitonin, raloxifene and falls assessments.

RESULTS

Thirty-five studies met our inclusion criteria and demonstrated that adults who experience fragility fracture are not receiving osteoporosis management. An osteoporosis diagnosis was reported in 1 to 45% of patients with fractures; laboratory tests were ordered for 1 to 49% and 1 to 32% of patients had bone density scans. Calcium/vitamin D and pharmacological therapy was reported in 2 to 62% and 1 to 65% of patients, respectively. Osteoporosis treatment was recommended more often in women than men, and more often in patients with vertebral fractures than in patients with nonvertebral fractures. Older patients were more likely to be diagnosed with osteoporosis, but treatment was more likely in younger patients. A history of prior fracture was reported in 7 to 67% of patients. Between 1 and 22% of patients had a subsequent fracture during follow-up periods of 6 months to 5 years. Falls assessments were not often reported; when they were, they were infrequently performed. A greater proportion of patients were diagnosed/treated during follow-up studies than in studies evaluating diagnosis/treatment on discharge from acute care.

CONCLUSIONS

The majority of individuals who sustain fragility fractures are not receiving adequate osteoporosis management. Future research should address barriers to appropriate management and the efficacy of implementation strategies designed to close the osteoporosis care gap.

RELEVANCE

This article is of particular importance to health care professionals who provide care for patients with fragility fracture.

Are osteoporotic fractures being adequately investigated? A questionnaire of GP & orthopaedic surgeons

Background

To investigate the current practice of Orthopaedic Surgeons & General Practitioners (GP) when presented with patients who have a fracture, with possible underlying Osteoporosis.

Methods

Questionnaires were sent to 140 GPs and 140 Orthopaedic Surgeons. The participants were asked their routine clinical practice with regard to investigation of underlying osteoporosis in 3 clinical scenarios.

55 year old lady with a low trauma Colles fracture

60 year old lady with a vertebral wedge fracture

70 year old lady with a low trauma neck of femur fracture.

Results

Most doctors agreed that patients over 50 years old with low trauma fractures required investigation for osteoporosis, however, most surgeons (56%, n = 66) would discharge patients with low trauma Colles fracture without requesting or initiating investigation for osteoporosis. Most GPs (67%, n = 76) would not investigate a similar patient for osteoporosis, unless prompted by the Orthopaedic Surgeon or patient.

More surgeons (71%, n= 83) and GPs (64%, n = 72) would initiate investigations for osteoporosis in a vertebral wedge fracture, but few surgeons (35%, n = 23) would investigate a neck of femur fracture patient after orthopaedic treatment.

Conclusion

Most doctors know that fragility fractures in patients over 50 years old require investigation for Osteoporosis; however, a large population of patients with osteoporotic fractures are not being given the advantages of secondary prevention.

Prescribed vitamin D and calcium preparations in patients treated with bone remodelling agents in primary care: a report of a pilot study

BACKGROUND

Recent guidelines recommend that patients receiving treatment for osteoporosis should also receive supplementation with calcium and vitamin D unless they are calcium and vitamin D replete. Given that the majority of elderly patients have inadequate levels of vitamin D and that determining nutritional status is time-consuming and costly, it seems prudent to ensure that the majority of patients aged over 65 and receiving medication for osteoporosis should receive supplementation as a matter of course.

OBJECTIVES

To determine the level of co-prescription of calcium and vitamin D in patients receiving treatment for osteoporosis with bisphosphonates, teriparatide, raloxifene or strontium.

STUDY DESIGN AND METHODS

A pilot audit of nine general practices covering a population of 61 202.

RESULTS

Overall, 1.1% (n = 662) of patients were receiving treatment for osteoporosis; of those, only 34.1% of patients were co-prescribed calcium or calcium and vitamin D. Levels of co-prescription varied considerably across practices from 74.0% to 12.2%.

CONCLUSIONS

Despite national guidelines, co-prescription of calcium and vitamin D with treatment for osteoporosis remains sub-optimal with considerable variation between practices. Strategies should be adopted to increase physician awareness of widespread vitamin D inadequacy, the rationale for supplementation and poor compliance.

An osteoporosis and fracture intervention program increases the diagnosis and treatment for osteoporosis for patients with minimal trauma fractures

BACKGROUND

As fewer than 25% of patients with an osteoporotic minimal trauma fracture (MTF) are evaluated and treated for osteoporosis, an osteoporosis and fracture intervention program (OFIP) was developed.

METHODS

Patients hospitalized with MTF were educated about and treated for osteoporosis and were evaluated by the osteoporosis team at 6 and 12 months after discharge. Patients seen in the emergency department were given information about osteoporosis and encouraged to seek medical care at the osteoporosis office.

RESULTS

While 165 patients hospitalized with an MTF participated in the OFIP, 38 patients received routine osteoporosis education. At the 6-month follow-up, in the OFIP group, 68% of patients with hip fracture and 54% of patients with non-hip fracture were taking antiresorptive medications. There was no change in treatment rate among patients receiving conventional care.

CONCLUSIONS

The rates of diagnosis of osteoporosis and treatment implementation following an MTF increased when the intervention occurred at the time of hospitalization.

Closing the osteoporosis management gap in primary care: a secondary prevention of fracture programme

BACKGROUND

Effective treatments are available to reduce fracture risk in patients with osteoporosis. Prioritisation of assessment and treatment for those patients at highest risk of fracture will and treatment for those patients at highest risk of fracture will will ensure the optimal utilisation of healthcare resources.

OBJECTIVES

To confirm prior fracture to be a strong predictor of osteoporosis, evaluate a simple means of identifying patients with osteoporosis, assess the current management gap in this high risk patient group and to enable initiation of treatment where appropriate.

RESEARCH DESIGN AND METHODS

All women >/=65 years of age living at home and registered with a general practitioner (GP) in Coatbridge, Lanarkshire, Scotland (4045) were mailed an osteoporosis questionnaire. Participants were from an area of generally low socioeconomic background, where 16% of the population are over >/=65 years and >/=99% are Caucasian. Those who had sustained a fracture or had >/=2 osteoporosis risk factors and had not previously been screened for osteoporosis were invited for a Dual energy X-ray Absorptiometry scan. A second group of women at high risk of osteoporosis were referred by their GP for a scan. Bone mineral density (BMD) was determined and treatment was reviewed and prescribed according to national guidelines.

RESULTS

2386/4045 women returned the questionnaire (response rate 59%); 2286 were correctly completed and made up the sample size. Eight hundred and fifty two had sustained >/=1 fracture(s), of whom 43 (5%) had previously had BMD testing and 80 (9.4%) were receiving treatment. There were 1434 women with no history of fracture that had >/=2 risk factors for osteoporosis. Of 395 women referred by their GP, 113 had sustained fractures. Following the audit, 1054 women were scanned, including 463 women who had not sustained fractures that had >/=2 osteoporosis risk factors. Of the 1054, 591 women had sustained 763 fractures: 46 (6.0%) hip, 284 (37.2%) wrist, 37 (4.8%) humerus and 396 (51.9%) other bones (mainly ankle or rib). Eighty (13.5%) women with a fracture history had normal BMD, 204 (34.5%) were osteopenic and 307 (51.9%) were osteoporotic. Older women were more likely to have osteoporosis: overall, 12.8%, 46.8% and 63.0% of women were osteoporotic in age groups <65 years, 65-75 years and >75 years, respectively. Treatment was prescribed according to Lanarkshire's osteoporosis guidelines for 670 (63.6%) patients: 90.0% received bisphosphonate + calcium/vitamin D and 10% received calcium/vitamin D.

CONCLUSIONS

A simple scan identified patients with prior fracture and with osteoporosis. Prior fracture was confirmed to be a strong predictor of osteoporosis; 86.4% of women with a fracture history had low BMD and 51.9% had osteoporosis. Similar disease management programmes elsewhere in primary care to identify high risk patients and ensure appropriate prescribing would, in addition to implementing national guidelines, be pharmaco-economically prudent and improve management of patients with fragility fracture across the UK.

Failure to treat osteoporosis and the risk of subsequent fractures in elderly patients with previous hip fracture: a five-year retrospective study

BACKGROUND AND AIMS

Considering the results of cost-effective analyses, the National Osteoporosis Foundation recommends osteoporosis treatment for patients with previous hip fracture. The aim of this study was to examine the application of adequate treatment for osteoporosis among patients who have had a hip fracture. We also evaluated the rate of subsequent fractures after five years.

METHODS

We conducted a retrospective data study, with a follow-up at five years after discharge, in a tertiary teaching hospital with orthopedic services and all medical specialities. Treatment for osteoporosis and subsequent fracture rates were evaluated in 114 patients with hip fracture. Functional status was assessed using the Barthel Index (BI). We also evaluated the rate of subsequent fractures after five years.

RESULTS

Twenty-five patients (22%) had a new fracture at some moment during the follow-up. Six percent at discharge and 12% at five years of follow-up were receiving adequate treatment for osteoporosis. After five years of follow-up, a decline in their BI persisted in 72% of the 43 surviving patients.

CONCLUSIONS

Few patients were receiving adequate treatment for osteoporosis after hip fracture. Their fracture rates and functional decline were important.

A risk assessment tool (OsteoRisk) for identifying Latin American women with osteoporosis

OBJECTIVE

To develop a simple and easy-to-use tool for identifying osteoporotic women (femoral neck bone mineral density [BMD] T-scores<or=-2.5) in Latin America.

DESIGN

Retrospective study involving review of medical records.

SETTING

Osteoporosis clinics in 6 Latin American countries.

PATIENTS

Postmenopausal women ages >or=50 in Latin America who had femoral neck BMD measurements.

MEASUREMENTS AND MAIN RESULTS

A risk index was developed from 1,547 patients based on least square regression using age, weight, history of fractures, and other variables as predictors for BMD T-score. The final model was simplified by reducing the number of predictors; sensitivity and specificity were evaluated before and after reducing the number of predictors to assess performance of the index. The final model included age, weight, country, estrogen use, and history of fractures as significant predictors for T-score. The resulting scoring index achieved 91% sensitivity and 47% specificity. Simplifying the index by using only age and weight yielded similar performance (sensitivity, 92%; specificity, 45%). Three risk categories were identified based on OsteoRisk, the index using only age and body weight: high-risk patients (index <=-2; 65.6% were osteoporotic), moderate-risk patients (-2< index <=1; 26.7% were osteoporotic), and low-risk patients (index>1; 8% were osteoporotic). Similar results were seen in a validation sample of 279 women in Brazil.

CONCLUSION

Age and weight alone performed well for predicting the risk of osteoporosis among postmenopausal women. The OsteoRisk is an easy-to-use tool that effectively targets the vast majority of osteoporotic patients in Latin America for evaluation with BMD.

Follow-up treatment for osteoporosis after fracture

Studies of the management of osteoporosis in older women who have had hip or wrist fractures have found underdiagnosis and undertreatment of the disease. Few such studies have been conducted in the United States, however, and most studies have been confined to a subset of the treatments currently available to treat osteoporosis. Mail surveys were sent to 381 women between 50 and 84 years of age who had been treated for a hip or wrist fracture at a large northeast US teaching hospital between October 1, 1998, and September 30, 2000. These surveys included questions about osteoporosis risk factors and physician treatment both before and after the index fracture. Of 381 surveys mailed, 70 were returned because of an invalid address or by a relative because a patient was deceased. Of the remaining 311 surveys, 147 completed responses were received. Fifty-two percent of respondents reported having received either a prescription or a recommendation for a nonprescription medication used to treat osteoporosis before the fracture. After fracture, 60% of subjects were advised to take any osteoporosis medication, and 42% of were advised to take a prescription medication. Of women reporting no treatment advice before fracture, 33% reported treatment after. Twenty-four percent of patients reported a change in treatment after fracture versus before. No significant differences in treatment were found according to fracture history, maternal history of fracture, or maternal history of osteoporosis. Both prescription and nonprescription treatment prevalence after fracture were lower than expected, and there was only a small change in reported treatment prevalence after fracture versus before. There was also little difference in treatment prevalence based on risk factors for osteoporosis or osteoporotic fractures. A sizeable opportunity exists for intervention to reduce the risk of osteoporotic fractures for patients who have a history of fracture.

Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions

OBJECTIVE

To assess current osteoporosis treatment guidelines, studies of osteoporosis treatment, and interventions to improve osteoporosis treatment.

METHODS

We searched the medical literature for articles published between January 1, 1992, and December 31, 2003, and assessed all relevant articles using a structured data abstraction process. Because of substantial heterogeneity in study design, no attempt was made to summarize the data using meta-analytic techniques.

RESULTS

Seventy-six articles met criteria for inclusion. Eighteen practice guidelines were studied. Most guidelines were consistent in key treatment recommendations. Among 18 studies of treatment rates in patients who had fractures, the weighted average varied from 22% for nonhormonal treatment to 19% for calcium. We found slightly higher treatment rates for patients taking oral glucocorticoids or for those older than 65 years. There were no consistent correlates of which patients received treatment. Six studies that examined treatment frequencies after bone densitometry all found that patients with lower bone mineral density were more likely to receive treatment. Most of the 8 interventions designed to improve osteoporosis treatment showed improvement in treatment rates; however, only 3 were randomized, and these showed the smallest effects.

CONCLUSIONS

Frequency of treatment of osteoporosis in at-risk populations is low. However, our assessment of the literature revealed no clear and consistent predictors of undertreatment. Few carefully controlled interventions have been reported.

Does a distal forearm fracture lead to evaluation for osteoporosis? A retrospective cohort study in 147 Danish women

In postmenopausal women, a low-trauma distal forearm fracture is a risk factor for osteoporosis and future fracture, which indicates osteoporosis follow-up according to prevailing guidelines. We decided to determine how often women over 45 yr presenting with a low-trauma distal forearm fracture to a Danish emergency department during a 1-yr period were followed up for osteoporosis. We performed a retrospective review of hospital records and we sent the women and their general practitioners (GPs) questionnaires regarding the follow-up undertaken in primary care. Finally, we invited the women for a densitometry to estimate the prevalence of osteoporosis. From May 1, 2001 to April 30, 2002, 147 women presented with a low-trauma distal forearm fractures. According to the review of hospital records, none of the women was referred for bone densitometry or spine X-rays. One woman had calcium and vitamin D supplementation (CVDS) prescribed and two were recommended to consult their GPs for osteoporosis follow-up. In primary care, 12 women were referred for densitometry or spine X-rays, and 11 women started CVDS after the fracture. Women with risk factors for osteoporosis in addition to the forearm fracture were not more likely to be referred for densitometry or spine X-rays (p = 0.10). The prevalence of osteoporosis was 24% among the 79 women who underwent densitometry. Our study demonstrates a low use of available measures to reduce the risk of future fracture in women with a low-trauma distal forearm fracture, and it emphasizes the need to decide on a local level how to provide osteoporosis follow-up for women with fragility fractures.

Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review

Fragility fractures are a strong indicator of underlying osteoporosis (OP). With the risk of future fracture being increased 1.5- to 9.5-fold following a fragility fracture, the diagnosis and treatment of OP in men and women with fragility fractures provides the opportunity to prevent future fragility fractures. This review describes the current status of practice in investigation and diagnosis of OP in men and women with fragility fractures, the rates and types of postfracture treatment in patients with fragility fractures and OP, interventions undertaken in this population, and the barriers to OP identification and treatment. A literature search performed in Medline, Healthstar, CINAHL, EMBASE, PreMedline, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 37 studies on OP diagnosis, treatment, and interventions. The studies varied in design methodology, study facilities, types of fractures, and pharmacological treatments. Some studies revealed that no patients with fragility fractures received investigation or treatment for underlying OP. Investigation of OP by bone mineral density was low: 14 of 16 studies reported investigation of less than 32% of patients. Investigation by bone mineral density resulted in high rates of OP diagnosis (35-100%), but only moderate use of calcium and vitamin D (8-62%, median 18%) and bisphosphates (0.5-38%) in patients investigated postfracture. Studies on barriers to OP identification and treatment focused on various groups of health practitioners. Barriers included the cost of therapies, time and cost of resources for diagnosis, concerns about medications, and the lack of clarity regarding the responsibility to undertake this care.

Risk factors for fracture in a UK population: a prospective cohort study

BACKGROUND

Common clinical risk factors for fracture in older women have been identified. To date, most of these risk factors have not been confirmed in a UK population.

AIM

To confirm the important risk factors for fracture in older women.

DESIGN

Comprehensive cohort study (CCS) with a nested randomized controlled trial.

METHODS

The CCS included 4292 women aged >70 years. We assessed potential risk factors for fracture, and followed-up participants for 24 months for incidence of non-vertebral fractures.

RESULTS

Odds ratios (ORs) for predicting any non-vertebral fracture were: previous fracture, 2.67 (95%CI 2.10-3.40); a fall in the last 12 months, 2.06 (95%CI 1.63-2.59); and age (per year increase), 1.03 (95%CI 1.01-1.05). ORs for predicting hip fracture were: previous fracture, 2.31 (95%CI 1.31-4.08); low body weight (<58 kg), 2.20 (95%CI 1.28-3.77); maternal history of hip fracture, 1.68 (95%CI 0.85-3.31); a fall in the last 12 months, 2.92 (95%CI 1.70-5.01); and age (per year increase), 1.09 (95%CI 1.04-1.13). ORs for predicting wrist fracture were: previous fracture, 2.29 (95%CI 1.56-3.34); and a fall in the last 12 months, 1.60 (95%CI 1.10-2.31). Being a current smoker was not associated with an increase in risk, and was consistent across all fracture types.

DISCUSSION

Older women with the clinical risk factors identified in this study should be investigated for osteoporosis or offered preventive treatment.

Pharmaceutical treatment of symptomatic vertebral fractures in primary care

BACKGROUND

Vertebral fractures are associated with a reduction in quality of life and are an important predictor of other non-spine fractures. Previous work has shown that up to 60% of patients with a vertebral fracture identified in primary care remain untreated.

OBJECTIVE

To examine the prevalence of pharmaceutical treatment and predictors of treatment in a primary care setting.

METHODS

Case-control study using the general practice research database (GPRD). All women aged 50 years and over with a first diagnosis of a vertebral fracture since 1990 were identified and matched with a control by age and practice. Appropriate use of a pharmaceutical agent was defined as a prescription occurring within 30 days of the diagnosis being recorded.

RESULTS

We identified 2719 women with the same number of controls. Within 30 days of diagnosis 61% of women were prescribed treatment, compared with only 3% of the controls. Bisphosphonate was the single most important treatment prescribed. Predictors of any drug treatment included: year of fracture (most recent year increased the likelihood of treatment); age (younger patients were more likely to receive treatment); history of back pain; low body weight; history of steroid use.

CONCLUSIONS

Treatment of diagnosed vertebral fractures is becoming more common. Treated patients tend to be younger but to have a higher prevalence of clinical risk factors than untreated patients. There remain significant numbers of patients who are not offered treatment.

Knowledge about osteoporosis in a cohort of Polish females: the influence of age, level of education and personal experiences

In this study, a group of 1065 women aged 16-72 years recruited from patients attending general practitioners was studied to investigate knowledge of osteoporosis and attitude towards methods of preventing the disease. The interviews were carried out by students of the Silesian School of Medicine, using a structured questionnaire. The average number of correct answers in the whole population was 7.05, and in women with established osteoporosis 6.89. In the whole population, the majority of answers were correct and ranged from 60% to 95% in seven out of ten questions. The answers for three questions were incorrect in about half or more of the cohort: 53% of subjects considered that osteoporosis could be cured; for 50% of women osteoporosis is a minor health problem (except for the youngest women and women with university education--74% and 69% of correct answers, respectively); and 58% of women considered that those with osteoporosis should not engage in physical activity due to the risk of falling and causing a fracture. A simple chi-squared test was used to show the role of age, level of education and personal experiences with osteoporosis on answers given by the subjects studied. Age (six out of ten answers), level of education (seven out of ten answers) and personal experience (four out of ten answers) significantly affected answers given. The number of correct answers decreased with age and increased with level of education, and there was no systematic influence of personal experience. In summary, data collected provide important information about knowledge of osteoporosis. Generally, the level of knowledge about osteoporosis was high. Higher level of education and younger age improve the knowledge of osteoporosis with no systematic influence of personal experience with the disease.

The orthopaedic surgeon's role in diagnosing and treating patients with osteoporotic fractures: standing discharge orders may be the solution for timely medical care

Patients who suffer osteoporotic fractures do not typically receive medical/pharmaceutical treatment for osteoporosis. Orthopedic surgeons are concerned about, but not always diligent in following up on, the medical treatment of their fracture patients. The objective of this study was to determine whether orthopedic surgeons could effectively and consistently refer patients with osteoporotic fractures to a primary care provider (PCP) for possible work-up and treatment of osteoporosis. Fourteen orthopedic surgeons participated in the program. Sixty-nine qualifying patients were >/=50 years old, had a low-energy fracture, and had no prior treatment for osteoporosis. For each patient, two letters requesting a PCP appointment were sent to their PCP: one within 10 days of fracture and another 3-10 weeks after fracture. Patients were also instructed that they might have osteoporosis, and were directed to see their PCP. Results showed that of 69 patients (59 females, ten males: average age 69.5+/-10.9 years), 30 (43.5%) did not see a PCP within 84 days. Thirty-nine (56.5%) patients saw a PCP within 84 days, but osteoporosis was not addressed in four (average days to PCP, 39.8+/-18.6: range 7-78 days). Of patients seen within 84 days, anti-resorptive medications (e.g. bisphosphonate) were started in 21/39 (53.8%), but typically not within 41 days of fracture. Of the 14 orthopedic surgeons, five were non-compliant and seven were inconsistent in their participation, forgetting to send the letters and/or inform patients to make PCP appointments. Standing discharge orders (for medications, PCP follow-up, bone-density scanning, etc.) may be more effective in achieving timely medical treatment for patients of orthopedic surgeons with osteoporotic fractures.

Undertreatment with anti-osteoporotic drugs after hospitalization for fracture

This study assessed the proportion of patients treated with anti-osteoporotic drugs during the 1-year period after hospitalization for a fracture, and the influence of a guideline in the period 1998-2000 on the likelihood of receiving treatment for osteoporosis after a fracture. Patients were assessed retrospectively for anti-osteoporotic drug use during a 1-year period following hospitalization for non-traumatic fracture. The PHARMO system, a population-based database ( n=865,000) containing drug and hospitalization data of community-dwelling inhabitants of defined areas in the Netherlands, was used. The study population comprised 1654 patients age 50 years and over who were admitted to hospital for a fracture resulting from a fall during the period 1998-2000. The treatment rate of newly treated patients and the change in treatment rate throughout the period 1998-2000 were the outcome measures. The majority of these patients were women (73%), and had femur fractures (51%). In total, 247 out of 1654 patients (15%) were prescribed anti-osteoporotic drugs within 1 year after discharge from the hospital. Of these 247 patients, 86 were newly treated, mainly with bisphosphonates in the year after discharge following the fracture, yielding a new treatment rate of 5%. The likelihood of receiving treatment for osteoporosis following fracture did not change with the calendar year of fracture (OR 0.95; 95% CI: 0.68-1.30). The result of this study shows that despite the introduction of an osteoporosis treatment guideline in 1999 recommending treatment for fracture patients, most of the time, fracture patients are not being treated for osteoporosis. Thus, to a large extent, osteoporosis remains under-treated.

Validation and comparative evaluation of the osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium

BACKGROUND

Risk indices have been developed to identify women at risk of low bone mineral density (BMD) who should undergo BMD testing.

AIM

To compare the performance of four risk indices in White ambulatory women in Belgium.

DESIGN

Epidemiological cross-sectional study.

METHODS

Records were analysed for 4035 postmenopausal White women without Paget's disease or advanced osteoarthritis, seen at an out-patient osteoporosis centre between January 1996 and September 1999. Osteoporosis risk index scores were compared to bone density T-scores. The ability of each risk index to identify women with low BMD (T-score < -2.0) or osteoporosis (T < -2.5) was evaluated.

RESULTS

Using an Osteoporosis Self-Assessment Tool (OST) score <2 to recommend DXA referral, sensitivity ranged from 85% at the lumbar spine to 97% at the total hip to detect BMD T-scores of <or= -2.5, and specificity ranged from 34% at the total hip to 37% at the femoral neck and lumbar spine. The negative predictive value was high at all skeletal sites (89-99%), demonstrating the usefulness of the OST to identify patients who have normal BMD and should not receive DXA testing. All risk indices performed similarly, although the OST had somewhat better sensitivity and somewhat lower specificity than the other indices at the cut-offs evaluated. Among the 11-12% of women who were classified as highest risk using OST or the Osteoporosis Index of Risk (OSIRIS), 81-85% had low bone mass and 68-74% had osteoporosis.

DISCUSSION

The performance of these risk indices among women in Belgium was similar to that reported earlier for other samples in Asian countries, the US, and the Netherlands. The OST and other risk indices are effective and efficient tools to help target high-risk women for DXA testing.

The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture

INTRODUCTION

Fracture care often represents the first opportunity for clinical management of osteoporosis; however, many patients do not receive any evaluation after a fracture. In Glasgow, Scotland, fewer than 10% of fracture patients underwent bone mineral density (BMD) testing. In an effort to better meet the needs of fracture patients by providing routine assessment and, where necessary, treatment for osteoporosis after their fracture, a novel service (The Fracture Liaison Service) was designed and implemented in two separate National Health Service trusts in Glasgow.

METHODS

An agreed-upon standard of care for men and women 50+ years of age with fractures was established in collaboration with orthopedic surgeons and primary care physicians. The Fracture Liaison Service assumes responsibility for fracture case-finding and for assessing and performing diagnostic evaluations (including axial DXA), and making specific treatment recommendations for the secondary prevention of osteoporotic fractures.

RESULTS

During the first 18 months of operation, more than 4,600 patients with fractures of the hip, wrist, humerus, ankle, foot, hand, and other sites were seen by the Fracture Liaison Service's osteoporosis specialist nurses. Nearly three quarters of these patients were considered for BMD testing; treatment was recommended for approximately 20% of the patients without need for BMD testing. Overall, 82.3% of patients who had BMD testing were found to be osteopenic or osteoporotic at the hip or spine.

CONCLUSIONS

The Fracture Liaison Service has successfully identified and evaluated most patients with fractures. Only those patients who declined were not evaluated. The ultimate success of the program will be measured by the subsequent fracture experience of these patients, but clear improvements in diagnosing and treating low bone mineral density in patients with fracture have already been demonstrated.

Pins and plaster aren't enough: a call for the evaluation and treatment of patients with osteoporotic fractures

A history of an osteoporotic fracture is a powerful predictor of future fractures. Older patients who sustain low trauma fractures are candidates for interventions that should include confirmation of the diagnosis of osteoporosis, adequate calcium and vitamin D administration, and use of an osteoporosis therapy that is proven to lower fracture risk. Recently, however, several reports in the literature have indicated that, in general, those physicians who diagnose and treat fractures, i.e. radiologists, orthopedic surgeons, physiatrists, and those who provide general medical care to these fracture patients, the primary care physicians, are not evaluating patients with acute fractures for the presence of osteoporosis and are not prescribing calcium, vitamin D, or specific pharmacological therapy to reduce future fracture risk. These reports suggest that implementation of a standard of care for the subsequent medical management of the older patient with an acute fracture is needed urgently. Diagnostic tools and several effective therapies exist, but these are underused by the physicians who interface with these patients. A call to action is necessary to reduce the human and economic costs associated with this serious and treatable disease.

Functional status in older women following hip fracture

BACKGROUND

Women aged 65 years and over are at high risk for a fractured hip because of osteoporosis. One of the devastating effects of a fracture is the loss of ability to live independently.

AIM

The major aim of this study was to describe the functional status, or ability to perform activities of daily living, of women aged 65 years and older who had experienced a fractured hip in the recent past and to explore possible differences in selected variables (e.g. age and length of rehabilitation) for those who were fully performing activities of daily living at least 6 months after fracture and those who were not.

DESIGN

Following Institutional Review Board approval, data were collected from 23 Caucasian women ranging from 65 to 95 years of age (M = 82, SD = 6.83) who had experienced fractured hips related to a fall in the recent past (6 months to 4 years). All were living independently prior to their fractures. Three Registered Nurses, in a structured interview, collected the data using a Demographic Data Form, an Osteoporosis Risk Factor Checklist, the Katz Index of Independence in Activities of Daily Living, and the Lawton Instrumental Activities of Daily Living Scales.

RESULTS

Nine of the participants reported prior fractures, suggesting that this could have been a risk factor for this group. Eighteen achieved the maximum independence score of six on the Katz Index of Independence in Activities of Daily Living; help with bathing was required by the other five. Of the Instrumental Activities of Daily Living, those requiring physical activity for home maintenance were the most problematic. Ability to perform Instrumental Activities of Daily Living was significantly related to ability to perform the activities required to live independently.

CONCLUSIONS

Results suggest that achieving a functional level that will support independence is possible for older women who were residing independently prior to a hip fracture.

The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients

We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture "controls," selected from among fracture clinic attendees in the 6-9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years; 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p<0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results.

Diagnosis and treatment of osteoporosis in patients with vertebral compression fractures

OBJECTIVES

To determine whether patients with vertebral compression fractures are diagnosed with or treated for osteoporosis.

DESIGN

Retrospective cohort study.

SETTING

Two primary care practices in Massachusetts.

PARTICIPANTS

Two hundred six patients with vertebral compression fractures noted on routine radiographs in 1997-1998.

MEASUREMENTS

Percentage of patients diagnosed with osteoporosis and treated with prescription medications (estrogen, bisphosphonates, raloxifene, or calcitonin). Factors associated with missed osteoporosis diagnosis and treatment, including risk factors for osteoporosis, comorbidities, vertebral fracture severity, and processes of care communication were also examined.

RESULTS

The median patient age was 76, 71% of the cohort was female, and 13% of patients had a history of corticosteroid use. Thirty-eight percent of subjects (46% of women and 19% of men) were diagnosed with osteoporosis and 32% (39% of women and 14% of men) received prescription medications for osteoporosis. Of women who were diagnosed with osteoporosis, 69% received prescription medications. In adjusted analyses women younger than 50 (adjusted odds ratio (AOR) = 0.09; 95% confidence interval (CI) = 0.01-0.71) and 90 and older (AOR = 0.27; 95% CI = 0.08-0.98) were less likely to be diagnosed with osteoporosis, whereas women with a prior hip or radial fracture (AOR = 3.65; 95% CI = 1.28-10.38) or back pain (AOR = 2.84; 95% CI = 1.38-5.85) were more likely to be diagnosed with osteoporosis.

CONCLUSIONS

Physicians frequently did not diagnose osteoporosis in primary care patients with vertebral fractures, missing an important preventive opportunity for patients at high risk for future fractures. Efforts targeted to improving diagnosis of osteoporosis could improve patient care.

Hip fracture patients are not treated for osteoporosis: a call to action

OBJECTIVE

To determine whether hip fracture patients, a group at very high risk for additional fragility fractures, are being evaluated and treated effectively for osteoporosis.

METHODS

Clinical and bone densitometry (dual x-ray absorptiometry [DXA]) records were reviewed in hip fracture patients at 4 Midwestern US health systems to determine the frequency of DXA use, calcium and vitamin D supplementation, and antiresorptive drug treatment.

RESULTS

DXA was performed at the 4 study sites in only 12%, 12%, 13%, and 24% of patients, respectively. Calcium and vitamin D supplements were prescribed in 27%, 1%, 3%, and 25% of the patients at the 4 study sites. Antiresorptive drugs were prescribed in 26%, 12%, 7%, and 37% of the patients with only 2-10% receiving a bisphosphonate.

CONCLUSION

Reducing osteoporotic fractures will require more effective approaches to managing hip fracture patients and other high-risk populations.

Acceptability of pharmacy-based bone density measurement by women and primary healthcare providers

OBJECTIVES

To assess women's information sources regarding, and monetary value placed on, pharmacy-based bone density screening. In addition, we evaluated clinicians' response to peripheral bone mass measurements.

DESIGN

We recruited 197 women 50 years of age or older in four rural Midwestern community pharmacies. Each woman completed a questionnaire and underwent calcaneal bone density testing. Results were sent to participants' primary care providers. These providers, and others practicing within a 50-mile radius, were surveyed anonymously to evaluate usefulness of bone density data provided by this program or pharmacy-based osteoporosis screening in general. In addition, clinicians were asked how they would manage a woman with a calcaneal T-score of -1.3.

RESULTS

Fifty-six percent of participants [95% CI, 49%-63%] became interested in screening through the media, and only 6% (CI, 3%-9%) became interested through contact with their primary care provider. Women were willing to pay a median of $25 for screening. Of 18 responding clinicians with patients in this study, 72% (CI, 47%-90%) found the results useful. Of the 67 responding clinicians, 51% (CI, 39%-63%) supported pharmacy-based bone mass measurement. For a case scenario of a woman with a calcaneal T-score of -1.3, 57% (CI, 46%-68%) of clinicians indicated that they would have ordered central dual-energy x-ray absorptiometry, and 20% (CI, 11%-29%) would have prescribed antiresorptive therapy.

CONCLUSIONS

This study suggests that (1) women are an important force in obtaining bone density testing outside the clinic setting, both by self-education and willingness to pay, and (2) primary care clinicians receiving such results find them useful and indicate willingness to use them in decision-making.

The underuse of therapy in the secondary prevention of hip fractures

There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.

Performance of risk indices for identifying low bone density in postmenopausal women

OBJECTIVE

To examine the ability of 4 published osteoporosis risk indices to identify women with low bone density.

SUBJECTS AND METHODS

Subjects included postmenopausal women 45 years and older consecutively recruited from US clinics, women from general practice centers in The Netherlands (age range, 50-80 years), women in the Rotterdam Study (The Netherlands) 55 years and older, and women aged 55 to 81 years old screened for a clinical trial of alendronate. Bone mineral density (BMD) was measured at the femoral neck or lumbar spine; T scores represent the number of SDs below the mean for young healthy women. One risk index was calculated from age and weight; the other risk indices included up to 4 additional variables obtained by questionnaire. We calculated the sensitivity and specificity for identifying women with BMD T scores of -2.5 or less or -2.0 or less in the US clinic sample and created 3 risk categories, using each of the 4 indices.

RESULTS

Data were available for 1102 women from the US clinic sample, 3374 women in the Rotterdam Study, 23,833 women screened for a clinical trial of alendronate, and 4204 women from general practice centers in The Netherlands. Specificity for identifying BMD T scores of -2.5 or less ranged from 37% to 58% (depending on risk index) when sensitivity was approximately 90%. The prevalence of osteoporosis (defined as T scores < or = -2.5) differed widely across the 3 risk categories, ranging from 2% to 4% for the low-risk category to 47% to 61% for the high-risk category in the US clinic sample. For spine BMD in the US clinic sample, the prevalence of T scores of -2.5 or less ranged from 7% (low risk) to 38% (high risk). The large differences in prevalence across risk categories were consistent across the other 3 samples of postmenopausal women in the United States and The Netherlands for all 4 risk indices.

CONCLUSIONS

We recommend measuring BMD in women who are classified as having an increased risk of osteoporosis by using any of these risk indices because all 4 indices appear to predict low bone mass equally well. The Osteoporosis Self-assessment Tool index is easiest to calculate and therefore may be most useful in clinical practice.

[Diagnosis of osteoporosis by lateral chest X-ray]

BACKGROUND

Lateral chest X-rays may be helpful in the early detection of osteoporotic patients. We studied the proportion of chest X-ray reports in which the radiologist highlighted the presence of vertebral osteoporotic signs, as well as the proportion of patients with such records who were further studied by their physicians in order to confirm the diagnosis of osteoporosis.

PATIENTS AND METHOD

We reviewed both lateral chest X-ray records of 3,500 consecutive patients and their medical records with the ultimate diagnosis.

RESULTS

Radiology reports referred to the presence of vertebral abnormalities suggestive of osteoporosis in only 20% of potentially expected cases. Final medical records registered a diagnosis of osteoporosis in only one third of positive radiological records (6.3% of expected cases with vertebral abnormalities). Only two thirds of patients diagnosed with vertebral osteoporosis by their physician were adequately treated (4% of positive lateral chest X-ray reports).

CONCLUSION

Osteoporosis is a disease overlooked by both radiologists and clinicians. Lateral chest X-ray is a helpful diagnostic tool for osteoporosis but its usefulness is often

Expanding the role of the orthopaedic surgeon in the treatment of osteoporosis

Osteoporosis is an increasingly prevalent disease among the aging population, and osteoporotic features account for substantial morbidity, mortality, and healthcare costs associated with this disease. Because the disease is silent until a fracture occurs, the orthopaedic surgeon often may be the physician in the best position to establish the diagnosis and consider the initiation of appropriate treatment. Historically, osteoporosis has been underdiagnosed and treated, but new methods allow accurate diagnosis using bone densitometry, and a range of effective treatment options that can reduce fracture risk. Diagnosis and treatment of osteoporosis fits readily into an efficient algorithmic approach in the office practice of orthopaedics. Orthopaedic surgeons can play a major role in improving the treatment of osteoporosis and decreasing morbidity from this disease. In addition, this can augment the office practice of orthopaedics with a large yet relatively underserved patient population. Finally, densitometry services can provide modest supplemental revenue sources for an orthopaedic practice.

Development of a questionnaire (OPQ) to assess patient's knowledge about osteoporosis

OBJECTIVE

to develop a self-administered questionnaire (OPQ) to assess the patient's knowledge about osteoporosis.

METHODS

An initial item pool of 71 questions was developed with input from clinicians involved in the management of patients with osteoporosis. It was piloted in ten patients for face validity and comprehension. The questionnaire was then administered to 50 first-time attendees at a specialist osteoporosis unit. After item analysis using index of difficulty and index of discrimination, 20 items were selected for the final questionnaire (OPQ). These were in the areas of general information (5), risk factors (7), consequences and treatment (four each).

RESULTS

the average index of difficulty and index of discrimination (D) of the 20 items was 0.56 (>0.75 is suggestive of a poor discriminator) and 54.8% (D value of 50% is associated with highest level of item discrimination) respectively. This means that all the items actively discriminated between high and low scorers. The Flesch readability index was 74.3 (a score between 70 and 100 means a document is easily understood) and the reliability coefficient was 0.84 (acceptable range 0.8-0.9). Criterion validity (verification that the scale measures what it claims to measure) was confirmed by the method of contrasted groups where members of an osteoporosis awareness charity had a significantly higher score than the first time attendees (13.6 +/- 4.3 vs. 8.5 +/- 5.4; P=0.003).

CONCLUSIONS

we have developed a self-report, 20-item questionnaire (OPQ) to assess the patient's knowledge about osteoporosis. Psychometric analysis has shown that the items have a satisfactory index of difficulty and discrimination. The OPQ is internally reliable, valid and easily understandable. It can be used to identify individuals in need of educational interventions as well as assess the effectiveness of education efforts as a part of management of osteoporosis.

Postmenopausal osteoporosis: fracture consequences and treatment efficacy vary by skeletal site

At least half of all postmenopausal women will experience fractures during their lifetime, and the consequences are often serious, but most women at risk are not receiving adequate treatment. The objective of this paper is to summarize the literature concerning the consequences of osteoporotic fractures, and the effectiveness of pharmacologic agents for preventing fractures and their consequences, emphasizing a systematic, evidence-based summary of treatment results from randomized, controlled trials that were published previously. Osteoporosis is associated with increased risk of fractures at most skeletal sites. Hip fractures have much greater prognostic significance in terms of health than any other single type of fracture. However, symptomatic vertebral fractures and other non-hip fractures also represent enormous morbidity and economic burdens, and signal increased risk of future fractures of all types, including the hip. There is convincing evidence that two bisphosphonates (alendronate and risedronate) reduce the risk of both spine and non-spine fractures. The evidence for reducing hip fracture risk is greater for alendronate, with a consistent approximately 50% reduction in hip fractures across studies. Alendronate has also been demonstrated to maintain quality of life by reducing outcomes such as hospitalization and bed rest related to back pain. Among other agents, raloxifene reduces the risk of vertebral fractures by approximately 30%; the published evidence for most other agents is inconclusive. Osteoporosis should be regarded as seriously as other important chronic disorders such as hypertension and hyperlipidemia. Postmenopausal patients with a high risk of fractures--such as those with prior fractures or osteoporosis as measured by BMD--need to be treated. Although other therapeutic modalities are available, the evidence is most convincing for the bisphosphonates, alendronate and risedronate.

Alendronate in the treatment of osteoporosis: a review of the clinical trials

Osteoporosis is a highly prevalent disease. More than half of postmenopausal women will experience fractures. Women at high risk (osteoporosis as measured by bone density, low trauma fractures of any type, or certain other risk factors) often require pharmacological therapy. However, surveys show that most women who have recently had fractures are currently not being treated. Recent results from the first megatrial of osteoporosis with >6400 participants, the Fracture Intervention Trial (FIT), have provided important advances in our understanding of osteoporosis and the efficacy of alendronate. The FIT study and other large clinical trials show that alendronate effectively increases bone density, reduces the risk of hip and vertebral fractures by approximately half within the first 12-18 months, and, most importantly, reduces the health consequences of fractures. Alendronate is also effective for preventing bone loss in early postmenopausal women. Thus, alendronate represents an important option for preventing and treating this common and debilitating disease. This article summarizes the wealth of data from FIT and other studies of alendronate in the context of the burden of illness associated with osteoporosis.

Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis

Numerous studies have reported increased risks of hip, spine, and other fractures among people who had previous clinically diagnosed fractures, or who have radiographic evidence of vertebral fractures. However, there is some variability in the magnitudes of associations among studies. We summarized the literature and performed a statistical synthesis of the risk of future fracture, given a history of prior fracture. The strongest associations were observed between prior and subsequent vertebral fractures; women with preexisting vertebral fractures (identified at baseline by vertebral morphometry) had approximately 4 times greater risk of subsequent vertebral fractures than those without prior fractures. This risk increases with the number of prior vertebral fractures. Most studies reported relative risks of approximately 2 for other combinations of prior and future fracture sites (hip, spine, wrist, or any site). The confidence profile method was used to derive a single pooled estimate from the studies that provided sufficient data for other combinations of prior and subsequent fracture sites. Studies of peri- and postmenopausal women with prior fractures had 2.0 (95 % CI = 1.8, 2.1) times the risk of subsequent fracture compared with women without prior fractures. For other studies (including men and women of all ages), the risk was increased by 2.2 (1.9, 2.6) times. We conclude that history of prior fracture at any site is an important risk factor for future fractures. Patients with a history of prior fracture, therefore, should receive further evaluation for osteoporosis and fracture risk.

[Diagnosis and treatment of postmenopausal osteoporosis after a Colles' fracture]

OBJECTIVES

To investigate whether the presence of Colles fracture leads to diagnostic studies or treatment of osteoporosis in postmenopausal women.

DESIGN

Retrospective study with follow-up of incident cases.

SETTING

Hospital General de Vic and Primary Care Centre Osona. Vic. Barcelona.

PARTICIPANTS AND METHODS

We studied 80 postmenopausal women with Colles' fracture during 1995-1996. The clinical records were systematically reviewed and treatment with antiosteoporotic drugs before and after Colles' fracture were compared.

MEASUREMENTS AND MAIN RESULTS

Diagnostic studies were found in 3 (3.8%) patients. 6 patients (7.5%) took antiosteoporotic drugs before the fracture while 21 (26.3%, p < 0.001) did so after it.

CONCLUSIONS

A recent Colles' fracture induces few osteoporosis diagnostic studies. However, it leads to a significant increase in the use of antiosteoporotic drugs.