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From the Center for Health Research, Kaiser Permanente (Drs Feldstein, Elmer, and Hillier), Department of Endocrinology and Bone and Mineral/Osteoporosis, Oregon Health & Science University (Dr Orwoll), and Northwest Permanente (Drs Feldstein and Herson), Portland, Ore. Drs Feldstein and Elmer have received research grants from Merck & Co, Inc, Westpoint, Penn. Dr Orwoll has received research grants from Eli Lilly, Indianapolis, Ind; Merck & Co, Inc; and Pfizer, New York, NY. He has consulted with Eli Lilly; Merck & Co, Inc; Procter & Gamble, Cincinnati, Ohio; Roche Laboratories, Nutley, NJ; NPS, Salt Lake City, Utah; and Novartis, East Hanover, NJ.
Osteoporosis evaluation and treatment guidelines state that, because of the high risk for future fractures, a fracture in an older individual warrants initiation of pharmacological treatment or bone mineral density (BMD) measurement followed by treatment according to BMD. We compared current practice with these guidelines.
We used the electronic data systems of a health maintenance organization to collect fracture, BMD measurement, and pharmacy data for women aged 50 to 89 years and men aged 65 to 89 years who sustained a study-defined fracture during 1998 or 1999. We determined those who had BMD measurement or pharmacological treatment for osteoporosis (bisphosphonate or estrogen) during the 2 years. We compared the evaluation and treatment data with evidence-based clinical guidelines (for women) or expert consensus (for men).
Of 70 513 members in the eligible age groups, 2804 persons sustained study-defined fractures. Overall, only 4.6% of those with fractures had treatment initiated after the fracture. Women sustained 80.7% of the study-defined fractures; 8.4% had BMD measurement and 42.4% received any treatment during the 2 years. Bone mineral density measurement and treatment frequency decrease significantly with age in women. In men, 1.5% had BMD measurement and 2.8% received any treatment. Approximately 51% (51.2%) of women and 95.5% of men in our study population were not evaluated or treated in accord with guideline or expert recommendations.
Evaluation and treatment rates for osteoporosis in older individuals with fractures fall far below national recommendations, especially for men. Intervention strategies should be developed and evaluated to prevent refracture in older individuals with fractures.
THE HUMAN and economic toll of osteoporotic fractures is staggering. One in 2 white women will suffer an osteoporotic fracture in her lifetime.1 The mortality rate from osteoporotic fractures in women is greater than the combined mortality rates from breast and ovarian cancers.2 In 1995, osteoporotic fractures led to 432 000 hospitalizations, 2.5 million physician visits, and 180 000 nursing home admissions, with direct expenditures estimated to be $13.8 billion.3 Osteoporotic fractures result in significant chronic pain and disability. About 20% of hip fracture patients die, and one third receive nursing home care in the first year after fracture.4 The death and disability rate is similar in men after hip fracture.5
Patients who have had a prior osteoporotic fracture are at high risk for future fractures.6- 9 A recent summary of the literature revealed that women with preexisting vertebral fractures had a 4 times greater risk for subsequent vertebral fracture compared with those without a prior fracture. Perimenopausal and postmenopausal women with a prior fracture had twice the risk of subsequent fracture compared with women without a prior fracture.10 Findings were similar in men.5,11
There are now several national and international evidence-based clinical practice guidelines for preventing osteoporotic fractures in women.4,12- 16 Recommendations for men are based on the consensus of experts.17 The guidelines present similar recommendations for preventing osteoporosis and for treatment strategies once osteoporosis is diagnosed. They vary in their recommendations regarding the timing and target population for screening.18 The guidelines agree that a prior fracture in an older individual warrants immediate initiation of treatment (if osteoporosis is clinically apparent or if bone mineral density [BMD] will not change treatment) or BMD measurement followed by treatment according to BMD.
Unfortunately, despite the availability of effective treatment and well-publicized treatment guidelines, there are significant gaps in implementing the guidelines. Osteoporosis has appropriately been referred to as a silent epidemic. Even cases with a clinically apparent fracture are overlooked. Fewer than 5% of patients with osteoporotic fractures are referred for medical evaluation and treatment for osteoporosis.4 It is likely that targeting evaluation and treatment of those at highest risk could be one of the more cost-effective population-based strategies for preventing osteoporotic fractures.19 Cummings19 estimated that, if those with prior fractures were targeted for treatment, there would be a 9% reduction in the incidence of hip fractures during 5 years (eg, from about 10 to 9 fractures per 1000 women aged 65 years).
In 2000, our health maintenance organization (HMO) embarked on an organizational quality initiative to improve the identification, evaluation, and treatment of members with prior fractures and low bone mass. As part of this effort, this retrospective cohort study collected the 2 years of data reported herein to compare BMD measurement and treatment frequencies of HMO members with guidelines and expert consensus. Unlike other recent evaluations of postfracture management of osteoporosis,20- 24 we were able to evaluate a contemporary cohort of patients (including men) with any fracture that has been associated with an increased risk of osteoporosis.
The protocol for this study was approved by the HMO's internal institutional review board.
The study was conducted in a nonprofit, group-model HMO in the Pacific Northwest with about 448 000 members. Thirty-five percent of the membership is older than 50 years, and more than 90% of this group have a prepaid drug benefit. Members in this age group tend to remain in the plan longer than younger groups and to disenroll at a rate of approximately 8% per year. About 54 000 members are Medicare beneficiaries. The plan insures 17% of the population of the greater Portland and Vancouver, Wash, metropolitan areas. The membership is representative of the sex and racial characteristics of the region, with 47% male, 92% white, 2.6% African American, 2.5% Hispanic, 2.5% Asian, and smaller percentages of other ethnic groups. The system maintains 1 hospital and is affiliated with 6 other geographically dispersed hospitals, and it operates 20 ambulatory care medical offices. Care is provided through a professional corporation with 669 physicians and surgeons working with 417 allied health practitioners.
Several electronic systems that store data on HMO members were used to collect data for this study. EpicCare, an electronic medical record, contains information for all patient contacts since 1996, such as patient demographics, medical history, procedures, and visit summaries. International Classification of Diseases, Ninth Revision (ICD-9) codes are embedded in the diagnosis selection screen for immediate coding of medical conditions, and all patient orders are entered electronically by clinicians. Four other electronic systems provide general member information, claims processing information for covered services provided by outside providers, data on inpatient procedures, and pharmacy data on prescriptions dispensed by outpatient pharmacies. Members provide consent to use these data for research purposes as part of their enrollment agreement.
We identified women aged 50 to 89 and men aged 65 to 89 who had continuous HMO membership during calendar years 1998 and 1999. These age groups were selected because during these years women's rate of bone loss accelerates, a significant percentage of men and women develop osteoporosis, and the risk of osteoporotic fracture increases rapidly.15,25,26 An upper age limit of 89 was selected to focus future prevention efforts on those patients who have significant expected longevity and who would be most able to respond to planned interventions.
Using the electronic databases for 1998 and 1999, we identified persons within the study population who had sustained a study-defined fracture—any clinical fracture except skull, facial, finger, toe, ankle, or any open fracture (suggestive of high force). Clinical fractures are those diagnosed by a physician, physician assistant, or nurse practitioner during a clinical encounter. Our study-defined fractures have been associated with decreased bone mass.27 They include ICD-9 codes 805 (vertebra), 807 (rib), 808 (pelvis), 810 (clavicle), 812 (humerus), 813 (radius and ulna), 814 (carpal bones), 815 (metacarpal bones), 820 (neck of the femur), 821 (femur, other, or unspecified), 822 (patella), 823 (distal tibia), and 825 (≥1 tarsal or metatarsal). We excluded open fractures in those categories.
Study-defined fractures were identified from the databases by searching for the first notation of inpatient or outpatient study fracture ICD-9 codes. This method of fracture ascertainment was validated through medical record review for a previous study.28 The percentage of reviewed fracture-related claims confirmed as actual fractures was greater than 93% for all fracture categories reviewed, except for rib (67%) and vertebra (80%).
Bone mineral density measurement procedures were identified through appropriate procedure codes using the HMO's external referral database. All BMD measures were performed using dual X-ray absorptiometry (DXA) by a single osteoporosis diagnostic center under contract with the HMO. This procedure is not available internally. Dual X-ray absorptiometry was performed on a Lunar DPX-L (GE Medical Systems, Milwaukee, Wis) until April 1999 and on a Lunar Prodigy DXA (GE Medical Systems) after that time. Measurements included BMD of the hip (femoral neck) and lumbar spine (L1-L4).
Information on use of pharmaceuticals for the prevention and treatment of osteoporosis during 1998 and 1999 was obtained from the HMO's outpatient pharmacy system. About 95% of all prescriptions written by the HMO's physicians are filled at the HMO's pharmacies, including those for members without a prepaid drug benefit, and are recorded in the pharmacy database. Pharmaceuticals examined for this study included bisphosphonates, estrogens, selective estrogen receptor modulators, and calcitonin. We included all products containing the bisphosphonates alendronate sodium, etidronate disodium, and risedronate sodium. For estrogens, we included the oral and transdermal preparations of esterified estrogens, conjugated estrogens, estradiol cypionate and estradiol valerate, estropipate, ethinyl estradiol, and norethindrone acetate, or their combinations, and excluded vaginal estrogen preparations. Because selective estrogen receptor modulators were used in only 1.7% of those treated and calcitonin in only 3.1%, these are not included in the tables or in analyses.
Pharmacological treatment of osteoporosis was defined for this study in 2 ways: (1) any use (dispensing) during 1998 and 1999 and (2) "new" use (dispensing) within the 6 months after the index fracture. New use for estrogen compounds after a fracture is defined as no use for 6 months before the fracture, followed by any use in the 6 months after the fracture. New use for a bisphosphonate is defined as no use in the 2 years before the fracture, followed by any use in the 6 months after the fracture. We selected a longer prefracture window for bisphosphonates because these agents have a longer protective effect on BMD and for fractures. The 6-month postfracture window was selected because most treatment for the acute fracture should be complete, allowing consideration of secondary prevention; past a 6-month window, it would be more difficult to associate treatment initiation with the fracture. New use was of particular interest to this study because the medication may have been initiated to reduce perceived increased risk related to the study fracture.
The HMO clinicians have access to the HMO's intranet-based clinical guideline for the evaluation and treatment of osteoporosis. The internal guideline available during the study pertained to women only, recommended DXA only for women with 2 or more risk factors, and provided treatment recommendations consistent with prevailing national guidelines.12- 16 Clinicians also had access from all clinical workstations to the Internet and therefore to other prevailing guidelines. For the purposes of this study, we defined guideline-recommended evaluation and treatment as BMD measurement alone, treatment alone, or combination BMD measurement and treatment. We then estimated the percentage of the study population who received guideline-based management.
Two-year clinical fracture frequencies by age and sex and significance testing by χ2 and Cochran-Armitage for trend were performed using SAS version 8.2 (SAS Institute, Inc, Cary, NC).
Of the 70 513 persons in the study population, 2264 women aged 50 to 89 (4.2% of 54 163 women) and 540 men aged 65 to 89 (3.3% of 16 350 men) had study fractures that occurred in 1998 and 1999. Table 1 presents the HMO population by age category and the number and percentage in each age category who sustained new clinical fractures during the 2 years. Two-year fracture frequencies increased with age for women and men, with the frequency for women aged 80 to 89 being 5 times that of women aged 50 to 64 (11.9% vs 2.4%). Men aged 80 to 89 had twice the frequency of fracture as men aged 65 to 79 (5.5% vs 2.8%).
Table 2 displays the rates of BMD measurements and any dispensed treatment in 1998 and 1999 by fracture category. We categorized the fractures as hip, vertebral, and "other" clinical fractures to be able to compare evaluation and treatment with other studies and prevailing guidelines. For all fractures, 8.4% of women and 1.5% of men received BMD measurement, and 42.4% of women and 2.8% of men received any pharmacological treatment for osteoporosis during the study.
Of 490 hip fractures, 74.1% were sustained by women and 25.9% by men. Nearly 5% (4.7%) of the women and 1.6% of the men with hip fractures had a BMD measurement in the 2-year period. Almost 43% of the women and 2.4% of the men with hip fractures received pharmacological treatment.
Of 269 vertebral fractures, 74.7% were sustained by women and 25.3% by men. Eight percent of the women and 7.4% of the men with vertebral fractures had a BMD measurement in the 2-year period. Almost 71% of the women and 13.2% of the men with vertebral fractures received pharmacological treatment.
Of 2044 other clinical fractures, 83.2% were sustained by women and 16.8% by men. Just over 9% of the women and 0.3% of the men with other fractures had a BMD measurement. Almost 39% of the women and 0.9% of the men with other fractures received pharmacological treatment.
Of the other clinical fractures, 255 (15.0%) in women and 34 (9.9%) in men were wrist fractures (ICD-9 code 813.4). Among those with wrist fractures, 25 (9.8%) of the women and 1 (2.9%) of the men received BMD screening by DXA, and 89 (34.9%) of the women and 1 (2.9%) of the men received pharmacological treatment.
Table 3 shows the percentages of subjects who received pharmacological treatment for osteoporosis during the study by the class of agent received. Of the 42.4% of women with fractures who were treated, 77.9% of those treated received estrogen (hip fractures, 68.4%; vertebral fractures, 64.8%; and other clinical fractures, 82.9%). Almost 15% (14.6%) of the women who were treated received bisphosphonate (hip fractures, 21.2%; vertebral fractures, 19.7%; and other clinical fractures, 11.9%), and 7.5% received estrogen and bisphosphonate (hip fractures, 10.3%; vertebral fractures, 15.5%; and other clinical fractures, 5.1%). The 2.8% of men with fractures who were treated pharmacologically all received bisphosphonate.
The final column of Table 3 displays the percentage of the study population who received any new treatment in the 6 months after a fracture. Only 4.6% of the study group received a new dispensing in the 6 months after a study-defined fracture. Thirty-five percent of those who received bisphosphonate received it as a new postfracture dispensing, whereas only 10.1% of those using estrogen received it as a new postfracture dispensing.
Table 4 displays the number and percentage of women and men by age category who had BMD measurements or received pharmacological treatment for all study fractures. Figure 1 graphically demonstrates this for hip and vertebral fractures (fractures with the highest prevalence of osteoporosis) combined. Bone mineral density measurement and treatment frequencies fell as women's ages increased (P<.001). There was a similar but statistically nonsignificant decrease for men (P<.40).
Number (percentage) of women and men by age category who had bone mineral density measurements or received pharmacological treatment for hip and vertebral fractures combined. Rx indicates pharmacological treatment; DXA, dual X-ray absorptiometry.
In women, 40.0% of all fractures and 71.4% of hip and vertebral fractures in the group aged 50 to 64 were treated, compared with 37.2% and 43.3% in women aged 80 to 89, respectively. In men, treatment fell from 3.4% of all fractures and 8.1% of hip and vertebral fractures in the group aged 65 to 79, to 1.2% and 2.8% in men aged 80 to 89, respectively. In women, DXA screening fell from 11.6% of all fractures and 11.6% of hip and vertebral fractures in the group aged 50 to 64, to 2.2% for all fractures and 2.4% of hip and vertebral fractures in women aged 80 to 89. In men, DXA screening fell from 1.9% of all fractures and 4.9% of hip and vertebral fractures in the group aged 65 to 79, to 0.6% for all fractures and 1.4% of hip and vertebral fractures in men aged 80 to 89.
Figure 2 displays the percentages of women and men in the study group who received study-defined guideline-recommended evaluation and treatment (ie, those who were not evaluated but were treated, were evaluated but not treated, or were evaluated and treated) and those who did not (ie, those who were neither evaluated nor treated). Approximately 51% (51.2%) of women were not managed according to clinical guidelines. Approximately 96% (95.5%) of men were not managed according to expert consensus.
Percentages of men (A) and women (B) in the study group who received study-defined guideline-recommended evaluation and treatment and those who did not.
Our data support the extensive prior work by others that concludes that the incidence of fractures associated with osteoporosis is higher in women, is substantive in women and men, and increases with age in both sexes.29- 31 Clinical guidelines recommend that older individuals with fractures should be directly treated for osteoporosis (if clinically apparent or if BMD measurement would not change treatment) or tested and then treated according to BMD measurement.4,13- 17 Approximately 51% (51.2%) of women and 95.5% of men in our study population were not screened or treated in accord with these recommendations. Only 4.6% of patients in our study population had pharmacological treatment initiated after a study-defined fracture. This small percentage of new postfracture treatment, when combined with the fact that most women (77.9%) who had any treatment during the study received estrogen, suggests that most of the "treatment" identified is incidental and may have been initiated for reasons other than osteoporosis.
Older individuals who have had a prior fracture comprise a sizable group and are easily identifiable during treatment and from medical records. Our data support the conclusion that this high-risk group is not sufficiently recognized and targeted for evaluation and treatment. Evaluation and treatment rates decrease with age, when risk increases, representing a missed opportunity to prevent refracture. This finding is similar to the significant decrease in treatment with age found by Freedman et al23 in women with wrist fractures.
This study has several important strengths. It includes a representative sample of all fractures treated in inpatient and outpatient settings in older individuals in a large HMO. The study includes men, unlike other reports of postfracture screening and treatment for osteoporosis.20- 24 The evaluation and treatment patterns described are based on clinical (not claims) data and include a broad range of physicians and allied health practitioners in various specialties.
We found that BMD measurements were infrequent (eg, only 8.4% for women). This frequency is lower than that reported within 1 to 2 years after hip fracture at 4 other managed care sites (range, 12%-24%),20 but higher than that reported in women who had wrist fractures (3%).23
In our study population, the frequency of pharmacological treatment varied by the fracture type. In persons with fractures, 42.4% of women and 2.8% of men received at least 1 dispensing during 1998 and 1999. We found that 42.7% of hip fractures in women and 2.4% in men, 70.7% of vertebral fractures in women and 13.2% in men, 38.9% of other clinical fractures in women and 0.9% in men, and 34.9% of wrist fractures in women and 2.9% in men received any pharmacological treatment. The treatment frequency we found in women with wrist fractures is higher than that found in a retrospective study23 of a claims database from 30 states (23%), but similar to that found in wrist fracture patients in Canada (38%).32
The overall postfracture treatment frequency found in our study population (4.6%) is lower than that found in a Rochester, Minn, community after a wrist fracture (17%).21 It is similar to a recent study20 of hip fracture patients in 4 other US health care systems, in which postfracture pharmacological treatment for osteoporosis varied from 5% to 44%, and similar to the 6% treatment rate found in Alberta, Canada.33 It is also similar to a case-control study24 in the United Kingdom that found a significant increase in the use of bone drugs only after vertebral fracture. Our low postfracture new treatment rate could be misleading because of the subject HMO's high prevalence of estrogen treatment that predated the fractures. In the case of some patients who were already taking estrogen at the time of a fracture, the clinicians may have concluded that the patients were already treated.
Estrogen was the predominant treatment seen in women in this study. Nearly 78% (77.9%) of the pharmacological treatment was estrogen, similar to the 85% use of estrogen preparations found after wrist fracture.21 It is unclear how much of the treatment was prescribed to preserve bone vs to treat perimenopausal symptoms or to provide what was a presumed cardioprotective effect. A study34 in another large integrated HMO found similar rates of estrogen treatment in women who had a diagnosis of osteoporosis or a prior fracture, compared with women who did not. That study concluded that the high rate of estrogen treatment was likely due to women receiving hormone therapy for reasons other than treatment of low bone mass. Estrogen use in our study population appears to be higher than that reported by others in patients with fracture. Pal22 reported a 19% use rate of estrogen in a survey of women in Great Britain with vertebral or hip fracture. Broy et al20 reported 0% to 14% estrogen use after hip fracture in 4 managed care organizations. The higher estrogen use found in our study may be due to this HMO's active campaigns in the early 1990s to increase use in postmenopausal women. Another study35 of our HMO reported that 50% of women aged 50 to 64 had at least 1 dispensing of hormone therapy in 1995.
Although national guidelines include estrogen as a treatment for osteoporosis, its adequacy for preventing and treating osteoporotic fractures is controversial.36 The Federal Drug Administration has approved hormone therapy for prevention of osteoporosis but not treatment. Randomized controlled trials of hormone therapy are in progress but have not yet assessed its preventive benefits for nonvertebral fractures.37
Bisphosphonate is used less than estrogen for osteoporosis treatment in women. Our findings are similar to the 15% of hip and vertebral fracture patients (women only) reporting bisphosphonate use in Pal's survey,22 but are slightly higher than reported by Broy et al,20 who found that 2% to 10% of hip fracture patients (men and women combined) at 4 managed care organizations received a bisphosphonate.
The reasons for the gap in evaluation and treatment for osteoporosis in older individuals after fracture are unknown. It is likely the result of a combination of patient, clinician, and health care system barriers. For patients, several factors may hinder initiation and adherence to osteoporosis treatment. Lack of patient knowledge about osteoporosis and hormone therapy has contributed to a lack of adherence to treatment.38,39 Low adherence to estrogen therapy in postmenopausal women has been well documented40; one retrospective study41 revealed long-term adherence of 30%.
Adherence has also been a concern with the next most commonly used pharmacological agent, bisphosphonates. Randomized controlled trials of a bisphosphonate found no significant differences in reported adverse effects among subjects taking an active drug compared with placebo.19 However, in an observational study,42 new upper gastrointestinal symptoms were reported in 33% of users of a bisphosphonate 3 months after initiation, and 35% discontinued the medication. The health care benefit, cost, and patient convenience likely also play a role. For example, an older patient with high out-of-pocket prescription drug costs may not consider treatment for osteoporosis a high priority. Transportation and other issues regarding access to BMD measurement and treatment may also come into play.
A large percentage of clinicians remain uncomfortable with use of BMD measurements and osteoporosis treatment. In 1994, 72% of primary care physicians in Rochester, NY, had never used BMD screening.43 Reported barriers to the use of BMD screening were cost, unfamiliarity with guidelines, uncertainty about clinical applicability, questions about the effect on treatment decisions, and availability of DXA devices. Although a recent literature review of prospective studies reveals that the association between low bone mass and most fractures is well established in women, this connection is not yet appreciated by many health care providers.44 Bone mineral density measurement is not available internally in our study HMO and requires an out-of-plan referral. This may partially explain the infrequency of BMD measurement herein. Saadi et al45 documented that, once osteoporosis was identified, treatment rates varied significantly by physician specialty, from a 96% treatment rate for metabolic bone disease specialists to 53% for general internists.
The epidemiology of osteoporotic fractures and the prevalence of osteoporosis in various fracture categories in men are less clear than for women, and randomized controlled trial data are limited. There are no published evidence-based guidelines for evaluation and treatment of osteoporosis in men, to our knowledge. It is therefore premature to conclude based on our data that clinicians are not following evidence-based guidelines for evaluating and treating osteoporosis in men. However, our data provide important baseline information to track over time as this science evolves. Our data suggest that, although the fracture burden in men is lower than in women, it is still significant. Therefore, as the population ages and the understanding of fracture prevention in men evolves, men will become more important to population management of this disabling condition than previously appreciated. A recent literature review revealed that most types of prior fractures increase the risk of future fractures in men and women.10 Therefore, although most clinicians would rightly not order a BMD for an older man with a minor fracture, such as a rib fracture from an automobile crash, serious consideration should be given to an evaluation for modifiable risk factors for fractures from falls and osteoporosis. Further research is needed to guide osteoporosis management in older men who have had fractures, as well as to identify patient, clinician, and system barriers to evaluation and treatment that might be amenable to intervention.
This study has several potential weaknesses. Although the population base in this study is similar to the community in which it resides, it may not be fully representative of that community or the US population at large. Therefore, conclusions from our study may be limited to the HMO population evaluated. The results are based on comprehensive electronic data, and although the incidence and type of fractures were not validated by medical records review, prior work has shown high validity of the data.28 We elected not to try to eliminate all high-force fractures (eg, a closed fracture from a motor vehicle crash). Our rationale is that there is good evidence that there is an increased relative risk for osteoporosis in high-force fractures and lower-force ones.46 Similar relationships between BMD and risk of nontraumatic and traumatic fractures were also found in the Study of Osteoporotic Fractures (S. R. Cummings, MD, written communication, February 2002).
We did not evaluate potential predictors of screening and treatment other than patient age and sex, nor could we evaluate differences in patient management by patient refracture risk level. Future studies should evaluate the effect of the full complement of patient risk factors for fracture, such as concomitant disease and activity status, on BMD measurement and treatment rates. Additional factors that might affect treatment should also be included in future studies, such as life expectancy, quality of life, and contraindications to treatment. Ideally, we would have evaluated whether or not treatment was appropriate after BMD measurement, but we did not have electronic access to BMD results. However, because BMD measurement was so infrequent, assessing patient management for appropriateness of treatment after BMD would not have substantially changed the percentage of individuals receiving guideline-based treatment. Further research is indicated in these areas.
Based on our data, we conclude that fracture in an older individual rarely prompts evaluation and treatment for osteoporosis, and intervention strategies should be developed, implemented, and evaluated to close the osteoporosis evaluation and treatment gap in older individuals with fractures. Intervention strategies should address barriers to patient participation and adherence, as well as clinician barriers to patient risk identification and management. Promising strategies may include combining patient and clinician education with methods to facilitate care, such as care pathways, alerts and reminders, or case management systems.
Corresponding author and reprints: Adrianne Feldstein, MD, MS, Center for Health Research, Kaiser Permanente, 3800 N Interstate Ave, Portland, OR 97227-1110 (e-mail: firstname.lastname@example.com).
Accepted for publication December 10, 2002.
This study was supported by a research consulting agreement through Merck & Co, Inc.
This study was presented in part as a poster at the 8th Annual HMO Research Network Conference; April 9, 2002; Long Beach, Calif.
We gratefully acknowledge the contributions of Thomas Weiss, PhD, and Ya-ting Chen, PhD, for their expert input on the manuscript; Jeff Showell, BA, and Chuhe Chen, PhD, for analysis and statistical support; Martha Swain, BA, for editing; Lin Neighbors, BA, for graphics; and Mary Harper for secretarial support.
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text: New Delhi: The seventh sound of the 2012-13 Ranji Trophy season gets underway across the country on Saturday, with the previous round having resulted in six wins, including some exhilarating results and draws. Punjab have booked their place in the quarter-finals and remain head and shoulder above all others with 32 points, but below there is a tight battle to reach the knockout phase. Three teams stand on 20 and 17 points, one has 16, two 15 and another 14. Heading into the third-last round before the quarter-finals start on January 6, itâs too close to call who could join Punjab in the knockout. Hereâs a look at the Group C matches starting December 15. Services v Jammu & Kashmir at Delhi: Taking the first-innings lead from Goa in round six kept Services at the top of the Group C table, and a win over a rejuvenated Jammu & Kashmir will secure their place in the quarter-finals. If they do not win, Services still have one match against Jharkhand to try and make it further. Veteran batsman Yashpal Singh scored his second century (166*) of the season against Goa to cross 600 runs, and with two centuries in two matches the captain Soumik Chatterjee has blossomed. Services possess a determined bowling attack and against J&K, who have won two in two, it will have to deliver. How J&K has transformed after a poor start to the season, and one dogged by infighting and politics, is shaping up to one of the underdog stories of the season. Their 74-run win over Kerala last round was the first time J&K had won a second Ranji Trophy match in a season since 2000-01, and against the group leaders they will be eying a hat-trick. With consecutives centuries in both wins, the captain Ian Dev Singh is enjoying a purple patch while the allrounder Parvez Rassol has 17 wickets in both successes. A bit more from some of the others, and J&K could surprise Services. Jharkhand v Andhra at Dhanbad: Three points behind Services on 17, Jharkhand have three matches in which to push their case for the quarter-finals and it is reliable aspiration. They have won two matches, the second of which came inside two days during the previous round, and with Kerala and Services to follow after this match Jharkhand remain one of the strongest teams in Group C. The bowlers set up the win over Tripura, in particular Ajay Yadav with ten wickets in the match and Shankar Rao with 5 for 36 in the second innings. Jharkhandâs batting remains shaky and that will be an area Andhraâs bowlers will look to expose. The visitors boast a potent bowling attack, with D Shivkumar (16 wickets at 15) and DP Vijaykumar (17 at 18.29) carrying the team this far. Goa v Himachal Pradesh at Porvorim: Despite possessing talented and in-form batsmen - one of whom has four centuries and 617 runs in six matches - and the seasonâs leading wicket-taker, Himachal Pradesh have failed to win a single match. With 11 points and two matches to go, they too face a mountain to climb to stay alive. Paras Dograâs purple patch has seen him reach three figures more than any other batsman this season, while allrounder Rishi Dhawan has 460 runs with three centuries and a season-leading 32 wickets with his medium pace. Yet repeatedly Himachal have failed to bowl out sides after getting into favorable positions thanks to the batsmen. Dhawan has been backed very well by veteram seamer Vikramjeet Malik (25 wickets) but the support after that has been disappointing. The next highest wicket-taker is Gurvinder Singh with eight, meaning that Dhawan and Malik have taken 67 percent of the wickets to fall to bowlers (excluding run outs). Goa, meanwhile, have nine points from five matches without a victory. Thought they have yet to lose, the lack of penetration with the ball has left them facing the prospect of drawing more often than not. Like Himachal, the bowling has been carried by two individuals â Saurabh Bandekar with 23 wickets and skipper Shadab Jakati with 17. No other bowler has crossed 10 wickets. With the bat, only Ravikant Shukla has topped 400 and the professional, former Haryana and Himachal batsman Manvinder Bisla, the only one to 300 though he has not scored a century in six innings. Tripura v Kerala at Agartala: Itâs the clash of the basement dwellers. Neither Tripura (eight points) nor Kerala (four points) look capable of crossing 20 points in the remainder of the season, and considering both are coming off crushing defeats the morale would be low. Tripura were rolled over in two days by Jharkhand in round six, with their second-innings collapse to 86 â their fourth-lowest total in first-class cricket â hastening defeat after seamers Timir Chanda (6 for 44) and Manisankar Murasingh (4 for 51) had combined to bowl the opposition out for 109. Kerala were beaten by 74 runs at home, chasing a target of 204 against J&K. From 44 for 0 they lost five wickets for 21 runs and their last four for 15.


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This is the song that caused a lot of stir between Coko and the other members of SWV last week on their WEtv Show, SWV Reunited. But if you didn't catch it on the show I have it right here for you to take a listen!
Don't forget to like our Facebook Page and follow us on Twitter to share your thoughts on this song :)
Coko – At Your Feet
Also On AM 1310: The Light:
comments – Add Yours


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Page 73 and the Play Company do right with this well-mounted production of "Edgewise."
Workshops are all very cozy, but it takes the full professional treatment for untested playwrights to see how far they've come — and how far they have to go. Page 73 and the Play Company do right by emerging young scribe Eliza Clark with this well-mounted production of "Edgewise," a dystopian drama about three New Jersey teens struggling to hold onto their humanity as a violent civil war rages outside the fast-food restaurant where they work. While the political ideology stands up, show's loose structure and shaky internal logic indicates that it's back to the workshop for this one.
Penning for both stage and smallscreen ("Rubicon") venues must have sharpened Clark's facility for thinking outside the box. Although she's obviously comfortable writing about confused young people, her imagination takes her beyond that narrow world.
At first look, "Edgewise" seems to be a conventionally realistic study of two shirker teens (and one busy bee) working the early shift at Dougal's, a depressing fast-food joint (which raises a shudder in Andromache Chalfant's grungy set) in some unnamed New Jersey suburb.
Ruckus (Philip Ettinger) is the self-important boss of this crew, having been elevated to shop manager by his father, who owns the franchise. Marco (Tobias Segal) is the good-natured, weak-kneed grunt who shares Ruckus' weed and puts up with his aggressive bullying. Emma (Aja Naomi King) is the conscientious kid who fires up the grill, fills the mayonnaise dispensers and does her best to keep the boss in check.
Under Trip Cullman's assured helming, the hyper-naturalistic production style plays out in the utterly natural manner in which these adolescents flirt, fight, complain, goof off, and otherwise relate to one another.
What's horribly unnatural about the scene at Dougal's is the bloody civil war that's being fought outside.
The first indication of the chaos is Marco's account of a shoot-out on the highway. Sudden blackouts (engineered by Nicole Pearce) and the shuddering sound (Bart Fasbender) of low-flying planes dropping bombs are stronger indicators that the fighting is getting closer. But it's the shocking appearance of a stranger who staggers into Dougal's covered in blood that really brings the violence home.
Once he's installed in the storage room of the restaurant, the wounded Louis (Alfredo Narciso, who does yeoman duty in this punishing role) brings out all the latent impulses of these young people — along with the moral qualms that have kept them in check throughout this long war.
Clark 's premise — of how easily the innocent are corrupted by violence — is borne out by the brutal treatment Louis receives at the hands of these confused kids. But the more we learn about the war and the extent of their involvement in it, the less convincing their behavior seems. Scenes that might have been attributed to lazy writing or awkward character development are revealed as dramatic contrivances for keeping the characters from saying and doing what should come naturally to anyone as savvy in the savage ways of the world as these poor kids are.
No criticism of the actors intended here, but they'll never convince us that anyone in this post-Apocalyptic hell is still buying burgers at Dougal's..


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Other projects made by knitisfun:
Offer some kudos...
Join the conversation...
Ask a question...
Add your comment...
|Here are some details about my project:
|Romantic, Outdoorsy, Mod, Cute
What was your source for this crocheting project?
Online Photo or Website
Name of website or photo berlingot beret
What advice would you give someone starting this project? Skill level for this pattern is intermediate. The pattern is written in Standard US terminology, and requires knowledge of basic stitches and front post double crochet stitches. Anyway all the stitches are fully detailed in the tutorial with many pictures. Row by row instructions + one chart are in the file. This pattern is for an adult or teen sized hat. The pattern is available in 2 sizes: Teen l: 19.5 20.5 (51-53 cm) Woman: 21- 22.8 (54- 58 cm For any questions please don't hesitate to contact me... I am always helping!
How can I get the pattern for this hat?


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Systemwide Events Calendar
Film Making, Art & Activism: A Conversation with Director Tadashi NakamuraMarch 19, 12:30pm - 2:00pm
West Oahu Campus, D237
Film Screening and Q&A with Director Tadashi Nakamura
The Film Maker: Nakamura, a Los Angeles-based filmmaker, was named one of CNN's "Young People Who Rock" for being the youngest filmmaker at the 2008 Sundance Film Festival as well as one of the "30 Most Influential Asian Americans Under 30" by the popular website Angry Asian Man. Nakamura's trilogy of documentary films on the Japanese American experience, Yellow Brotherhood (2003), Pilgrimage (2007) and A Song for Ourselves (2009) have garnered over 20 awards at film festivals around the world with Pilgrimage being one of 83 short films out of 7,500 submissions selected for the 2008 Sundance Film Festival.
The Film: Jake Shimabukuro: Life on Four Strings, Nakamura's first full-length documentary, is a compelling portrait of an inspiring and inventive musician whose virtuoso skills on the ukulele have transformed all previous notions of the instrument's potential. On the road from Los Angeles to New York to Japan, the film captures the solitary life on tour: the exhilaration of performance, the wonder of newfound fame, the loneliness of separation from home and family.
Ticket Information
Free and open to the public
Event Sponsor
UHWO Distinguished Visiting Scholar Series , West Oahu Campus
More Information
|Wednesday, March 19
|2014 Annual Veterans Conference
Manoa Campus, UHM Campus Center Ballroom
|First Aid / CPR / AED Class
Manoa Campus, Campus Center Dining Room 203E
|Prior Learning Assessment Meeting
West Oahu Campus, Library Ulu`ulu Archive center
|Experience the World: Greece
Honolulu Campus, 874 Dillingham Blvd
|Inside the Ethnic Studies Studio...Featuring Jeff Bernat and JBird
Manoa Campus, George Hall 227
|Chinese Studies Public Lecture
Manoa Campus, Tokioka Room (Moore Hall 319)
|How to use STAR
Maui Campus, The Learning Center
|Film Making, Art & Activism: A Conversation with Director Tadashi Nakamura
West Oahu Campus, D237
|"Making Sense of Micronesia..." - Francis X. Hezel, SJ
Hilo Campus, Campus Center 301
|Meteorology Seminar
Manoa Campus, Marine Sciences Building, MSB 100
|The Ethnobiology Society Invited Lecture Series
Manoa Campus, St. John Plant Science Building Room 11
|Global Chef Program - Colombia
Manoa Campus, Multiple Locations (See Schedule)
|"Women's Roles in Micronesia: Then and Now" - Francis X. Hezel, SJ
Hilo Campus, Campus Center 301
|ASUH Executive Committee Meeting
Manoa Campus, Campus Center 310
|Wednesday Night Southeast Asia Movie
Manoa Campus, Center for Korean Studies Building
- Highlighted dates have scheduled events.
- Select the date to view all events for that day.
Ongoing Events
- Our Musical Heritage: The Royal Hawaiian Band
- Na Pa'i Ki'i o Brother Bertram
- A World of Chinese Puppets from the Lin Liu-Hsin Museum, Taiwan
- i.KEA Inspiring Knowledge, Empowerment and Achievement
- TRIO-SSS Summer Bridge 2014
- Waikiki Parc Features Tonia Moreno
- YUAN: by Beili Liu
- "Intermediate Drawing & Painting" by Reem Bassous' students
- Windward CC Art Faculty Exhibit at Gallery 'Iolani
- Traveling Exhibit: Gardens of Hawaii
- Ho`okele: Navigating the Forest
- Book Making in the 18th Century: In Diderot's Encyclopedie, 1751-1780
- 4th Annual Veterans Conference
- Contemporary Religion & Science Dialouges


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CLAYSBURG - After clinching the Inter-County Conference North Division with a win over Bellwood-Antis Thursday, the Claysburg-Kimmel softball team has its sights set on an undefeated season and the top seed in the upcoming District 6 Class A playoffs.
The Lady Bulldogs took another step towards those goals Friday with an 11-0 win over Chestnut Ridge at the Claysburg-Kimmel High School field.
Ronette Claar continued to dominate opposing hitters, giving up just one hit and striking out 10 in the five inning mercy rule victory. Jana Fickes' one-out single in the top of the first was the Lady Lions lone hit of the game.
"It was not her best game, but she's pitched 25 innings this week," Claysburg coach Mike Barbarini said. "We probably wouldn't need her to pitch as much, but we're trying to wrap up the number one seed in the district and Conemaugh Valley has just one loss."
The win polished off a perfect 4-0 week and improved Claysburg's record to 16-0 with three regular season games left on the schedule.
Claar sparked the offense as well with three singles and three runs scored out of the leadoff spot.
Lydia Fleck, Hannah Claycomb and Madison Ickes each had two hits apiece. Fleck also drove in three runs.
Fleck started a seven-run rally in the bottom of the fifth with a leadoff walk and capped it with a two-run single that scored Abby Kulick and Claar.
Following the Fleck walk, Claycomb singled to left, and Ickes reached on a bunt single to load the bases with no outs.
A Mallory Cox fielder's choice scored Fleck, and Kiersten Coho doubled to bring home Claycomb and Ickes.
Mercedeze LeMaster's ground out brought in a run, and a Kulick single scored another run before Fleck singled to left to end the game.
"We took a spanking. They have a good ball team that could go the state semis or state finals," Ridge coach Chuck Corle said. "I'm disappointed with our defense. We didn't make the plays we should have made. You can't give a team like that that many chances."
Chestnut Ridge (10-4) committed three errors, two of which led to single runs in the first and fourth innings.
Claysburg reached the state semifinals in 2009 and 2010 before losing in the first round a year ago.
"We've got a young team. Lydia and Ronette are our only two seniors, but we're looking to go deep in the postseason," Barbarini said.
Chestnut Ridge000 00x x-0 1 3
Claysburg-Kimmel102 17x x-11 12 0
2B-Fleck, Claycomb, Coho (CK). Multiple hits-Claar 3, Fleck 2, Claycomb 2, Ickes 2 (CK). RBI-Claar 3, Coho 2, Claycomb, Cox, LeMaster, Kulick. WP-Claar. LP-Yothers. SO-Claar 10. BB-Yothers 1.
Records: Chestnut Ridge (10-4); Claysburg-Kimmel (16-0).


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Long answer: The Straight Dope on Cholesterol: 10 Things You Need to Know – Part 1 | Mark's Daily Apple
Really long answer: http://www.google.com/url?sa=t&rct=j...41642243,d.eWU
So Ive just got back from my appt with a senior pathology specialist about my high cholesterol.
Here are my Jan 2013 numbers:
Total 10.26(396)
Cpr <1
Vit D 59(148)
My numbers have been around these numbers since I went high fat, low carb a few years ago.
Previously my numbers were a lot lower, though trigs were slightly higher and HDL a bit lower.
This is the first time Ive had the Apoliprotein A & B tested, the specialist said hes concerned about the high LDL, and the Apo B numbers.
Can anyone look at these numbers and determine if I should be worried or not.
Im male, 46, 59, 138lbs, very active, run, cycle or weights most days.
I eat a fair amount of fish a week, salmon, mackerel, cod.
Lamb and Beef once a week.
A small amount of lambs liver twice a week.
8-10 eggs a week.
Little dairy,a bit of greek yoghurt and raw cream.
Lots of veg with lots of butter and EVOO.
Avocadoes, 1 piece of fruit a day
Coconut ouil and milk regularly.
Macadamia nuts(50g a day) and 1 or 2 brazil nuts a day.
1 small sweet potatoe a day.
A couple of glasses of red wine a week.
Small amount of dark chocolate.
No caffeine at all, just herbal teas and water.
Thats about it for my diet, the doc said to have 1 egg a week, no liver, no lamb(too fatty!) a small amount of EVOO, no butter, no avocadoes.
He said to eat lots of fish, chicken, veg and fruit, and not a lot else!
Now, as I said, I work out most days, and generally aim for 2,500-3000 cals a day. Thats an awful lot of fish, fruit and veg with no fats to get to 3000 cals!
All my other labs were excellent, he said the Vit D and B were very high, he couldnt believe I dont take Vit B supplements, guess its the liver.
He checked me over for cholesterol deposits, none anywhere. He ruled out FH.
He listened to my arteries and heart, all excellent.
He was desperate to put me on statins, but has given me 4 months to sort via diet.
Hes sending me for a scan to check for any furring in the arteries.
Any feedback.advice would be greatly appreciated.
Long answer: The Straight Dope on Cholesterol: 10 Things You Need to Know – Part 1 | Mark's Daily Apple
Really long answer: http://www.google.com/url?sa=t&rct=j...41642243,d.eWU
Stroke mortality and the apoB/apoA-I ratio: res... [J Intern Med. 2006] - PubMed - NCBI
Google apoB/apoA ratio for more information. In particular, there's a ppt show online aimed at cardiologists that explains the research well: http://cardiolipid.com/cardiolipid%2...010/012001.pdf
Maybe next time you plan to get a test you should follow his advice for a few months and see if it actually changes anything. I didn't eat any meat for a decade except for occasional fish and my cholesterol numbers were terrible.
Female, 5'3", 50, Max squat: 202.5lbs. Max deadlift: 225 x 3.
Have you had your thyroid checked? I don't have the article, but I read a relatively long piece recently on how some people get very high cholesterol numbers on paleo diets, caused by abnormal thyroid function, or in rare cases infection.


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BOALSBURG - The Pennsylvania Military Museum in Centre County will hold its sixth annual Vietnam Revisited Living History weekend on Saturday and Sunday, July 20-21.
Visitors will experience the sights, smells and sounds of the era as re-enactors, museum staff and volunteers bring the time period to life.
Weekend events include live music at 1 p.m. Saturday and a patrol ambush demonstration both days at 1:45 p.m.
Visitors also can participate in a recon patrol mission lead by a point-man. Those who wish to participate in the mission are advised to wear long pants and good shoes, as participants will be led through the "jungle." The lush undergrowth and thick tree canopy surrounding Spring Creek beside the museum, as well as the hot and humid July weather, provide for an excellent representation of the Central Highlands jungle environment in which the soldiers fought.
The living history bivouac provides both entertainment and education. Throughout the activities of U.S. and NVA camp tours, Armed Forces Radio VIETNAM 1968-69 will play on the base "intercom" while each day's ambush demonstration will be preceded by a short summary of American involvement in Vietnam.
Returning to the event will be Doug Irwin, a local folk guitarist who will entertain the troops and public. Irwin served with the post-war 82nd Airborne Division's 1/505th Parachute Infantry Regiment. He performs at 1 p.m. Saturday.
"This year I'll be playing songs that are military/soldier-themed exclusively," Irwin said. His music will "capture the sacrifice that veterans make, both physical and mental, and the struggles they deal with on their return, especially those who have been in combat."
The bivouac opens to the public at 10 a.m. each day. Patrol ambush demonstrations are scheduled for 1:45 p.m.
The Pennsylvania Military Museum and 28th Infantry Division Shrine is administered by the Pennsylvania Historical and Museum Commission. For more information on the museum, call 814-466-6263 or visit the website at www.pamilmuseum.org.


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SEJ Guide to Diversity in Environmental Reporting
The Society of Environmental Journalists published this resource for journalists who want to address diversity concerns and practice more inclusive journalism. Authors Jennifer Oladipo and Talli Nauman created the guide, inspired by discussions by members of SEJ's Diversity Task Force. Their focus is mainly journalistic practice in North America. Journalists who have not consciously addressed diversity in their work should find multiple entry points here.


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MyHeritage: A 'titanic' family discovery
Our post on the 100th anniversary of the Titanic's sinking produced a breakthrough for a South African member of MyHeritage.
Christopher Brian Jennings (known as Brian), 44, of Johannesburg, South Africa became interested in family history as his elders aged. He realized that their wealth of information would disappear if he did not document the family.
Brian lives with his wife Adri, 44, and children Natasha, 19, and Michael, 15. He is an insurance industry director.
Continue reading "MyHeritage: A 'titanic' family discovery" »
Titanic's 100th Anniversary: Your stories
As the world commemorates the 100th anniversary of the tragic sinking of the Titanic, families are still affected by April 15, 1912.
Many MyHeritage members have a personal connection to this tragedy. We invited them to share their Titanic stories for today's special post.
Thank you to everyone who shared their personal stories.
Henry W. Gradidge, England:
Mr. Ernest Edward Gradidge, 32, of Southampton, died in the Titanic sinking. His body was recovered by the Mackay-Bennett and was buried at Fairview Cemetery, Halifax, Nova Scotia on 6 May 1912.
This is the description:
CLOTHING - Green suit; mourning band; flannel shirt.
EFFECTS - Pipe; key; padlock; purse; three shillings; British Seafarer Union Book, No. 560.
He was wearing a mourning band for his brother Stephen John Gradidge who drowned from the Royal Mail Ship Thames in Buenos Aires on December 26th 1911
Their brother William Charles sailed on the Olympic, "sister ship to the Titanic"
Marek Jankowski, Poland:
Continue reading "Titanic's 100th Anniversary: Your stories" »
[Guest Post] Commemorating the Titanic
This is a guest post from Dr Nick Barratt, (author, historian and broadcaster) who runs Sticks Research Agency and is a regular presenter of TV shows as well as his own vodcast www.familyhistoryshow.net, in association with MyHeritage.com. He currently serves as the President of the Federation of Family History Societies, Vice President of AGRA, Executive Director of FreeBMD, Editor in Chief of Your Family History magazine, Honorary Teaching Fellow at the University of Dundee, and Trustee at the Society of Genealogists.
Don't forget to send your family's Titanic stories to firstname.lastname@example.com by Friday for your chance to win a copy of Dr Barratt's book - Lost Voices from the Titanic. Continue reading "[Guest Post] Commemorating the Titanic" »
Titanic 100th Anniversary: Survivor stories [competition]
Do you have an ancestor who was on board the Titanic?
April 15, 2012 marks 100 years since the Titanic collided with an iceberg and sank into the depths of the North Atlantic Ocean.
This disaster claimed 1,514 lives and is one of the deadliest maritime peacetime incidents on record. Continue reading "Titanic 100th Anniversary: Survivor stories [competition]" »